MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES NGUYEN HOANG MINH PHUONG RESEARCH RESULTS OF LEFT MAIN CORONARY ARTERY INTERVENTION[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - NGUYEN HOANG MINH PHUONG RESEARCH RESULTS OF LEFT MAIN CORONARY ARTERY INTERVENTION UNDER INTRAVASCULAR ULTRASOUND - GUIDED IN CHRONIC CORONARY ARTERY DISEASE PATIENTS Speciality: Internal Medicine/ Internal Cardiology Code: 9720107 ABSTRACT OF MEDICAL PHD THESIS Hanoi – 2023 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: A Prof PhD Pham Thai Giang A Prof PhD Pham Manh Hung Reviewer: A Prof PhD Luong Cong Thuc A Prof PhD Nguyen Ngoc Quang A Prof PhD Nguyen Oanh Oanh This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year 2023 The thesis can be found at: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences Central Institute for Medical Science Infomation and Tecnology INTRODUCTION Coronary artery disease is the leading cause of death and disability in developing and developed countries According to the Vietnam Heart Institute, the hospitalization rate for coronary artery disease increased from 3.4 - 6.0% (in 1994 - 1996) to 11.2 - 24% (in 2003 2007) [1] The main cause of coronary artery disease is coronary atherosclerosis Due to large myocardial involvement, left coronary artery disease is associated with high mortality and disability Therefore, the European Heart Association in 2019 recommended reperfusion in patients with left main coronary stenosis > 50% diameter to improve prognosis at the I-A recommendation In the past, bypass surgery was considered the standard reperfusion approach However, in recent years, coronary intervention has been considered more frequently To avoid misclassification of the disease, many useful adjunct tools are applied to decision making In particular, intravascular ultrasound (IVUS) is the best considered intravascular imaging method in the evaluation of the left coronary artery [7] The clinical guidelines of the European Heart Association have reviewed its use IVUS in the assessment of severity of left main coronary artery disease with recommendation class IIa, level evidence B [7] In Vietnam, interventional cardiology techniques have been widely deployed in the provinces However, LM intervention is still a challenge for many intervention rooms Objectives: Survey on clinical, subclinical characteristics and left main coronary artery lesions on intravascular ultrasound in patients with chronic coronary artery disease undergoing intervention Evaluation of early outcomes of left main coronary artery percutaneous intervention under intravascular ultrasound guidance in patients with chronic coronary artery disease Chapter OVERVIEW 1.1 Diagnosis and treatment of left main coronary artery disease 1.1.1 Anatomy of the left main coronary artery 1.1.2 Left main coronary artery disease 1.1.2.1 Frequency Significant left main coronary artery stenosis was present in 6% of patients undergoing percutaneous coronary angiography [12] 1.1.2.2 Definitions Significant stenosis of the left main coronary artery is defined as stenosis > 50% of the diameter Intermediate LMCA disease: defined when the LM severity is difficult to assess by angiography but has a narrowing of about 30-50% These patients require additional trials such as FFR or IVUS to guide treatment [14] Left main equivalent disease is defined as severe (≥70%) stenosis of the left anterior descending and circumflex arteries, with a similar prognosis to true left main disease [15] 1.1.2.3 Classification and causes 1.1.3 Diagnosis of left main coronary artery disease 1.1.4 Treatment of left main coronary artery disease 1.1.4.1 Risk of treatment strategy for systemic disease 1.1.4.2 Strategies for the treatment of LMCA disease Includes medical treatment, percutaneous coronary intervention, and coronary artery bypass graft surgery In the past, bypass graft surgery was considered the gold standard in the treatment of left main disease However, with the advancement in technology as well as equipment, percutaneous coronary intervention plays an increasingly important role in the treatment of left main diseases 1.2 Intravascular ultrasound in the diagnosis and treatment of LMCA disease 1.2.1 Intravascular ultrasound 1.2.1.1 Outline Intravascular ultrasound (IVUS) is a catheter-based invasive imaging It gives a cross-sectional view of the blood vessel at a time and a series of images at a predetermined rate Based