201
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Malik J, Zahid T, Majedi O, Ishaq U, Faizi MI. A Widow-Maker and a Doppelganger: An Anomalous Case of the Coronaries. Cureus 2020; 12:e9603. [PMID: 32923207 PMCID: PMC7478500 DOI: 10.7759/cureus.9603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The anomalous origin of the left circumflex (LCX) artery from the right coronary sinus is a relatively rare condition. A ‘double’ left anterior descending (LAD) artery is probably the rarest of coronary artery anomalies. We present a case of acute myocardial infarction with a clot and a critical distal stenosis in the left main stem (LMS) supplying a dual LAD and an aberrant origin of the LCX.
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202
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Kezerle L, Yohanan E, Cohen A, Merkin M, Ishay Y, Weinstein JM, Cafri C. The impact of Heart Team discussion on decision making for coronary revascularization in patients with complex coronary artery disease. J Card Surg 2020; 35:2719-2724. [PMID: 32743834 DOI: 10.1111/jocs.14892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. METHODS We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group). RESULTS There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P < .01). HT discussion led to a significant delay to PCI (8 ± 5 vs 1.8 ± 4 days; P = .02), while surgical revascularization times were not affected. CONCLUSION HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.
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Affiliation(s)
- Louise Kezerle
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eli Yohanan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Avshalom Cohen
- Southern Division, Clalit Health Services, Tel Aviv, Israel
| | - Miri Merkin
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yaron Ishay
- Deparment of Cardiothoracic Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jean M Weinstein
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Carlos Cafri
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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203
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Maskell P, Oo S, Muir AD, Fan KS, Harky A. Techniques and approaches for revascularisation of left heart coronary diseases. Br J Hosp Med (Lond) 2020; 81:1-11. [PMID: 32845756 DOI: 10.12968/hmed.2020.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Coronary artery disease and its associated clinical sequelae are a significant medical burden to clinicians and patients. Severe coronary artery disease presenting in the context of acute myocardial ischaemia, or stable plaques causing chronic symptoms despite best conservative and pharmacological intervention, are often amenable to further intervention such as coronary artery bypass grafting. This procedure has been extensively compared to newer and less invasive techniques, such as percutaneous coronary intervention, and other minimally invasive procedures such as robotic or endoscopic techniques. This review summarises the current evidence on revascularisation of the left coronary artery system, with particular emphasis on key clinical endpoints of mortality, myocardial infarction, stroke and repeat revascularisation.
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Affiliation(s)
- Perry Maskell
- Department of Medical Education, Countess of Chester Hospital, Chester, UK
| | - Shwe Oo
- Department of Cardiothoracic Surgery, Bristol Royal Infirmary, Bristol, UK
| | - Andrew D Muir
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| | - Ka Siu Fan
- St. George's Medical School, University of London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Institute of Integrative Biology, University of Liverpool, Liverpool, UK
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204
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Lehto HR, Pietilä A, Niiranen TJ, Lommi J, Salomaa V. Clinical practice patterns in revascularization of diabetic patients with coronary heart disease: nationwide register study. Ann Med 2020; 52:225-232. [PMID: 32429711 PMCID: PMC7877943 DOI: 10.1080/07853890.2020.1771757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Aims: To compare diabetic patients with coronary heart disease (CHD) needing revascularization to corresponding non-diabetic patients in terms of revascularization methods, comorbidities and urgency of procedure. We also examined the impact of patient characteristics and comorbidities on the revascularization method.Methods: We identified all diabetic (n = 33,018) and non-diabetic (n = 106,224) patients with first-ever, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) from electronic health records in Finland between 2000 and 2015.Results: Overall, PCI was the most common revascularization method. PCI outnumbered CABG in women and men both in diabetic and non-diabetic patients. However, diabetic patients were more likely to undergo CABG than PCI (OR 1.30; 95% CI 1.27-1.34, adjusted for age, gender, region of residence and procedure year). Moreover, 26.9% of diabetic patients' urgent procedures were CABG compared to 21.6% in non-diabetic patients (p<.001). Among diabetic patients, prior myocardial infarction was associated with increased odds of CABG, whereas female gender, atrial fibrillation, congestive heart failure, hypertension and later procedure year were associated with lower odds of CABG.Conclusions: CABG has been performed more frequently in diabetic than in non-diabetic CHD patients. Nevertheless, PCI was the dominant revascularization method over CABG both in diabetic and non-diabetic patients. KEY MESSAGESPCI was the dominant revascularization method in both diabetic and non-diabetic patients. Diabetic patients were more likely to undergo CABG than PCI when compared to non-diabetic patients (OR: 1.30; CI 1.27-1.34).Diabetic patients underwent urgent CABG procedures more often than non-diabetic patients and had more comorbidities compared to non-diabetic patients.
