title: Impact of 3-dimensional bifurcation angle on 5-year outcome of patients after percutaneous coronary intervention for left main coronary artery disease: a substudy of the SYNTAX trial (synergy between percutaneous coronary intervention with taxus and cardiac surgery).
abstract: OBJECTIVE
  This study sought to investigate the impact of left main coronary artery (LMCA) 3-dimensional (3D) bifurcation angle (BA) parameters on 5-year clinical outcomes of patients randomized to LMCA percutaneous coronary intervention (PCI) in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial.
  
  
  BACKGROUND
  BA can affect outcome after bifurcation PCI; 3D angiographic analysis provides reliable BA measurements.
  
  
  METHODS
  The diastolic distal BA (between left anterior descending and left circumflex) and its systolic-diastolic range were explored. A stratified post-hoc survival analysis was performed for 5-year major adverse cardiac and cardiovascular events (MACCE) (all-cause death, cerebrovascular accident, myocardial infarction, or repeat revascularization), a safety endpoint (all-cause death, cerebrovascular accident, or myocardial infarction), and repeat revascularization. Analysis was performed in patients where 3D BA was available pre- and post-PCI.
  
  
  RESULTS
  Of 266 patients eligible for analysis, 185 underwent bifurcation PCI (group B); 1 stent was used in 75 patients (group B1), whereas ≥2 stents were used in 110 patients (group B2). Stratification across pre-PCI diastolic distal BA tertiles (<82°, 82° to 106°, ≥107°) failed to show any difference in MACCE rates either in the entire study population (p = 0.99) or in group B patients (p = 0.78). Group B patients with post-PCI systolic-diastolic range <10° had significantly higher MACCE rates (50.8% vs. 22.7%, p < 0.001); repeat revascularization and safety endpoint rates were also higher (37.4% vs. 15.5%, p = 0.002, and 25.4% vs. 14.1%, p=0.055, respectively). Post-PCI systolic-diastolic range <10° was an independent predictor of MACCE (hazard ratio: 2.65; 95% confidence interval: 1.55 to 4.52; p < 0.001) in group B patients.
  
  
  CONCLUSIONS
  A restricted post-procedural systolic-diastolic distal BA range resulted in higher 5-year adverse event rates after LMCA bifurcation PCI. Pre-PCI BA value did not affect the clinical outcome.
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Chrysafios
authors.initials: C
authors.lastname: Girasis
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Roberto
authors.initials: R
authors.lastname: Diletti
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Takashi
authors.initials: T
authors.lastname: Muramatsu
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Christos V
authors.initials: CV
authors.lastname: Bourantas
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Yoshinobu
authors.initials: Y
authors.lastname: Onuma
authors.affiliation: Department of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.affiliation: Division of Cardiology, Evanston Hospital, Evanston, Illinois.
authors.forename: Ted E
authors.initials: TE
authors.lastname: Feldman
authors.affiliation: Cardialysis B.V., Rotterdam, the Netherlands.
authors.forename: Marie-Angele
authors.initials: MA
authors.lastname: Morel
authors.affiliation: Cardialysis B.V., Rotterdam, the Netherlands.
authors.forename: Gerrit-Anne
authors.initials: GA
authors.lastname: van Es
authors.affiliation: Boston Scientific Corporation, Natick, Massachusetts.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Dawkins
authors.affiliation: Department of Cardiology, Institut Cardiovasculaire Paris Sud, Massy, France.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands. Electronic address: p.w.j.c.serruys@erasmusmc.nl.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
mesh_terms: D000368:Aged; D002317:Cardiovascular Agents / Q000008:administration & dosage*; D016009:Chi-Square Distribution; D017023:Coronary Angiography / Q000379:methods*; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D003328:Coronary Thrombosis / Q000209:etiology / Q000401:mortality; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D054855:Drug-Eluting Stents; D006801:Humans; D021621:Imaging, Three-Dimensional; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D017239:Paclitaxel / Q000008:administration & dosage*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011857:Radiographic Image Interpretation, Computer-Assisted; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents; D017239:Paclitaxel
keywords: 2-dimensional; 2D; 3-dimensional; 3D; BA; CI; HR; LMCA; MACCE; MI; PCI; QCA; SB; SDR; bifurcation angle; clinical outcomes; confidence interval(s); hazard ratio(s); left main coronary artery; major adverse cardiac and cardiovascular events; myocardial infarction; percutaneous coronary intervention; quantitative coronary angiography; side branch; systolic-diastolic range