Classification and treatment of coronary artery bifurcation lesions: putting the Medina classification to the test.
BACKGROUND
Coronary bifurcation lesions are common, difficult to treat, and associated with poorer outcomes compared to non-bifurcation lesions. The Medina classification has been widely adopted as the preferred system to classify bifurcation lesions, however there have been little efforts to characterize this metric. The objective of this study was to characterize the inter-observer variability of the Medina classification and examine its contribution to treatment selection strategy.


METHODS
We invited 150 interventional cardiologists from the United States and Europe to complete an online survey evaluating 12 freeze frame coronary angiograms of bifurcation lesions. Each respondent was asked to characterize the bifurcation lesions using the Medina classification and other metrics including side branch vessel size and angle. Respondents were asked to designate either a provisional (1 stent) or dedicated (2 stent) treatment strategy. 'Complex' lesions were defined as Medina scores 1.1.1, 0.1.1, or 1.0.1.


RESULTS
A total of 49 interventional cardiologists responded. In 7 of the 12 angiograms evaluated, there was >75% agreement regarding lesion classification using the Medina system. There was moderate inter-observer agreement when using Medina to classify lesions as 'Complex' vs. 'non-Complex'. 'Complex' bifurcation designation and side branch size were predictive of selection of a dedicated treatment strategy, whereas side branch angle was not.


CONCLUSIONS
The Medina classification is a useful tool in characterizing coronary bifurcation lesions. For the majority of the angiograms evaluated there was good inter-observer agreement in lesion classification using the Medina system. 'Complex' bifurcation designation and side branch size were predictive of selection of a dedicated treatment strategy.
Section of Cardiology, Dartmouth-Hitchcock Medical Center/Dartmouth Medical School, Lebanon, NH 03756, USA. david.m.zlotnick@hitchcock.org
David M
DM
Zlotnick
Vijay S
VS
Ramanath
Jeremiah R
JR
Brown
Aaron V
AV
Kaplan
D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000145:classification* / Q000000981:diagnostic imaging* / Q000628:therapy; D003661:Decision Support Techniques; D005060:Europe; D019538:Health Care Surveys; D006801:Humans; D020407:Internet; D016015:Logistic Models; D015999:Multivariate Analysis; D015588:Observer Variation; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D014481:United States