From October 27 to 31, 2021, the 32nd Great Wall International Congress of Cardiology 2021 was successfully held in the form of online+offline.Professor Hyo-Soo Kim of the Cardiovascular Center of Seoul National University Hospital gave a presentation on “Double stent strategy: Inspiration from Cobis III”.He is the lead author of HOST-Reduce-Polytech-ACS and HOST-EXAM trials,this journal invites him to share his experience in the treatment of bifurcation lesions.
International Circulation:Bifurcation lesions are major difficulties which we are facing in the field of interventional treatment of coronary heart disease. In your opinion, what are the main challenges in its interventional treatment?
Prof.Hyo-Soo Kim:Bifurcation PCI is a really important field in interventional cardiology. The other important area that we have to solve is chronic total occlusion, because CTO intervention requires long term experience and skill, and CTO PCI is accompanied by serious complications such as operational coronary artery. Thus, I think CTO intervention is also a very important area in addition to bifurcation PCI.
International Circulation:For true bifurcation lesions, which strategy should we adopt, single stent or double stent? What messages can we take home from the latest results of COBIS III study?
Prof.Hyo-Soo Kim:In general, one stent technique is sufficient to get satisfactory clinical outcome of the patients. Because if you implant two stents in the bifurcation area, it is inevitable to get crushed metal or double layers or triple layers of metal in the bifurcation area where blood flow is turbulent, leading to high possibility of thrombosis. Thus, in general, single stent is always associated with better clinical outcomes than two stent technique.
But in some patients who require two stent technique, for example, the side branch is big enough to supply more than 10 percent of myocardium. In that case, treatment of side branch is accompanied by better outcomes for the patient. For this big side branch, we have to do two stent technique if the side branch lesion is critical and long segment. Thus, in this situation, we have to consider which technique is best among several different technologies of two stent technique. The second issue is: how long do we have to maintain dual antiplatelet therapy(DAPT)?
International Circulation:Based on your experience and relevant research results, how do you think we should better select the optimal strategy for bifurcation lesions in clinical practice?
Prof.Hyo-Soo Kim:Among several different two stent techniques, we analyzed the clinical outcomes of four different two stent techniques. The majority of techniques used in South Korea is mini crush technique. The second dominant strategy is T stent. The third and fourth are minor technology techniques such as culotte stenting or the kissing stent. We analyzed the four year outcomes of the patients treated with one of four different two stent techniques. Overall, comparable to each other, the clinical outcomes were not so different. Because in some techniques, such as culotte and kissing stent technique, this emphasized were too few. But anyway, at the present moment, when we analyzed about 450 patients treated with two stent technique, there was no significant difference in clinical outcomes among the four different techniques.
Regarding the second issue, how long do we have to maintain dual antiplatelet therapy? We analyzed the patients who experienced recurrent events versus patients who did not have any recurrent events. The major difference between the two was duration of DAPT. Thus, when we analyzed the patients into two groups, DAPT lasted 2.5 years versus more than 2.5 years. There was a huge difference of the recurrent event. That was really high in patients with shorter DAPT.
In our previous COBIS II registry, we also got the similar message. When we analyzed left lane bifurcation lesion treated with two stent technique, there was a huge difference of clinical outcomes between DAPT less than 1 year versus more than 1 year. Longer DAPT is associated with better clinical outcomes after a left main and bifurcation PCI. Thus, in general, we can shorten DAPT down to six, three, or even one month depending on the bleeding plus diastasis of the patients. But in this subcohort, such as bifurcation lesion treated with two stent technique, we have to continue DAPT if the patients can tolerate it.
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