on the obtained images, people will analyze the structure of atheroma, vascular properties 1.2.1.2 Coronary artery imaging on IVUS 1.2.2 Intravascular ultrasound assessment of left coronary artery lesions Because the left main coronary artery has an important role in myocardial blood supply, is short in size, and difficult to accurately assess on angiography, invasive imaging studies are recommended (class IIA recommendations according to recommendations) Report of the American College of Cardiology [12], for intermediate LM injury, and recommended IIA for intervention as recommended by the European Heart Association [36] 1.2.3 Intravascular ultrasound guided intervention of the LMCA 1.2.3.1 Before the intervention Prior to intervention, IVUS is used to assess: risk of lateral branch stenosis, and determine stent size 1.2.3.2 During the intervention IVUS after intervention to evaluate the outcome of stents [61] To decide on a second stent, IVUS (as well as FFR) plays an important role in assessing the extent of the lesion (as well as function) before and after the first stent, and in evaluating the outcome of the intervention [61] 1.2.3.3 After the intervention After stenting, IVUS is used to evaluate procedural complications and risk of restenosis in the stent 1.2.4 The prognostic role of intravascular ultrasound in interventional guidelines for left main coronary artery disease Despite the limitations of observational studies, all studies point to IVUS guidelines to improve long-term prognosis and mortality 1.3 Related studies The LITRO registry study reported 354 patients with LMCA reperfusion in 90.5% (152/168) with MLA over IVUS 50% of the lumen diameter according to the method of quantification of coronary angiography) or severe lesions (≥ 70% of the diameter) of ostium or proximal segment of the left anterior descending (LAD) and/or left circumflex (LCx) arteries (left main equivalent disease) with left main intermediate disease (30-50% lumen stenosis) The patient and the patient's family consented to IVUS When the patient is at high surgical risk and the SYNTAX score < 32, the patient is indicated for left main intervention when the minimum lumen area (MLA) is mm2 on IVUS according to the majority of previous study authors [6] Agree to participate in the study 2.1.2 Exclusion criteria Injury to the LMCA < 30% of the lumen diameter Injury to the LMCA > 50% has a SYNTAX score ≥ 33 and low surgical risk The patient underwent coronary artery bypass surgery Severe comorbidities or survival < year The patient did not consent to participate in the study 2.1.3 Sample size: Convenient sampling method, regardless of ethnicity, age and gender The number of patients is equal to 55 patients 2.1.4 Research place: Cardiology Institute, Bach Mai Hospital 2.2 Research Methods 2.2.1 Research Methods: Prospective, descriptive, no control group 2.2.2 Conduct research 2.2.2.1 The method of data collection Eligible patients were included in the study Conduct data collection on history, medical history, clinical and paraclinical according to the study case Clinically documented: cardiovascular risk factors (smoking, obesity, dyslipidemia), history of coronary artery disease and coronary intervention, comorbidities, degree of chest pain on admission according to CCS, degree of heart failure on admission according to NYHA Subclinical: when entering the hospital, the patient has blood drawn for testing at the Department of Hematology/ Biochemistry, Bach Mai Hospital Patients underwent echocardiography at the Ultrasound Room, Cardiology Institute, Bach Mai Hospital Conduct percutaneous coronary angiography by catheter at the angiography room, Vietnam Heart Institute The patient's angiogram results will be evaluated by Quantitative Coronary Angiography (QCA) software The results of coronary angiography with left main lesions ≥ 50% of the lumen diameter, or left main equivalent disease, explain the indications for IVUS to the patient and family If the patient and family members agree, perform intravascular ultrasound Based on the results of IVUS and coronary angiography, the intervention team consulted and decided to intervene and the general method of intervention After placement of the LM stent, intravascular ultrasound was performed to optimize the stent as well as to evaluate complications Successful assessment of imaging based on coronary angiography after intervention When the patient was discharged