Clinical and Procedural Outcomes of Ostial Left Anterior Descending Artery Intervention With or Without Crossover to Left-main

Aim of the work:

1. Evaluate the clinical and procedural outcomes in patients undergoing percutaneous intervention (PCI) for ostial left anterior descending (LAD) lesions while comparing the outcomes between those treated with a stent crossing over (CO) to the left main (LM) versus ostial stenting (OS) alone.
2. Define predictors of success in Ostial LAD lesion PCI.

Patients and methods:

1)Patients:

Inclusion criteria:

1. Patients with Significant ostial LAD >50% stenosis within 5mm from ostium
2. Either chronic coronary syndrome (CCS) (ongoing symptoms despite medical therapy) or acute coronary syndrome (ACS) patients.
3. De-novo lesions.

Exclusion Criteria:

1. Those with coronary angiography results such as: (significant disease of the LM more than 40% or ostial left circumflex (LCX) greater than 50%).
2. Patients with protected LM.
3. In adherence to a dual antiplatelet regimen by enrolled patients within the first 12 months after the procedure.

Methods:

It is prospective cohort study on patients in Assiut university heart hospital catheterization lab. with ostial LAD lesion (median, 0.1.0) that will include baseline demographic, clinical, and angiographic data.

All patients will be thoroughly informed about the procedure's possible risks and benefits, as well as alternative therapeutic choices prior to the intervention, and obtained signed consent from all participants.

In all cases, percutaneous coronary interventions and stenting will be performed according to standard techniques either trans-radial or transfemoral approach.

All patients pre-treated with dual antiplatelet therapy, including aspirin and loading dose of either clopidogrel or ticagrelor.

Unfractionated heparin will be given to all patients during the procedure with a target activated clotting time of >250 seconds.

Two main strategies for treating ostial LAD lesions will be used and analyzed in this study:

1. Crossover stenting (CO) from the LM into the LAD, using standard provisional bifurcation techniques and proximal stent optimization (POT), where post dilatation was typically performed.

2. Ostial stenting of the LAD (OS) with no crossover back to the LM. The choice of the technique and the use of intravascular imaging (IVUS) depends on the discretion of the treating interventional cardiologist.

   • Patients included in our study will be subjected to:

     1. Detailed History.
     2. General and complete cardiac examination.
     3. 12-Leads ECG.
     4. Detailed Echocardiography. \ 5)Coronary angiography findings including:

A. Quantitative angiographic measurements:

1. Reference diameter (mm).
2. Diameter stenosis (%).
3. Lesion length and distance from LAD ostium(mm).
4. Medina classification.
5. Bifurcation angle.

B. Techniques used:

1. Ostial LAD stenting.
2. Crossover with LM. C. IVUS or angiography guided PCI.

Basic IVUS Measurement

The following basic measurements may be made with IVUS:

1. Minimum lumen diameter (MLD): the shortest diameter via lumen's center.
2. Minimum lumen area (MLA): the smallest area via the lumen's center.
3. Stenosis area: (reference lumen area - stenosis lumen area)/reference lumen area.
4. Plaque burden: (EEM area - lumen area) / EEM area .

D. Contrast volume (ml) E. Fluoroscopy time (min.) Data will be gathered during hospital admission and follow-up. In-hospital mortality and morbidity will be documented.

Follow up:

During the hospital admission:

Both techniques used by our operators in these cases will be overviewed and evaluated as regarding:

1. Angiographic success in target vessel defined as (residual stenosis ≤ 30% and TIMI flow grade 3) and side branch (SB) angiographic success (residual stenosis ≤ 50% and TIMI flow grade 3).
2. Procedural Success A successful PCI should achieve angiographic success without in-hospital major clinical complications (e.g., cardiac death, target vessel related MI, emergency coronary artery bypass surgery) during hospitalization
3. Clinical Success in the short term, a clinically successful PCI includes anatomic and procedural success with relief of signs and/or symptoms of myocardial ischemia after the patient recovers from the procedure.

Information about the in-hospital outcome will be obtained from an electronic clinical database for patients maintained at our institution and by review of hospital records for those discharged to referring hospitals.

Short term follow up (after 6 months):

1. Per our institutional protocol, clinical follow-up will be performed by physicians in outpatient clinic after 4 months.
2. Control coronary angiography will be scheduled at 6 months to all cases.
3. Information on the occurrence of cardiac death, target vessel related myocardial infarction or repeated revascularization during period of follow-up will be collected by consulting our institutional electronic database and by contacting referring physicians and institutions and all living patients.