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BACKGROUND: Although stent underexpansion on intravascular ultrasound (IVUS) has been a major predictor for adverse outcomes in previous studies, these studies have primarily focused on angiographic restenosis or repeat revascularization with short-term follow-up. This study sought to evaluate the long-term benefit of different criteria for IVUS-defined optimal stent expansion on hard clinical outcomes. METHODS: From the pooled data of 2 randomized trials, IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions) that compared IVUS- versus angiography-guided drug-eluting stent implantation, a total of 1254 patients with IVUS-guided drug-eluting stent implantation into 1484 long lesions (implanted stent length, =28 mm) were included. Different criteria for IVUS-defined optimal stent expansion based on minimum stent area (MSA) as an absolute measure or MSA relative to reference lumen area were applied and validated. The primary end point was composite of cardiac death, target lesion-related myocardial infarction, or stent thrombosis at 3 years. RESULTS: The rate of the primary end point was lower in patients with optimal stent expansion versus those without optimal stent expansion according to 3 IVUS-defined optimal stent expansion criteria: MSA >5.5 mm2 (0.5% versus 2.2%; hazard ratio, 0.21 [95% CI, 0.06-0.75]; P=0.008), MSA >5.0 mm2 (0.6% versus 2.6%; hazard ratio, 0.24 [95% CI, 0.09-0.68]; P=0.003), and MSA/distal reference lumen area >90% (0.5% versus 2.4%; hazard ratio, 0.32 [95% CI, 0.12-0.88]; P=0.019). Achieving other relative expansion criteria, MSA/distal reference lumen area >100% or 80% or MSA/average reference lumen area >90% or 80%, was not associated with a reduction in hard clinical events. CONCLUSIONS: In patients undergoing IVUS-guided drug-eluting stent implantation for long lesions, achieving optimal stent expansion of MSA >5.5 mm2, >5.0 mm2, or MSA/distal reference lumen area >90% was associated with improved long-term hard clinical outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: In patients with acute coronary syndrome (ACS) with a high risk of ischemia, the impact of ticagrelor monotherapy after short-term dual antiplatelet therapy (DAPT) has not been clearly elucidated. METHODS: This post hoc analysis of the TICO trial (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) compared the impact of ticagrelor monotherapy after 3-month DAPT versus ticagrelor-based 12-month DAPT in patients with high-ischemic risk ACS, defined as any of the following: number of stents implanted =3, total stent length >60 mm, complex procedures (chronic total occlusion, left main occlusion, or bifurcation plaques remedied using the 2-stent technique), or a history of diabetes or chronic kidney disease. Ischemic (composite of death, myocardial infarction, stent thrombosis, stroke, and target vessel revascularization) and bleeding outcomes (major bleeding) were evaluated at 12 months. RESULTS: Of the total population (N=3056), 1473 (48.2%) patients were identified as having high-ischemic risk ACS. The rate of the ischemic outcome was significantly higher in high-ischemic risk ACS patients than in nonhigh-ischemic risk ACS patients (3.9% versus 1.9%, hazard ratio, 2.14 [95% CI, 1.37-3.35], P=0.001). Furthermore, the risk of major bleeding (3.2% versus 1.5%, hazard ratio, 2.23 [95% CI, 1.36-3.68], P=0.001) and the composite ischemic and bleeding outcome (6.6% versus 3.3%, hazard ratio, 2.02 [95% CI, 1.44-2.84], P<0.001) were also higher in the high-risk ACS population. In ACS patients with or without high-ischemic risk, the effect of ticagrelor monotherapy after 3-month DAPT, as compared to that of 12-month DAPT, was consistent with ischemic (Pint=0.718), bleeding (Pint=0.092), and composite outcomes (Pint=0.094) without significant interactions. CONCLUSIONS: There were no significant heterogeneities in the impact of ticagrelor monotherapy after 3-month DAPT compared with that of ticagrelor-based 12-month DAPT on clinical outcomes according to the presence of highischemic risk. [ABSTRACT FROM AUTHOR]

Background—There is general agreement that the optimal duration of dual antiplatelet therapy (DAPT) in patients treated with drug-eluting stents should be individualized. We hypothesized that the extent of coronary artery disease may affect the clinical outcomes of DAPT. Methods and Results—We pooled patient-level data from 5 large, randomized trials comparing short-term DAPT with prolonged therapy. From the data, we identified 5476 patients who received newer-generation drug-eluting stents. Net adverse clinical event (NACE) was defined as a composite of all-cause mortality, myocardial infarction, stroke, or major bleeding. At 1 year, NACE had occurred in 171 patients (3.1%). Independent predictors of NACE were older age (>65 years), sex, presence of diabetes mellitus, left ventricular dysfunction (ejection fraction <40%), and angiographic multivessel disease. Multivessel disease and DAPT duration were significantly associated with NACE (P for interaction=0.002); the association was driven by the greater occurrence of myocardial infarction in patients with multivessel disease. In patients with multivessel disease, 6-month DAPT (versus 12-month DAPT) was associated with a higher incidence of myocardial infarction (adjusted hazard ratio=2.748; 95% confidence interval=1.375–5.491; P=0.004), compared with patients with single-vessel disease (P for interaction=0.001). Conclusions—In patients treated with newer-generation drug-eluting stents, a significant interaction between DAPT strategy and multivessel disease was found regarding the occurrence of NACE at 1 year. Among adverse events, myocardial infarction was more frequent in 6-month DAPT than in 12-month DAPT in patients with multivessel disease. [ABSTRACT FROM AUTHOR]

Background: Intravascular optical coherence tomography (OCT) imaging provides limited information on the functional assessment of coronary stenosis. We evaluated a new approach to OCT image-based computation modeling, which can be used to estimate the fractional flow reserve (FFR) in patients with intermediate coronary stenosis. Methods and Results: Ninety-two patients with intermediate diameter stenosis in the left anterior descending artery underwent both FFR measurement with pressure wires and OCT examination. Using the OCT data, a computational fluid dynamics algorithm was used to calculate the computational FFR (FFROCT). The diagnostic performance of the FFROCT was assessed based on the pressure wire-based FFR. The median FFR and FFROCT values were 0.86 (0.79-0.89) and 0.89 (0.82-0.94), respectively. The average diameter stenosis in quantitative coronary angiography and area stenosis in OCT were 58.1±13.4% and 67.5±13.5%, respectively. The FFROCT was better correlated to the FFR than were the anatomic variables (r=0.72; P<0.001 versus r=0.46; P<0.001 for minimal luminal diameter on quantitative coronary angiography or r=0.57; P<0.001 for minimal lumen area on OCT). When functionally significant stenosis was defined as an FFR cutoff value of =0.8, FFROCT resulted in 88.0% accuracy, 68.7% sensitivity, and 95.6% specificity. The positive and negative predictive values were 84.2% and 89.0%, respectively. Conclusions: The computation of FFROCT enables assessment not only of anatomic information, but also of the functional significance of intermediate stenosis. This measurement may be a useful approach for the simultaneous evaluation of the functional and anatomic severity of coronary stenosis. [ABSTRACT FROM AUTHOR]

The article presents a study which looks at the geometric changes mechanism after implantation of the main branch (MB) stent and determines the predictors of side branch (SB) ostial stenosis. It states that the aggravation of the SB ostial stenosis occurs due to the MB plaque shift to the SB ostium which is also known as snowplowing. It discusses techniques used to examine bifurcation lesions such as quantitative coronary angiography (QCA), two-dimensional and three-dimensional intravascular ultrasound (IVUS) analysis, and fractional flow reserve (FFR).