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Affiliation(s)
| | - Arto Pietilä
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Teemu J Niiranen
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Jyri Lommi
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Veikko Salomaa
- THL - Finnish Institute for Health and Welfare, Helsinki, Finland
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205
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Compagnone M, Taglieri N, Celeski M, Ghetti G, Marrozzini C, Reggiani MLB, Nardi E, Orzalkiewicz M, Bruno AG, Galiè N, Saia F, Palmerini T. Impact of Elective, Uncomplicated Target Lesion Revascularization on Cardiac Mortality After Elective Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Disease. Am J Cardiol 2020; 128:94-100. [PMID: 32650931 DOI: 10.1016/j.amjcard.2020.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 11/28/2022]
Abstract
This study sought to investigate the impact of elective, uncomplicated target lesion revascularization (TLR) on long-term cardiac mortality after percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease. Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in 1 interventional center in Northern Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HZ] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72). In conclusion, elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.
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Affiliation(s)
- Miriam Compagnone
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy.
| | - Nevio Taglieri
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Mihail Celeski
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Gabriele Ghetti
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Cinzia Marrozzini
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | | | - Elena Nardi
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Mateusz Orzalkiewicz
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Antonio G Bruno
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Tullio Palmerini
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy
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206
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Taxiarchi P, Kontopantelis E, Kinnaird T, Curzen N, Banning A, Ludman P, Shoaib A, Rashid M, Martin GP, Mamas MA. Adoption of same day discharge following elective left main stem percutaneous coronary intervention. Int J Cardiol 2020; 321:38-47. [PMID: 32739446 PMCID: PMC7392050 DOI: 10.1016/j.ijcard.2020.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/04/2020] [Accepted: 07/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI. METHODS We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality. RESULTS SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34). CONCLUSIONS We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.
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Affiliation(s)
- Paraskevi Taxiarchi
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Nick Curzen
- Coronary Research Group, University Hospital Southampton, Faculty of Medicine, University of Southampton, UK
| | | | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Glen P Martin
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Mamas A Mamas
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK.
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207
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Impact of unprotected left main percutaneous coronary intervention on long-term clinical outcomes: a large single-center study. Coron Artery Dis 2020; 30:249-254. [PMID: 30762624 DOI: 10.1097/mca.0000000000000725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the advancements of percutaneous coronary interventions (PCI), it is not clear whether unprotected left main (ULM) coronary artery disease (CAD) remains an independent predictor of adverse outcomes after PCI therapy. We have therefore carried out a large cohort study to investigate the impact of ULM disease on 2-year clinical outcomes in Chinese patients undergoing contemporary PCI treatment. METHODS AND RESULTS From January 2013 to December 2013, 10 724 consecutive patients undergoing PCI were prospectively collected. Two-year clinical outcomes were compared for patients undergoing ULM PCI and non-ULM PCI. Among the 10 724 patients, 272 (2.5%) patients underwent ULM PCI. Overall, these patients had higher baseline clinical risks of CAD and more extensive CAD compared with non-ULM PCI patients. During the 2-year follow-up, patients who underwent ULM PCI experienced higher incidence of cardiac death (2.2 vs. 0.7%; log-rank P=0.002), myocardial infarction (7.0 vs. 1.9%; log-rank P<0.001), stroke (2.9 vs. 1.3%; log-rank P=0.02), and definite and probable stent thrombosis (3.3 vs. 0.5%; log-rank P<0.001), than patients who underwent non-ULM PCI. However, the rates of revascularization (7.4 vs. 8.7%; log-rank P=0.48), target vessel revascularization (5.5 vs. 5.0%; log-rank P=0.66), and major adverse cardiac and cerebrovascular events (15.1 vs. 12.0%; log-rank P=0.11) were not significantly different between the groups. When performing adjusted Cox regression after propensity score matching, ULM PCI was not an independent risk factor of any clinical events (all P>0.05). CONCLUSION In this large cohort of patients who underwent modern PCI, ULM PCI patients had higher baseline clinical risks and poorer prognosis during 2-year follow-up. However, after multivariate analysis, ULM PCI was not an independent risk factor of any clinical adverse events.
