Samin K Sharma

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (197)1305.11 Total impact

  • Journal of the American College of Cardiology 10/2015; 66(15):B84. DOI:10.1016/j.jacc.2015.08.233 · 16.50 Impact Factor
  • Samin K Sharma · Usman Baber
    Journal of the American College of Cardiology 09/2015; 66(9):1046-9. DOI:10.1016/j.jacc.2015.07.015 · 16.50 Impact Factor
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    ABSTRACT: Background: Randomized clinical trials evaluating the role of thrombus aspiration (TA) in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) have yielded contrasting results. Therefore, the efficacy and safety of TA in STEMI is unclear. Objective: We sought to evaluate the efficacy and safety of TA during PPCI for STEMI compared with conventional PPCI alone. Methods: We included study-level data from 25 randomized controlled trials (RCTs), involving 21,733 patients with STEMI and PPCI. The primary efficacy endpoint was MACE according to study definitions; the primary safety endpoint was stroke. Results: The mean weighted follow-up time across studies was 8.2 months. Compared with conventional PPCI, TA was associated with significant lower risk for MACE (Relative Risk [RR]: 0.91; 95% Confidence Interval [CI]: 0.83 – 1.00; p = 0.042). However, this benefit in MACE was counterbalanced by a significant increase in the risk for stroke (RR: 1.58; 95% CI: 1.11 – 2.25; p = 0.01). There were no differences in the risk of myocardial infarction (RR: 0.94; 95% CI: 0.78 – 1.12; p = 0.49), target vessel revascularization (RR: 0.93; 95% CI: 0.82 – 1.04; p = 0.20) and definite or probable stent thrombosis (RR: 0.84; 95% CI: 0.66 – 1.07; p = 0.15). TA was associated with an ostensible lower risk for all-cause mortality, which did not reach statistical significance (RR: 0.88; 95% CI: 0.78 – 1.00; p = 0.059). Conclusions: Compared with conventional PPCI for STEMI, adjunctive TA reduces the risk of subsequent MACE. However, the benefit in MACE is counterbalanced by an increased risk in stroke. Considering the above potential risks and benefits, TA should be considered in selected patients lesions rather than routinely.
    Catheterization and Cardiovascular Interventions 07/2015; 66(15). DOI:10.1016/j.jacc.2015.08.920 · 2.11 Impact Factor
  • JACC. Cardiovascular imaging 06/2015; DOI:10.1016/j.jcmg.2015.02.018 · 7.19 Impact Factor
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    ABSTRACT: This study sought to assess the mechanistic effect of rotational atherectomy (RA) and orbital atherectomy (OA) on heavily calcified coronary lesions and subsequent stent placement using optical coherence tomography (OCT). RA and OA are two main approaches to ablate coronary calcium. While small case reports have described the mechanistic effect of RA in calcified coronary lesions, there has been no imaging study to assess the effect of OA on coronary artery architecture and/or compare the effects of two atherectomy devices. This study analyzed 20 consecutive patients with OCT imaging performed after atherectomy and after stent implantation, RA (n = 10) and OA (n = 10). Postatherectomy OCT analysis identified tissue modification with deep dissections in around a third of lesions after RA and OA; however, post OA dissections ("lacunae") were significantly deeper (1.14 vs. 0.82 mm, P = 0.048). Post OA/RA lesions with dissections had significantly higher percentage of lipid rich plaques and smaller calcification arcs as compared to plaques without dissections. Stents after OA were associated with a significantly lower percent of stent strut malapposition than post RA stents (4.36 vs. 8.02%, P = 0.038). Although the incidence of dissections was comparable between RA and OA cases, OA resulted in deeper tissue modifications (lacunae) as shown by OCT imaging. The finding might provide an explanation for a better stent apposition after OA as compared to RA. Their impact on long-term outcome needs to be determined. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 05/2015; DOI:10.1002/ccd.26000 · 2.11 Impact Factor
