B2 Lesions Are True Bifurcation Lesions Simply Categorized as One Group According to the Movahed Bifurcation Classification

ABSTRACT: Ito et al reported low adverse events in true bifurcation lesions treated with rotational atherectomy in a recent issue of the Journal of Invasive Cardiology. However, their definition of true bifurcation lesions is not correct. They defined only Medina 1,1,1 as a true bifurcation lesion. However, true bifurcation lesions are Medina 1,1,1, 1,0,1 and 0,1,1 lesions, which are all summarized as B2 lesions when using the Movahed classification. This letter discusses this important issue. J INVASIVE CARDIOL 2010;22:252 Key words: bifurcation; bifurcation coronary lesion; bifurcation disease; bifurcation intervention; coronary artery bifurcation classification; coronary artery disease; coronary bifurcation; coronary bifurcation intervention; coronary intervention Dear Editor: I read with interest the recently published manuscript entitled “Long-term outcomes of plaque debulking with rotational atherectomy in side-branch ostial lesions to treat bifurcation coronary disease”. ¹ In this study, the authors stated that they included only true bifurcation lesions in their study defined as Medina 1,1,1 lesion. This statement is not correct. True bifurcation lesions are defined as those with significant atherosclerotic disease involvement of the main and ostial side branches (so-called B2 lesions based on the Movahed classification). ^2–4 The Medina classification separates true bifurcation lesions into three irrelevant subgroups (1,1,1, 1,0,1 and 0,1,1). The group 1,1,1 only captures one-third of true bifurcation lesions. Actually, the case illustrated in this paper shows a bifurcation lesion with proximal main segment and ostial side-branch involvement and a normal distal main branch. This lesion is classified by Medina as 1,0,1 and not as a 1,1,1 bifurcation lesion. Using the Movahed classification, this lesion would still qualify as a true B2 bifurcation lesion. The authors’ confusion is understandable as they used an inappropriate classification for their study. Furthermore, using rotational atherectomy in angulated lesions markedly increases the risk of coronary perforation. The authors of this study did not report any data about side-branch angulation due to their inappropriate use of the Medina classification which lacks any description of side-branch angulation. In contrast, the Movahed bifurcation classification^3–5 summarizes all true bifurcation lesions in one clinically relevant category, the so-called B2 lesion (B for bifurcation and 2 for involvement of both bifurcation branch ostia), and includes the bifurcation angle as a separate suffix in the classification (V for shallow or T for steep angels). ^{2, 4} It is time to abandon misleading and incomplete Medina classifications in regards to true bifurcation lesions in studies evaluating coronary bifurcation interventions in favor of the clinically relevant, simpler and complete Movahed classification. Mohammad Reza Movahed, MD, PhD, FSCAI, FACC, FACP Associate Professor of Medicine Medical Director of Heart Transplant Program The Southern Arizona VA Health Care System The University of Arizona Sarver Heart Center Department of Medicine, Division of Cardiology 1501 North Campbell Avenue Tucson, AZ 85724 E-mail: rmovahed@email.arizona.edu or rmova@aol.com

References

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