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208
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Long-term clinical outcomes after a percutaneous coronary intervention with a drug-eluting stent in patients with unprotected left main coronary artery disease excluded from clinical trials. Coron Artery Dis 2020; 30:239-248. [PMID: 30688673 DOI: 10.1097/mca.0000000000000718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major randomized clinical trials assessing clinical outcomes in patients who underwent a percutaneous coronary intervention (PCI) for left main coronary artery disease excluded some high-risk subsets. Whether the effectiveness and safety of a percutaneous approach in this group of patients are comparable with those observed in clinical trials is unclear. We aimed to explore the long-term outcomes of contemporary drug-eluting stent (DES)-based revascularization for left main coronary artery disease in patients presenting with one or more clinical or angiographic characteristics who would have precluded inclusion in randomized trials. PATIENTS AND METHODS Between April 2003 and December 2011, 340 consecutive patients with unprotected left main coronary artery stenosis of at least 50% who underwent successful PCI with DES at Sejong General Hospital (Bucheon, Republic of Korea) were included in this retrospective study. Patients were classified into the exclusion group (group E; n=120) and the inclusion group (group I; n=220) according to the prespecified inclusion and exclusion criteria utilized in clinical trials. RESULTS During the median follow-up of 86 (52-114) months, major adverse cardiac or cerebrovascular events occurred in 69 (31.4%) patients in group I and 46 (38.3%) patients in group E (P=0.155). In the propensity score-matched population, group E was not associated with a higher incidence of major adverse cardiac or cerebrovascular events (hazard ratio: 1.42, 95% confidence interval: 0.76-2.65, P=0.758). Definite or probable stent thrombosis occurred in five patients of group I, with no cases in group E. CONCLUSION In our real-world registry, about a third of patients who underwent PCI for unprotected left main coronary artery stenosis had one or more high-risk characteristics or comorbid conditions that represent exclusion criteria of previous randomized trials. PCI using DES is feasible in these patients.
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209
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Van den Eynde J, Bennett J, McCutcheon K, Adriaenssens T, Desmet W, Dubois C, Sinnaeve P, Verbelen T, Jacobs S, Oosterlinck W. Heart team 2.0: A decision tree for minimally invasive and hybrid myocardial revascularization. Trends Cardiovasc Med 2020; 31:382-391. [PMID: 32712328 DOI: 10.1016/j.tcm.2020.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022]
Abstract
Recent years have seen an important shift in the target population for myocardial revascularization. Patients are increasingly presenting with more complex coronary artery disease (CAD), but also with multiple comorbidities and frailty. At the same time, minimally invasive strategies such as Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB) and Percutaneous Coronary Interventions (PCI) have been developed, which might be more appealing for this group of patients. As a result, the landscape of options for myocardial revascularization is evolving while adequate use of all resources is required to ensure optimal patient care. Heart Teams are confronted with the challenge of incorporating the new minimally invasive strategies into the decision process, yet current guidelines do not fully address this challenge. In this review, the current evidence regarding outcomes, indications, benefits, and risks of off-pump coronary artery bypass grafting (OPCAB), MIDCAB, PCI, and hybrid coronary revascularization (HCR) are discussed. Based on this evidence and on experiences from Heart Team discussions, a new decision tree is proposed that incorporates recent advances in minimally invasive revascularization strategies, thereby optimizing adequate delivery of care for each individual patient's needs. Introducing all important considerations in a logical way, this tool facilitates the decision-making process and might ensure appropriate use of resources and optimal care for individual patients.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Keir McCutcheon
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Walter Desmet
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steven Jacobs
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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210
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Mitsutake Y, Konishi A, Handa N, Ho M, Shirato H, Ito T, Koike K, Mochizuki S, Ishii K. Independent Factors for In-Hospital Death Following Drug-Eluting Stent Thrombosis From the Japanese Adverse Event Report System. Circ J 2020; 84:1568-1574. [PMID: 32684539 DOI: 10.1253/circj.cj-20-0133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Stent thrombosis (ST) is a serious complication after drug-eluting stents (DES) implantation. To identify the risk factors of mortality following ST, we evaluated adverse event reports used for safety measures after approval.Methods and Results:Between July 2004 and August 2019, 2,887 ST case reports were submitted to the Pharmaceutical and Medical Device Agency. Reports of probable or possible ST (n=604), with insufficient data regarding in-hospital outcome or duration between procedure and ST occurrence (n=37) or duplicate reports (n=191) were excluded. Accordingly, 2,045 reports with definite ST were analyzed. Among the subjects, there were 286 in-hospital deaths (14.0%). Multivariate logistic regression analysis revealed that left main trunk (LMT) (odds ratio [OR]: 4.76, 95% confidence interval [CI]: 3.26-6.96), chronic heart failure (CHF) (OR: 2.88, 95% CI: 1.61-5.14), hemodialysis (OR: 2.69, 95% CI: 1.66-4.36), prior stroke (OR: 2.28, 95% CI: 1.15-4.51), over 70 years old (OR: 1.62, 95% CI: 1.22-2.16), and right coronary artery (OR: 0.41, 95% CI: 0.27-0.63) were independent factors for in-hospital death after DES-ST. CONCLUSIONS LMT, CHF, hemodialysis, prior stroke, and older age were independently associated with higher risk of in-hospital death following DES-ST. If target patients have these factors, maximum preventive strategies against ST occurrence, including adequate dual-antiplatelet therapy duration and optimal DES deployment procedures, are required.