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    ABSTRACT: Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) are at elevated risk for bleeding and thromboembolic ischemic events. Currently, guidelines on antithrombotic treatment for these patients are based on weak consensus. We describe patterns and determinants of antithrombotic prescriptions in this population. The Antithrombotic Strategy Variability in Atrial Fibrillation and Obstructive Coronary Disease Revascularized with PCI Registry was an international observational study of 859 consecutive patients with AF who underwent PCI from 2009 to 2011. Patients were stratified by treatment at discharge with either dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) or triple therapy (TT; warfarin plus DAPT). Bleeding and thromboembolism risks were assessed by the HAS-BLED and CHADS2 scores, respectively, and predictors of TT prescription at discharge were identified. Major adverse cardiovascular events and clinically relevant bleeding (Bleeding Academic Research Consortium score ≥2) at 1-year follow-up were compared across antithrombotic regimens. Compared with patients on DAPT (n = 488; 57%), those given TT (n = 371; 43%) were older, with higher CHADS2 scores, lower left ventricular ejection fraction, and more often had permanent AF, single-vessel coronary artery disease, and bare-metal stents. In multivariate analysis, increasing thromboembolic risk (CHADS2) was associated with a higher rate of TT prescription at discharge (intermediate vs low CHADS2: odds ratio 2.2, 95% confidence interval [CI] 2.0 to 3.3, p <0.01; high vs low CHADS2: odds ratio 1.6, 95% CI 2.6 to 4.3, p <0.01 for TT). However, there was no significant association between bleeding risk and TT prescription in the overall cohort or within each CHADS2 risk stratum. The rates of major adverse cardiovascular events were similar for patients discharged on TT or DAPT (20% vs 17%, adjusted hazard ratio 0.8, 95% CI 0.5 to 1.1, p = 0.19), whereas the rate of Bleeding Academic Research Consortium ≥2 bleeding was higher in patients discharged on TT (11.5% vs 6.4%, adjusted hazard ratio 1.8, 95% CI 1.1 to 2.9, p = 0.02). In conclusion, the choice of the intensity of antithrombotic therapy correlated more closely with the risk of ischemic rather than bleeding events in this cohort of patients with AF who underwent PCI. Copyright © 2015 Elsevier Inc. All rights reserved.
    The American journal of cardiology 04/2015; 116(1). DOI:10.1016/j.amjcard.2015.03.033 · 3.28 Impact Factor
  • JACC Cardiovascular Imaging 03/2015; 8(3). DOI:10.1016/j.jcmg.2015.01.002 · 7.19 Impact Factor
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    ABSTRACT: The aim of this study is to compare the relative merits of optical coherence tomography (OCT), intravascular ultrasound (IVUS), and near infrared spectroscopy (NIRS) in patients with coronary artery disease for the prediction of periprocedural myocardial infarction (MI). Although several individual intravascular imaging modalities have been employed to predict periprocedural MI, it is unclear which of the imaging tools would best allow prediction of this complication. We retrospectively analyzed 110 patients who underwent OCT, IVUS, and NIRS. Periprocedural MI was defined as a post-procedural cardiac troponin I (cTnI) elevation above 3× the upper limit of normal; analysis was also performed for cTnI ≥5× the upper limit of normal. cTnI ≥3× was observed in 10 patients (9%) and 8 patients had cTnI ≥5×. By OCT, minimum cap thickness was significantly lower (55 vs. 90 μm, p < 0.01), and the plaque burden by IVUS (84 ± 9% vs. 77 ± 8%, p < 0.01) and maximum 4-mm lipid core burden index by NIRS (556 vs. 339, p < 0.01) were greater in the cTnI ≥3× group. Multivariate logistic regression analysis identified cap thickness as the only independent predictor for cTnI ≥3× the upper limit of normal (odds ratio [OR]: 0.90, p = 0.02) or cTnI ≥5× (OR: 0.91, p = 0.04). If OCT findings were excluded from the analysis, plaque burden (OR: 1.13, p = 0.045) and maximum 4-mm lipid core burden index (OR: 1.003, p = 0.037) emerged to be the independent predictors. OCT-based fibrous cap thickness is the most important predictor of periprocedural MI. In the absence of information about cap thickness, NIRS lipid core or IVUS plaque burden best determined the likelihood of the periprocedural event. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 03/2015; 65(10):A1810. DOI:10.1016/S0735-1097(15)61810-1 · 16.50 Impact Factor