from the hospital, the clinical assessment of the patient included complications of the intervention procedure, the degree of clinical improvement (chest pain, heart failure) 2.2.2.2 Technical equipment used in the study 2.2.2.3 Technical processes A Prepare the patient B Procedure steps Coronary angiography by DSA Intravascular ultrasound (IVUS) Coronary intervention under IVUS guided IVUS after intervention Coronary angiography after intervention End of procedure 2.3 Diagnostic criteria 2.3.1 Clinical parameters 2.3.2 Diagnostic criteria 2.3.3 Criteria for evaluating research results 2.3.4 Paraclinical parameters Chapter RESEARCH RESULTS During the period from April 2017 to October 2019, 55 patients with left main coronary artery intervention under intravascular ultrasound guidance were included in our study 10 3.2.4 Characteristics of lesions of the left main coronary artery on percutaneous coronary angiography 3.2.4.1 Characteristics of LMCA 3.2.4.2 Characteristics of lesions of the LMCA on percutaneous coronary angiography Table 3.11 Classification of left main diseases LM disease classifications N = 55 Frequency n (%) Significant LM stenosis (> 50%) 16 (29.1) Intermediate LM stenosis (30 – 50%) 39 (70.9) In our study, intermediate LM disease took part majority Intermediate LM disease which interventioned because of combination proximal LAD and/or LCx disorders Table 3.12 Lesion places of LMCA Lesion places LM stenosis Intermediate N = 55 n(%) LM stenosis n(%) Ostium, proximal Total n(%) (37.5) (10.3) 10 (18.2) Shaft (5,1) (3.6) Distal 10 (62.5) 33 (84.6) 43 (78.2) Total 16 (100) 39 (100) 55 (100) Lesions of distal LMCA were majority (78.2%) Table 3.15 Medina classification LM stenosis Intermediate LM n(%) N = 10 stenosis N = 33 Total N = 43 1,0,0 (10.0) (6.1) (4.7) 1,1,0 (30.0) 16 (48.5) 19 (44.2) 1,1,1 (60.0) (27.3) 15 (34.9) Medina 11 0,1,0 (15.2) (11.6) 0,1,1 (10.0) (3.0) (4.7) At bifurcation, Medina 1,1,0 were majority (44.2%) Table 3.16 SYNTAX score Score LM stenosis Intermediate N = 55 n = 16 LM stenosis n =39 SYNTAX score (M ± SD) SYNTAX score < 22 (n; %) Total 22,6 ± 6,5 18,2 ± 6,1 19,5 ± 6,4 (43,8) 27 (69,2) 34 (61,8) 3.2.5 Characteristics of the left main coronary artery on intravascular ultrasound Table 3.18 Location of LMCA stenosis according to intravascular ultrasound Stenosis accoring to Proximal Middle Distal n = 55 n = 51 n = 55 Non stenosis n (%) 45 (81.8) 44 (80) 12 (21.8) Stenosis n (%) 10 (18.2) (12.7) 43 (78.2) MLA Among 51 cases of left main length > 10mm (all segments), 12.7% had narrowing of the middle segment However, according to classification, mid-segment lesions that spread to the distal segment are counted as distal lesions, so we analyzed according to locations of the proximal and distal segments of the common body 3.2.5.2 Parameters on IVUS of the left main coronary artery Table 3.19 Parameters of diameter and area of lesions on IVUS Parameters (M ± SD) Proximal Shaft Distal 12 n= 55 n = 51 n = 55 MLD (mm) 2.52 0.11 2,91 0.23 2.70 0.08 MLA (mm2) 5.5 0.14 5,32 0.46 5.47 0.09 Table 3.21 Parameters of atheroma on IVUS Parameters (n = 55) Atneroma area (M ± SD; Proximal Shaft Distal n= 55 n = 51 n = 55 11,1 1,3 10,4 1,4 10,7 0,6 64,7 3,2 59,4 3,4 63,6 1,7 mm ) Atheroma burden (M ± SD; %) Atheroma characteristics (n; %) Fibrosis (9,1) (5,5) (14,5) Soft (5,5) 12 (21,8) Calcified 0 17 (30,9) Mix (5,5) 17 (30,9) Table 3.22 Parameters of calcium arch and remodelling Parameters(n = 55) o Calcium arch ( ) Proximal Shaft Distal n= 55 n = 51 n = 55 110 69 69,14 25,34 63,88 12,06 Remodelling (n; %) Negative (3,6) 21 (38,2) Intermediate 30 (53,5) 48 (87,3) 27 (49,1) Positive 21 (38,2) (9,1) (12,7) 3.2.5.3 Comparison of the LM assessment between coronary angiography and IVUS 13 Table 3.24 Comparison of the LM assessment between coronary angiography and IVUS Parameters N = 55 Angiography IVUS p Proximal MLD M ± SD (mm) 3.9 0.9 4.2 0.7 < 0.001 2.7 0.9 3.1 0.8 < 0.001 Distal MLD M ± SD (mm) Proximal LAD disorders (n; 52 (94.5) 47 - %) (90.4) Proximal LCx disorders (n; %) 20 (36.4) 12 < (21.8) Kappa = 0.001 0.57 Bifurcation related lesions (n; 20 (36.4) 12 < 0.001 %) (21.8) Kappa = 0.57 Assessment of bifurcation disorder between IVUS and angiography had fairy good consensus Kappa = 0.57 (p 10% Both LAD and LCx flow achieved TIMI Thus, all patients were successful in imaging 3.3.4.2 Clinical success After intervention, the level of chest pain improved statistically with p