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Affiliation(s)
- Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Akihide Konishi
- Clinical & Translational Research Center, Kobe University Hospital
| | - Nobuhiro Handa
- Office of Medical Devices I, Pharmaceuticals and Medical Devices Agency
| | - Mami Ho
- Office of Medical Devices I, Pharmaceuticals and Medical Devices Agency
| | - Haruki Shirato
- Office of Medical Devices I, Pharmaceuticals and Medical Devices Agency
| | - Takuya Ito
- Office of Medical Devices I, Pharmaceuticals and Medical Devices Agency
| | - Kazuhisa Koike
- Division of Safety for Medical Devices, Office of Manufacturing Quality and Vigilance for Medical Devices, Pharmaceuticals and Medical Devices Agency
| | - Shuichi Mochizuki
- Office of Medical Devices II, Pharmaceuticals and Medical Devices Agency
| | - Kensuke Ishii
- Office of Medical Devices II, Pharmaceuticals and Medical Devices Agency
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211
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Almeida AS, Fuchs SC, Fuchs FC, Silva AG, Lucca MB, Scopel S, Fuchs FD. Effectiveness of Clinical, Surgical and Percutaneous Treatment to Prevent Cardiovascular Events in Patients Referred for Elective Coronary Angiography: An Observational Study. Vasc Health Risk Manag 2020; 16:285-297. [PMID: 32764949 PMCID: PMC7371461 DOI: 10.2147/vhrm.s246963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/26/2020] [Indexed: 01/09/2023] Open
Abstract
Purpose To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography. Patients and Methods A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes. Results All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG. Conclusion Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.
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Affiliation(s)
- Adriana Silveira Almeida
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sandra C Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Felipe C Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline Gonçalves Silva
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Balbinot Lucca
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Samuel Scopel
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Flávio D Fuchs
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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212
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Baumann AAW, Mishra A, Worthley MI, Nelson AJ, Psaltis PJ. Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine. Ther Adv Chronic Dis 2020; 11:2040622320938527. [PMID: 32655848 PMCID: PMC7331770 DOI: 10.1177/2040622320938527] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.
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Affiliation(s)
- Angus A. W. Baumann
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Aashka Mishra
- Flinders Medical School, Flinders University, Adelaide, South Australia, Australia
| | - Matthew I. Worthley
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, NC, USA
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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213
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Milojevic M, Milacic P, Petrovic I, Bojic M, Milojevic A, Nikolic A, Sandner S, Sousa-Uva M. Mapping decision making for bypass surgery in the era of interventional medicine: towards an integrative model of patient-centeredness. Minerva Cardioangiol 2020; 68:469-479. [PMID: 32657555 DOI: 10.23736/s0026-4725.20.05228-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article reviews the context and evidence of recent myocardial revascularization trials on PCI versus CABG with particular emphasis on patient selection and treatment of surgical patients. Moreover, one of our intended purposes is to identify the values underpinning the integrated care model, which incorporates decision to proceed with surgical myocardial revascularization in conjunction with established pillars of the use of optimal surgical techniques, and aggressive risk-factor modification through guideline-directed pharmacological therapies and lifestyle modifications.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia - .,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands -
| | - Petar Milacic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Ivana Petrovic
- Department of Cardiothoracic Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Milovan Bojic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | | | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
| | - Sigrid Sandner
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Miguel Sousa-Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Lisbon, Portugal.,Department of Surgery and Physiology, Cardiovascular Research Center, Faculty of Medicine, Porto University, Porto, Portugal
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214
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3870] [Impact Index Per Article: 967.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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215
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Clinical Implications of Bifurcation Angles in Left Main Bifurcation Intervention Using a Two-Stent Technique. J Interv Cardiol 2020; 2020:2475930. [PMID: 32733170 PMCID: PMC7374237 DOI: 10.1155/2020/2475930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 12/04/2022] Open
Abstract
Objectives The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique. Background Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI). Methods Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1st generation drug-eluting stent (DES), 37% 2nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). Results In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes. Conclusions In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.
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216
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Ladwiniec A, Walsh SJ, Holm NR, Hanratty CG, Mäkikallio T, Kellerth T, Hildick-Smith D, Mogensen LJH, Hartikainen J, Menown IBA, Erglis A, Eriksen E, Spence MS, Thuesen L, Christiansen EH. Intravascular ultrasound to guide left main stem intervention: a NOBLE trial substudy. EUROINTERVENTION 2020; 16:201-209. [PMID: 32122821 DOI: 10.4244/eij-d-19-01003] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS We aimed to investigate the association between the use and findings of IVUS with clinical outcomes in the PCI arm of a randomised trial of LMS PCI. METHODS AND RESULTS The NOBLE trial randomised patients with LMS disease to treatment by PCI or CABG. Of 603 patients treated by PCI, 435 (72%) underwent post-PCI IVUS assessment, 224 of which were analysed in a core laboratory. At five years, the composite of MACCE was 18.9% if post-PCI IVUS was performed versus 25.0% if it was not performed (p=0.45, after adjustment). Overall repeat revascularisation was not reduced (10.6% vs 16.5%, p=0.11); however, LMS TLR was (5.1% vs 11.6%, p=0.01) if IVUS was used. For comparison of stent expansion, LMS MSA was split into tertiles. We found no significant difference in MACCE, death, myocardial infarction or stent thrombosis between tertiles. There was a significant difference between the lower and upper tertiles for repeat revascularisation (17.6% vs 5.2%, p=0.02) and LMS TLR (12.2% vs 0%, p=0.002). CONCLUSIONS Post-PCI IVUS assessment and adequate stent expansion are not associated with reduced MACCE; however, there is an association with reduced LMS TLR. The use of intracoronary imaging to prevent stent underexpansion in LMS PCI is likely to improve outcomes.
