A randomized comparison of sirolimus- vs. paclitaxel-eluting stents for treatment of bifurcation lesions by single stent and kissing balloon: results of the SINGLE KISS trial.

BACKGROUND: In the treatment of bifurcation lesions, routine stenting of both branches has thus far failed to demonstrate a clear clinical advantage over a provisional one-stent strategy. On the other hand, large scale data evaluating different stent types for clinical outcomes after one-stent treatment with final kissing inflation (FKI) of bifurcation lesions is also limited. This prospective study evaluated the clinical and angiographic outcomes of paclitaxel-eluting stents (PES) vs. sirolimus-eluting stents (SES) in single crossover main branch stenting followed by FKI in patients with bifurcation lesions. METHODS: We randomized 800 patients with single bifurcation lesions to PES (n=400) and SES (n=400) groups. RESULTS: Crossover rates to the two-stent strategy were low in both groups (PES 1.5%, SES 2.8%; p=0.23). At 1 year, there was no significant difference in the primary endpoint of this study, target lesion revascularization rate (PES 3.8%, SES 3.2%, hazard ratio 0.83; 95% confidence interval 0.39 to 1.76; p=0.62). Stent thrombosis occurred in only 1 case in the SES group after 282 days. At 9 months, a total of 593 patients underwent quantitative coronary measurement. The main branch restenosis rate in the PES group was significantly higher than that of the SES group (PES 12.2%, SES 5.5%; p=0.004), however both groups exhibited similar high side branch restenosis rates (PES 17.2%, SES 19.3%; p=0.6). CONCLUSIONS: In patients with bifurcation lesions, a single stent strategy using PES and SES with FKI indicated similar 1 year clinical outcomes and safety profiles.

Acute coronary syndrome due to coronary artery compression by a metastatic cardiac tumor.

A 60-year-old female without coronary risk factors was admitted to the hospital with ST-elevation acute coronary syndrome (ACS). She had previously suffered breast cancer and received radical mastectomy followed by chemotherapy and radiation. Emergent coronary angiography showed an occlusion of the proximal left anterior descending coronary artery (LAD) and coronary angioplasty was performed. Coronary computed tomography (CT) angiography (CTA) disclosed a tumor invading the left ventricular anterior wall and surrounding the coronary artery. Myocardial single-photon-emission CT (SPECT) using 123I-BMIPP showed a defect in the same portion. A fusion image of the CTA and the SPECT delineated a tumor surrounding the coronary artery. She finally died two months later from a terminal condition. Autopsy demonstrated a tumor involving the left ventricular anterior wall and surrounding the LAD. Pathology of the affected LAD showed only fibrous plaque without vulnerable plaque, thrombus, or tumor invasion to the coronary wall. Thus, compression of the coronary artery by the metastatic tumor was the most likely mechanism of ACS.

Cardiac sarcoidosis culminating in severe biventricular failure.

A 59-year-old woman with a history of lung sarcoidosis developed general edema and exertional dyspnea. An electrocardiogram showed first-degree atrioventricular block with complete right bundle branch block. Chest X-ray showed cardiomegaly. Echocardiography showed diffuse and severe hypokinesis of the left ventricle (LV) and biventricular enlargement with severe tricuspid regurgitation. Myocardial scintigraphy disclosed a perfusion defect at the ventricular septum and hypoperfusion at the posterior wall and the apex. On cardiac catheterization, pulmonary capillary wedge pressure, right ventricular, and right atrial pressures were elevated. Coronary angiograms were normal. Myocardial biopsy of the right ventricle histologically revealed epithelioid cell granuloma with infiltration of fibrous cells. The patient's symptom and LV function were improved with conventional medical therapy for heart failure. This is a rare case of cardiac sarcoidosis resulting in biventricular failure.