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    ABSTRACT: Background: The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is unclear, and its risks and benefits may vary according to DES generation. Objectives: The goal of this study was to evaluate safety and efficacy of DAPT after DES implantation. Methods: We included randomized controlled trials (RCTs), which tested different duration of DAPT after DES implantation: shorter DAPT (S-DAPT) defined as the per-protocol minimum duration of DAPT after the procedure and longer DAPT (L-DAPT) defined as the per-protocol period of more prolonged DAPT. Primary efficacy and safety outcomes were definite/probable stent thrombosis (ST) and clinically significant bleeding (CSB), respectively. Results: Ten RCTs (n = 32,135) were included. Compared with L-DAPT, S-DAPT had an overall higher rate of ST (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.26-2.32; p = 0.001). The effect on ST of S-DAPT was attenuated with use of second-generation DES (OR: 1.54; 95% CI: 0.96-2.47) compared with use of first-generation DES (OR: 3.94, 95% CI: 2.20-7.05; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of CSB (OR: 0.63; 95% CI: 0.52-0.75; p < 0.001). Finally, a numerically lower all-cause mortality was observed with S-DAPT (OR: 0.87; 95%CI: 0.74-1.01; p = 0.073). Conclusions: S-DAPT had overall lower rates of bleeding yet higher rates of ST compared with L-DAPT; the latter effect was significantly attenuated with use of second-generation DES, although this analysis may have been limited by the different DAPT durations among studies. All-cause mortality was numerically higher with L-DAPT without reaching statistical significance. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications.
    Journal of the American College of Cardiology 02/2015; 65(13). DOI:10.1016/j.jacc.2015.01.039 · 16.50 Impact Factor
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    ABSTRACT: To evaluate the efficacy of hemodynamic support using Impella 2.5 (IR2.5) vs intra-aortic balloon pump (IABP) in patients with 3-vessel coronary artery disease (3VD). PROTECT II demonstrated favorable 90-day outcomes in patients with impaired LVEF and left main or 3VD undergoing PCI with hemodynamic support with IR2.5 compared to IABP. It is unclear if this was due to a specific benefit in a patient sub-population and if certain patients may derive particular benefit from PCI with IR2.5 support. Patients in PROTECT II were stratified upon enrollment into the left main/last patent vessel or 3VD subgroups and randomized to IR2.5 or IABP within those groups. Patients in the 3VD substratum were required to have LVEF ≤30%. Among the 3VD subgroup (n = 325 patients; IR2.5 167, IABP 158) patients were well matched, except for prior heart failure or CABG, which were more common in the IR2.5 group (both P ≤ 0.01). Mean number of lesions treated was 3.0 ± 1.5 vs. 2.9 ± 1.4 (P = 0.61). At 30 days after PCI, patients that received IR2.5 compared to IABP support trended toward a reduction in incidence of major adverse events (MAE): 32.9% vs. 42.4% (P = 0.078). At 90 days after PCI, there was a significant difference favoring IR2.5 for incidence of MAE: 39.5% vs. 51.0% (P = 0.039), with this effect being consistent across multiple clinical subgroups. Use of IR2.5 was an independent predictor of improved 90-day outcomes. Patients with 3VD and reduced LVEF show improved outcomes when PCI is performed with IR2.5 hemodynamic support. (J Interven Cardiol 2015;28:32-40). © 2014, Wiley Periodicals, Inc.