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Affiliation(s)
- Andrew Ladwiniec
- Department of Cardiology, Glenfield Hospital, Leicester, United Kingdom
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217
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Ren YS, Li LF, Peng T, Tan YJ, Sun Y, Cheng GL, Zhang GM, Li J. The effect of milrinone on mortality in adult patients who underwent CABG surgery: a systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis. BMC Cardiovasc Disord 2020; 20:328. [PMID: 32640988 PMCID: PMC7346403 DOI: 10.1186/s12872-020-01598-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery. Methods We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration. Results The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences. Conclusions Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.
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Affiliation(s)
- Yu-Shan Ren
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Lan-Fang Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Tao Peng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Yu-Jun Tan
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Ying Sun
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Guo-Liang Cheng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Gui-Min Zhang
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Jie Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China. .,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China. .,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.
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218
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Kalil RAK, Sant´Anna RT, Salles FBD. Controversies in the Indications of Percutaneous Angioplasty Or Coronary Artery Bypass Grafting In The Treatment Of Left Main Disease. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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219
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Zhang J, Jiang T, Hou Y, Chen F, Yang K, Sang W, Wu H, Ma Y, Xu F, Chen Y. Five-year outcomes comparing percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in patients with left main coronary artery disease: A systematic review and meta-analysis. Atherosclerosis 2020; 308:50-56. [PMID: 32713512 DOI: 10.1016/j.atherosclerosis.2020.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/12/2020] [Accepted: 06/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS In patients with left main coronary artery disease (LMCAD), long-term outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) remain controversial. We conducted a meta-analysis to compare the efficacy and safety of PCI with DES and CABG in LMCAD patients. METHODS We comprehensively searched in Web of Science, EMBASE, PubMed, and Cochrane databases for eligible randomised controlled trials (RCTs) comparing the 5-year clinical outcomes between PCI with DES and CABG in LMCAD patients. Random-effect models were applied to analyse risk ratios (RRs) and hazard ratios (HRs) across studies, and I2 to assess heterogeneity. RESULTS We screened 4 RCTs including 4394 patients distributed randomly into PCI (n = 2197) and CABG (n = 2197) groups. In comparison to CABG, PCI showed non-inferiority concerning a composite of death, myocardial infarction, and stroke (HR 1.22, 95% confident interval [CI] 0.84-1.75), death (HR 1.06, 95% CI 0.81-1.40) and stroke (HR 0.80, 95% CI 0.42-1.53). Regarding major adverse cardiac or cerebrovascular events (MACCE) rate, both strategies show clinical equipoise in patients with a low-to-intermediate Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score (HR 1.20, 95% CI 0.85-1.70), while CABG had an advantage over PCI in those with a high SYNTAX score (HR 1.64, 95% CI 1.20-2.24). CONCLUSIONS CABG showed advantage over PCI with DES for LMCAD patients in MACCE. PCI and CABG showed equivalent 5-year clinical risk of a composite of all-cause mortality, myocardial infarction, and stroke, but the former had higher risk of repeat revascularization.
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Affiliation(s)
- Jian Zhang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Tangxing Jiang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yaping Hou
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Fengying Chen
- Emergency Department, The Affiliated Hospital of Inner Mongolia Medical University, Huhhot, China
| | - Kehui Yang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Wentao Sang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hongzhi Wu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yanyan Ma
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China.
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China.
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220
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Surgical excellence—an ongoing quest. Indian J Thorac Cardiovasc Surg 2020; 36:335-343. [DOI: 10.1007/s12055-020-00979-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022] Open
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221
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Meah MN, Denvir MA, Mills NL, Norrie J, Newby DE. Clinical endpoint adjudication. Lancet 2020; 395:1878-1882. [PMID: 32534650 DOI: 10.1016/s0140-6736(20)30635-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/07/2020] [Accepted: 03/10/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Mohammed N Meah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Martin A Denvir
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
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222
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Hoole SP, Bambrough P. Recent advances in percutaneous coronary intervention. Heart 2020; 106:1380-1386. [PMID: 32522821 DOI: 10.1136/heartjnl-2019-315707] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 01/24/2023] Open
Abstract
Percutaneous coronary intervention (PCI) continues to advance at pace with an ever-broadening indication. In this article we will review the recent technological advances in PCI that have enabled more complex coronary disease to be treated. The choice of revascularisation strategy must take into account the evidence-just because we can treat by PCI does not necessarily mean we should. When PCI is indicated, a safe, precision PCI approach guided by physiology, imaging and optimal lesion preparation should be the goal to obtain complete revascularisation and a durable long-term result. When these standards are adhered to, the outcomes can be excellent, in even complex coronary disease. We provide contemporary trial evidence to justify PCI and treatment algorithms that ensure optimal revascularisation decision making to achieve the best patient outcomes.
