Reply
Azeem Latib, MB, BCh,
Antonio Colombo, MD*
We appreciate Dr. Movahed's interest in our review (1). The 6 bifurcation classifications referenced in our review (2–7) were developed to allow researchers and clinicians to describe in a standardized way the distribution of plaque at the bifurcation. As can be seen from Figure 1
(8), all 6 describe the distribution of plaque in the 3 limbs of a bifurcation in a similar way and are thus easily comparable. The reason for our choice to emphasize the use of the Medina et al. (7) classification is that it does not require the interventionalist to commit to memory a complex mnemonic (9) to describe a bifurcation lesion and it gives the reader an immediate mental picture of the distribution of plaque at the bifurcation. We are pleased to see that our decision to emphasize the Medina classification is supported by Louvard et al. (10) of the European Bifurcation Club who have attempted to provide the first consensus document on bifurcation classifications, which states: "The classification by Medina et al. (7) is straightforward and does not need to be memorized even though it provides all the information contained in the others." Despite these refinements, all current classifications have inherent limitations. Importantly, they do not describe a number of anatomical features that will influence and affect the interventional approach to a bifurcation lesion, such as extent and length of disease on the side branch (limited to the ostium or involving the vessel beyond the ostium), its size ( 2.5 mm of reference diameter) and distribution, and the angle between the main and side branches (1). All of these factors are essential and need to be documented, but their inclusion in a bifurcation classification would again increase the complexity of the classification and limit is clinical utility. Thus we would echo the words of Medina et al. (7) that the main purpose of a bifurcation classification is that it "allows for homogenous terminology when comparing different series and techniques" (7). The further issue relates to whether a bifurcation classification can predict outcomes or determine the interventional approach. A major part of the complexity of treating bifurcations arises from the fact that bifurcations vary not only in anatomy (plaque burden, location of plaque, angle between branches, diameter of branches, bifurcation site) but also in the dynamic changes that occur during the procedure, such as plaque shift and dissection. As a result, no 2 bifurcations are identical and there is no single strategy that can be applied to every bifurcation. For all these reasons we are relatively skeptical about the value of adding another classification system for bifurcation lesions. Nevertheless, the letter by Dr. Movahed has given an opportunity, for the interest of the reader, to look into a new descriptive way of classifying bifurcations. Only experience and direct application will tell us about the incremental value of this new piece of information.
View larger version (15K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1 The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery
Various classifications of bifurcations according to plaque distribution: Duke (2), Sanborn (3), Safian (5), Lefevre (4), SYNTAX (6), and Medina (7). Reproduced with permission from Colombo et al. (8). Double box indicates a true bifurcation lesion. Medina (7) class: 1. main branch proximal lesion >50% = 1, <50% = 0; 2. main branch distal lesion >50% = 1, <50% = 0; 3. side branch lesion >50% = 1, <50% = 0.
|
|
* EMO Centro Cuore Columbus, Via Buonarroti 48, 20145 Milan, Italy (Email: info{at}emocolumbus.it).
 |
REFERENCES
|
|---|
- Latib A, Colombo A. Bifurcation disease: what do we know, what should we do? J Am Coll Cardiol Intv 2008;1:218-226.[Abstract/Free Full Text]
- Popma J, Leon M, Topol EJ. Atlas of Interventional CardiologyPhiladelphia, PA: Saunders; 1994.
- Spokojny AM, Sanborn TM. The bifurcation lesionIn: Ellis SG, Holmes DR, editors. Strategic Approaches in Coronary Intervention. Baltimore, MD: Williams and Wilkins; 1996. pp. 288.
- Lefevre T, Louvard Y, Morice MC, et al. Stenting of bifurcation lesions: classification, treatments, and results Catheter Cardiovasc Interv 2000;49:274-283.[CrossRef][Web of Science][Medline]
- Safian RD. Bifurcation lesionsIn: Safian RD, Freed M, editors. Manual of Interventional Cardiology. Royal Oak, MI: Physicians' Press; 2001. pp. 221-236.
- Sianos G, Morel MA, Kappetein AP. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease Eurointervention 2005;1:219-227.
- Medina A, Suarez de Lezo J, Pan M. A new classification of coronary bifurcation lesions Rev Esp Cardiol 2006;59:183.[CrossRef][Web of Science][Medline]
- Colombo A, Latib A. Ostial and bifurcation lesionsIn: Moliterno DJ, editor. CathSAP 3 Cardiac Catheterization and Interventional Cardiology Self-Assessment Program. Washington, DC: American College of Cardiology; 2008. pp. 665-677.
- Movahed MR, Stinis CT. A new proposed simplified classification of coronary artery bifurcation lesions and bifurcation interventional techniques J Invasive Cardiol 2006;18:199-204.[Medline]
- Louvard Y, Thomas M, Dzavik V, et al. Classification of coronary artery bifurcation lesions and treatments: time for a consensus! Catheter Cardiovasc Interv 2008;71:175-183.[CrossRef][Web of Science][Medline]
Related Article
-
What We Should Know About Bifurcation Disease
- Mohammad Reza Movahed
J. Am. Coll. Cardiol. Intv. 2008 1: 595-596.
[Full Text]
[PDF]
|
Top
REFERENCES