    Journal of Interventional Cardiology 02/2015; 28(1):32-40. DOI:10.1111/joic.12166 · 1.18 Impact Factor
  • Journal of Neurology 12/2014; 261(12):2449-50. DOI:10.1007/s00415-014-7510-9 · 3.38 Impact Factor
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    ABSTRACT: Percutaneous coronary intervention (PCI) of true bifurcation lesions (Medina classification 1, 1, 1; 1, 0, 1; or 0, 1, 1) is challenging and may involve either a 1-stent strategy with provisional side branch stenting, or a 2-stent strategy. Diabetes mellitus is associated with greater atherosclerotic burden and higher incidence of bifurcation lesions, and unfavorable outcomes after PCI. It is unknown whether use of newer everolimus-eluting stent (EES) implantation impacts relative outcomes of 1-stent and 2-stent strategies in patients with diabetes. We performed a retrospective analysis of consecutive patients with diabetes mellitus and complex true bifurcation lesions (side branch diameter >2.0 mm) who underwent PCI with EES between February 2010 and December 2011. We grouped subjects based on initial treatment to a 1-stent (n = 81) or 2-stent (n = 54) strategy, and compared baseline characteristics, quantitative coronary angiography, and 1-year major adverse cardiovascular event (MACE) rates, defined as death, myocardial infarction, target lesion revascularization (TLR), or target vessel revascularization (TVR). Baseline characteristics were well matched. A 2-stent strategy was associated with larger side-branch reference vessel diameter at baseline and post PCI. In-hospital events included 1 periprocedural myocardial infarction in each group and no deaths. At 1 year, there was no significant difference between 1-stent and 2-stent strategies in TVR rates (6.2% vs 3.7%; P=.53), TLR (both 3.7%; P>.99), or MACE (7.4% vs 3.7%; P=.37). In this series of diabetic patients undergoing complex bifurcation PCI using EES implantation, there was no difference between 1-stent and 2-stent strategies with respect to ischemic events at 1 year.
    The Journal of invasive cardiology 12/2014; 26(12):619-623. · 0.95 Impact Factor
  • Ganesh Athappan · Samin K Sharma
    The Journal of invasive cardiology 12/2014; 26(12):638-639. · 0.95 Impact Factor
  • John D. Puskas · Amit Pawale · Samin K. Sharma
    JACC. Cardiovascular Interventions 11/2014; 7(11). DOI:10.1016/j.jcin.2014.06.013 · 7.35 Impact Factor
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    ABSTRACT: Current practice guidelines advocate culprit vessel intervention alone in patients with ST-elevation myocardial infarction (STEMI) found to have multi-vessel coronary disease during primary percutaneous coronary intervention (PCI). The debate on timing of non-infarct artery intervention has recently been reinvigorated by the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) trial, in which patients undergoing preventive-PCI of significant non-culprit lesions at the time primary PCI for STEMI had reduced rates of cardiac death, nonfatal myocardial infraction, and refractory angina. Given that previous literature has cautioned against multi-vessel PCI during STEMI, this raises the question of whether technical and pharmacological advances in PCI may have opened the door to safely revisit this issue with additional clinical rigor. The impact of STEMI pathophysiology on non-culprit plaque, how treatment of non-culprit lesions alters the natural history of coronary disease following STEMI, and whether this results in a clinical benefit, remain unclear; and much of the existing data is retrospective. Additionally, the PRAMI trial did not include a staged-PCI, leaving questions as to how this approach might fare compared to simultaneous preventive PCI. In this review, we discuss the pathophysiology of non-culprit plaque in STEMI, provide a summary of the existing literature on the topic, and discuss the PRAMI trial in the face of prior data and possible future directions for further study.