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Affiliation(s)
- Stephen P Hoole
- Interventional Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Paul Bambrough
- Interventional Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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223
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Liu MJ, Chen CF, Gao XF, Liu XH, Xu YZ. In-hospital outcomes of chronic total occlusion percutaneous coronary intervention in patients with and without prior coronary artery bypass graft: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e19977. [PMID: 32501965 PMCID: PMC7306325 DOI: 10.1097/md.0000000000019977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/04/2020] [Accepted: 03/21/2020] [Indexed: 12/29/2022] Open
Abstract
The clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in prior coronary artery bypass graft (pCABG) patients have been investigated; however, the results are inconsistent.The present meta-analysis compared the clinical outcomes of CTO PCI in patients with and without prior CABG (nCABG). The endpoints included technical success, procedural success, all-cause mortality, myocardial infarction (MI), major bleeding, coronary perforation, pericardial tamponade, emergency CABG, and vascular access complication.A total of 7 studies comprising of 11099 patients were included in this meta-analysis. The results showed that compared to nCABG patents, pCABG patients were associated with lower technical success (82.3% versus 87.8%; OR, 0.60; 95% CI, 0.53-0.68; P < .00001; I = 0%) and procedural success (80.4% versus 86.2%; OR, 0.61; 95% CI, 0.53-0.70; P < .00001; I = 10%); a higher risk of all-cause mortality (OR, 2.95; 95% CI, 1.56-5.57; P = 0.0008; I = 0%), MI (OR, 2.30; 95% CI, 1.40-3.80; P = .001; I = 5%), and coronary perforation (OR, 2.16; 95% CI, 1.51-3.08; P < 0.0001; I = 52%). On the other hand, the risk of pericardial tamponade (OR, 0.42; 95% CI, 0.15-1.18; P = .10; I = 21%), major bleeding (OR, 1.51; 95% CI, 0.90-2.53; P = .11; I = 0%), vascular access complication (OR, 1.50; 95% CI, 0.93-2.41; P = .10; I = 0%), and emergency CABG (OR, 0.99; 95% CI, 0.25-3.91; P = .99; I = 0%) was similar in both groups.Compared to nCABG patients, pCABG patients had lower CTO PCI success rates, higher rates of in-hospital mortality, MI, and coronary perforation, and similar risk of pericardial tamponade and vascular complication rates.
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224
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Kinnaird T, Gallagher S, Anderson R, Sharp A, Farooq V, Ludman P, Copt S, Curzen N, Banning A, Mamas M. Are Higher Operator Volumes for Unprotected Left Main Stem Percutaneous Coronary Intervention Associated With Improved Patient Outcomes? Circ Cardiovasc Interv 2020; 13:e008782. [DOI: 10.1161/circinterventions.119.008782] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The relationship between operator volume and survival after unprotected left main stem percutaneous coronary intervention (uLMS-PCI) is poorly defined.
Methods:
Data from the British Cardiovascular Intervention Society national PCI database were analyzed for all uLMS-PCI procedures performed in England and Wales between 2012 and 2014 and 4 quartiles of annualized uLMS-PCI volume (Q1–Q4) generated. Individual logistic regressions were performed for 12-month mortality to quantify the independent association between operator quartile and outcomes.
Results:
In total, 6724 uLMS-PCI procedures were analyzed with a negatively skewed distribution and an annualized median of 3 procedures per year. Operator volume ranged from 1 to 54 uLMS-PCI procedures/year. Within Q1, 347 operators performed a median of 2 procedures/year (interquartile range, 1–3); in Q2, 134 operators performed a median of 5 procedures/year (interquartile range, 4–6); in Q3, 59 operators performed a mean of 10 procedures/year (interquartile range, 8–12); and in Q4, 29 operators performed a mean of 21 procedures/year (interquartile range, 17–29). Higher volume operators undertook uLMS-PCI in patients with greater comorbid burden and performed more complex procedures compared with lower operator volumes. Adjusted in-hospital survival (odds ratio, 0.39 [95% CI, 0.24–0.67];
P
<0.001), in-hospital major adverse cardiac and cerebral events (odds ratio, 0.41 [95% CI, 0.27–0.62];
P
<0.001), and 12-month survival (odds ratio, 0.54 [95% CI, 0.39–0.73];
P
<0.001) were lower in Q4 operators compared with Q1 operators. A close association between operator volume/case and superior 12-month survival was observed (
P
<0.001). The lower volume threshold of minimum operator uLMS-PCI volume associated with improved survival was ≥16 cases/year.