    JACC Cardiovascular Interventions 10/2014; 8(1). DOI:10.1016/j.jcin.2014.09.006 · 7.35 Impact Factor
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    ABSTRACT: Aims: To evaluate the relationship between lipid content and plaque morphometry as well as the process of lesion progression and regression in patients with significant coronary artery disease. Methods and results: The present study, using data from the YELLOW trial, was conducted in patients having significant coronary lesions (fractional flow reserve <0.8) who underwent serial intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) at baseline and after 7 weeks. For each coronary plaque (≥50% plaque burden that was ≥5 mm in length), we evaluated plaque characteristics and the extent of lipid-rich plaque [LRP, defined as the 4 mm long segment with the maximum lipid-core burden index (maxLCBI4 mm)] on NIRS. Among 66 patients (age 63.0 ± 10.1 years; 82% statin use at baseline), 94 plaques were identified. The extent of LRP at baseline was positively correlated with IVUS plaque burden (r = 0.317, P = 0.002). A large LRP (maxLCBI4 mm ≥500) was present only in plaques with a large plaque burden (≥70%). Multivariate analysis demonstrated that plaque burden was the best predictor of the extent of LRP (P < 0.001). In lesions with a large plaque burden and a large amount of LRP at baseline, a reduction in LRP was seen in all lesions in patients receiving intensive statin therapy (P = 0.004) without a significant change in plaque burden. Conclusions: Coronary lesions containing a large amount of LRP also had a large plaque burden. Short-term regression of LRP (without a change in plaque burden) was observed mainly in plaques with a large plaque burden and a large amount of LRP at baseline. Clinical trial registration: Unique identifier: NCT01567826.
    European Heart Journal – Cardiovascular Imaging 09/2014; 16(1). DOI:10.1093/ehjci/jeu169 · 2.65 Impact Factor
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    ABSTRACT: Objectives: The purpose of this study was to evaluate the 1-year clinical outcomes of more complex XIENCE V USA real-world patients with small versus non-small vessel lesions. Background: Patients with small vessel lesions undergoing coronary stent placement are at higher risk of major adverse cardiac events. Improved safety and efficacy of XIENCE V everolimus eluting stents (EES) have been previously demonstrated in selected low-risk small vessel populations in randomized clinical trials. Methods: The XIENCE V USA study was a condition of approval, single-arm study in unselected real-world patients. Baseline and 1-year clinical outcomes were compared between XIENCE V USA patients who received a single 2.5 mm stent (small vessel group, N = 838) and patients implanted with a single > 2.5 mm stent (non-small vessel group, N = 2015). Mean reference vessel diameter was 2.55 + 0.36 and 3.25 + 0.46 mm in the small and non-small vessel groups, respectively (p<0.001). Results: Small vessel group had more females, presented with a higher rate of diabetes, and had more complex lesion characteristics. The definite or probable ST rates analyzed using Kaplan-Meier method were low and not significantly different between the groups at 0.37% and 0.40% for the small and non-small vessel group (p=0.88), respectively. The composite rate of cardiac death or MI was comparable at 4.5% for the small and 5.1% for the non-small vessel 1 groups (p=0.57). The one-year target lesion revascularization rate was also comparable in the small vessel group (3.8% vs 3.0%, p=0.35) Conclusions: Despite gender difference, higher prevalence of diabetes and more complex lesions in the small vessel groups, the 1-year clinical outcomes were similar in both small and non-small vessel groups. These results demonstrate the therapeutic benefit of XIENCE V EES in a real-world all inclusive patient population with small vessel disease. © 2013 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 07/2014; 84(1). DOI:10.1002/ccd.25325 · 2.11 Impact Factor
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    ABSTRACT: Aims: The presence of thin-cap fibroatheromas (TCFA) is associated with high risk of acute coronary syndrome, hence their early detection may identify high-risk patients. In the present study we investigated the ability of a combined imaging catheter with near-infrared spectroscopy (NIRS) plus intravascular ultrasound (IVUS) to detect TCFA in patients with stable coronary artery disease. Methods and results: Optical coherence tomography (OCT) and combined NIRS-IVUS assessment were performed on identical coronary segments. IVUS analysis provided per-segment minimal cross-sectional area (CSA), plaque length (PL), plaque burden (PB), plaque volume (PV), and remodelling index (RI). OCT was used as the gold-standard reference to define TCFA (fibrous cap thickness <65 μm). Plaque lipid content was estimated by NIRS (lipid core burden index [LCBI]). OCT-defined TCFA was present in 18 of 76 segments. IVUS revealed that OCT-defined TCFA were positively remodelled lesions with greater PB and PV, smaller CSA, and longer PL, while NIRS revealed greater LCBI per 2 mm segment (LCBI2mm) (all p<0.001). Greatest accuracy for OCT-defined TCFA detection was achieved using LCBI2mm >315 with RI >1.046 as a combined criterion value. Conclusions: OCT-defined TCFA are characterised by positive vessel remodelling, high plaque burden and greater lipid core burden as assessed by dual NIRS-IVUS imaging.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 04/2014; 10(3). DOI:10.4244/EIJV10I3A53 · 3.77 Impact Factor
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    ABSTRACT: Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.