Conclusions:
These data suggest that operator volume is an important factor in determining outcome after uLMS-PCI.
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Affiliation(s)
- Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A., A.S., V.F.)
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom (T.K., M.M.)
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A., A.S., V.F.)
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A., A.S., V.F.)
| | - Andrew Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A., A.S., V.F.)
| | - Vasim Farooq
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., S.G., R.A., A.S., V.F.)
| | - Peter Ludman
- Departmen2 of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.L.)
| | - Samuel Copt
- Division of Statistics, Biosensors SA, Morges, Switzerland (S.C.)
| | - Nick Curzen
- Department of Cardiology, University Hospital NHS Trust, Southampton, United Kingdom (N.C.)
| | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford, United Kingdom (A.B.)
| | - Mamas Mamas
- Department of Cardiology, Royal Stoke Hospital, UHNM, Stoke-on-Trent, United Kingdom (M.M.)
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom (T.K., M.M.)
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225
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Grieshaber P, Oswald I, Albert M, Reents W, Zacher M, Roth P, Niemann B, Dörr O, Krüger T, Nef H, Sodah A, Hamm C, Schlensak C, Diegeler A, Sedding D, Franke U, Boening A. Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery. Eur J Cardiothorac Surg 2020; 57:1122-1129. [PMID: 32011670 DOI: 10.1093/ejcts/ezaa003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/02/2019] [Accepted: 12/11/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is an ongoing discussion about how to treat coronary stents during bypass surgery: Should patent stents be left alone and the stented vessels be ungrafted, or should every stented coronary artery receive a bypass graft? This study aims to determine the relevance of perioperative stent stenosis or occlusion on postoperative outcomes up to 3 years postoperatively. METHODS Patients undergoing coronary artery bypass grafting surgery (CABG) (±concomitant procedures) with previous percutaneous coronary intervention from 4 centres were prospectively included in this observatory study between April 2015 and June 2017. A coronary angiography was conducted between the fifth and seventh postoperative days. The preoperative and postoperative angiograms were assessed in a core laboratory, assessing the patencies of coronary stents and bypass grafts. The core lab investigators were blinded to the patients' characteristics and perioperative course. RESULTS A total of 107 patients were included in the study. In the postoperative coronary angiography, 265 bypass grafts and 189 coronary stents were examined angiographically. Ninety-seven percent of preoperatively patent stents remained patent. New coronary stent stenoses were observed in 5 patients (4.7%). All 5 patients were asymptomatic and managed conservatively. Bypass stenoses were observed in 12 patients (11%), of whom were managed conservatively, 4 underwent percutaneous coronary intervention and 1 underwent redo-CABG. Two years postoperatively, 97% of patients were alive. Patients with new stent stenosis tended to have a better survival compared with patients with bypass stenosis (100% vs 73%; P = 0.09) up to 3 years postoperatively. CONCLUSIONS Perioperative coronary stent stenosis occurs rarely. It is safe to leave a patently stented coronary vessel without bypass grafting.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Irina Oswald
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Wilko Reents
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Michael Zacher
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Peter Roth
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Oliver Dörr
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Tobias Krüger
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Holger Nef
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Ayman Sodah
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Christian Hamm
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Anno Diegeler
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Daniel Sedding
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine III, University Hospital Halle, Halle (Saale), Germany
| | - Ulrich Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Andreas Boening
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
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226
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Ragnarsson S, Janiec M, Modrau IS, Dreifaldt M, Ericsson A, Holmgren A, Hultkvist H, Jeppsson A, Sartipy U, Ternström L, Per Vikholm M, de Souza D, James S, Thelin S. No-touch saphenous vein grafts in coronary artery surgery (SWEDEGRAFT): Rationale and design of a multicenter, prospective, registry-based randomized clinical trial. Am Heart J 2020; 224:17-24. [PMID: 32272256 DOI: 10.1016/j.ahj.2020.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Abstract
The SWEDEGRAFT study (ClinicalTrials.gov Identifier: NCT03501303) tests the hypothesis that saphenous vein grafts (SVGs) harvested with the "no-touch" technique improves patency of coronary artery bypass grafts compared with the conventional open skeletonized technique. This article describes the rationale and design of the randomized trial and baseline characteristics of the population enrolled during the first 9 months of enrollment. The SWEDEGRAFT study is a prospective, binational multicenter, open-label, registry-based trial in patients undergoing first isolated nonemergent coronary artery bypass grafting (CABG), randomized 1:1 to no-touch or conventional open skeletonized vein harvesting technique, with a planned enrollment of 900 patients. The primary end point is the proportion of patients with graft failure defined as SVGs occluded or stenosed >50% on coronary computed tomography angiography at 2 years after CABG, earlier clinically driven coronary angiography demonstrating an occluded or stenosed >50% vein graft, or death within 2 years. High-quality health registries and coronary computed tomography angiography are used to assess the primary end point. The secondary end points include wound healing in the vein graft sites and the composite outcome of major adverse cardiac events during the first 2 years based on registry data. Demographics of the first 200 patients enrolled in the trial and other CABG patients operated in Sweden during the same time period are comparable when the exclusion criteria are taken into consideration. RCT# NCT03501303.