    Catheterization and Cardiovascular Interventions 04/2014; 62(4):485-98. DOI:10.1002/ccd.20081 · 2.11 Impact Factor
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    ABSTRACT: To compare the outcomes of initial one-stent (1S) versus dedicated two-stent (2S) strategies in complex bifurcation percutaneous coronary intervention (PCI) using everolimus-eluting stents (EES). PCI of true bifurcation lesions is technically challenging and historically associated with reduced procedural success and increased restenosis. Prior studies comparing initial one-stent (1S) versus dedicated two-stent (2S) strategies using first-generation drug-eluting stents have shown no reduction in ischemic events and more complications with a 2S strategy. We performed a retrospective study of 319 consecutive patients undergoing PCI at a single referral center with EES for true bifurcation lesions, defined by involvement of both the main vessel (MV) and side branch (SB). Baseline, procedural characteristics, quantitative coronary angiography and clinical outcomes in-hospital and at one year were compared for patients undergoing 1S (n=175) and 2S (n=144) strategies. Baseline characteristics were well-matched. 2S strategy was associated with greater SB acute gain (0.65±0.41mm vs. 1.11±0.47mm, p<0.0001). In-hospital serious adverse events were similar (9% with 2S vs. 8% with 1S, p=0.58). At one year, patients treated by 2S strategy had non-significantly lower rates of target vessel revascularization (5.8% vs. 7.4%, p=0.31), myocardial infarction (7.8% vs. 12.2%, p=0.31) and major adverse cardiovascular events (16.6% vs. 21.8%, p=0.21). In this study of patients undergoing PCI for true coronary bifurcation lesions using EES, 2S strategy was associated with superior SB angiographic outcomes without excess complications or ischemic events at one year.
    International journal of cardiology 03/2014; 174(1). DOI:10.1016/j.ijcard.2014.03.029 · 4.04 Impact Factor

Publication Stats

3k Citations
1,305.11 Total Impact Points


  • 1994–2015
    • Icahn School of Medicine at Mount Sinai
      • Division of Cardiology
      Borough of Manhattan, New York, United States
  • 1990–2014
    • Mount Sinai Medical Center
      New York City, New York, United States
  • 2013
    • Mayo Foundation for Medical Education and Research
      Rochester, Michigan, United States
  • 1993–2013
    • Mount Sinai Hospital
      New York City, New York, United States
  • 2012
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2001–2012
    • Sinai Hospital
      New York, New York, United States
  • 2009
    • Memorial University of Newfoundland
      Saint John's, Newfoundland and Labrador, Canada
  • 2002
    • New York Cardiovascular Reaserach
      New York, New York, United States
  • 1991
    • University of California, Los Angeles
      Los Ángeles, California, United States