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227
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Kataruka A, Maynard CC, Kearney KE, Mahmoud A, Bell S, Doll JA, McCabe JM, Bryson C, Gurm HS, Jneid H, Virani SS, Lehr E, Ring ME, Hira RS. Temporal Trends in Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting: Insights From the Washington Cardiac Care Outcomes Assessment Program. J Am Heart Assoc 2020; 9:e015317. [PMID: 32456522 PMCID: PMC7429009 DOI: 10.1161/jaha.119.015317] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Patient selection and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI‐ and CABG‐treated patients. Methods and Results We analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk‐adjusted in‐hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005–2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST‐segment–elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry CathPCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P<0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P<0.0001). Adjusted observed/expected in‐hospital mortality ratio increased for PCI (0.98 versus 1.19, P<0.0001) but decreased for CABG (1.21 versus 0.74, P<0.0001) over the study period. Conclusions Clinical acuity increased for patients treated with PCI rather than CABG. This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG. These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology University of Washington Seattle WA
| | - Charles C Maynard
- Department of Health Services University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
| | | | - Ahmed Mahmoud
- Division of Cardiology University of Washington Seattle WA
| | - Sean Bell
- Department of Medicine University of Washington Seattle WA
| | - Jacob A Doll
- Division of Cardiology University of Washington Seattle WA.,VA Puget South Health Care System Seattle WA
| | - James M McCabe
- Division of Cardiology University of Washington Seattle WA
| | | | | | - Hani Jneid
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Salim S Virani
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Eric Lehr
- Department of Cardiac Surgery Swedish Heart & Vascular Institute Seattle WA
| | | | - Ravi S Hira
- Division of Cardiology University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
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228
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de Araujo GN, Leiria TLL, Furtado MV, Matte BDS, Machado GP, Krepsky AM, Bergoli LCC, Goncalves SC, Wainstein MV, Polanczyk CA. Inter-observer variation of Syntax score among cardiac surgeons, clinical and interventional cardiologists. Ther Adv Cardiovasc Dis 2020; 14:1753944720924254. [PMID: 32438849 PMCID: PMC7249554 DOI: 10.1177/1753944720924254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Despite the complexity of SYNTAX score (SS), guidelines recommend this tool to help choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with left main of three-vessel coronary artery disease. The aim of this study was to compare the inter-observer variation in SS performed by clinical cardiologists (CC), interventional cardiologists (IC), and cardiac surgeons (CS). Methods: Seven coronary angiographies from patients with left main and/or three-vessel disease chosen by a heart team were analyzed by 10 CC, 10 IC and 10 CS. SS was calculated via SYNTAX website. Results: Kappa concordance was very low between CC and CS (k = 0.176), moderate between CS and IC (k = 0.563), and moderate between CC and IC (0.553). There was a statistically significant difference between CC, who classified more cases as low complexity (70%), and CS, who classified more cases as moderate complexity (80%) (p = 0.041). Conclusion: Concordance between SS analyzed by CC, CS and IC is low. The usefulness of SS in decision-making of revascularization strategy is undeniable and evidence supports its use. However, this study highlights the importance of well-trained professionals on calculating the SS. It could avoid misclassification of borderline cases.
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Affiliation(s)
- Gustavo Neves de Araujo
- Department of Cardiology, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903, Brazil.,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Tiago Luiz Luz Leiria
- Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Bruno da Silva Matte
- Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Guilherme Pinheiro Machado
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Ana Maria Krepsky
- Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Luiz Carlos Corsetti Bergoli
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Sandro Cadaval Goncalves
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Marco Vugman Wainstein
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
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229
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Inanc IH, Polat E, Coskun FY. One-year clinical follow-up and outcomes in patients after drug-eluting stent implantation for unprotected left main coronary stenosis: A single center study from Turkey. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2020. [DOI: 10.25083/2559.5555/5.1/43.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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230
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Second Generation Drug-Eluting Stent Implantation versus Coronary Artery Bypass Grafting in the Treatment of Young Patients with Left Main and/or Multivessel Coronary Disease. J Interv Cardiol 2020; 2020:6736704. [PMID: 32372888 PMCID: PMC7191400 DOI: 10.1155/2020/6736704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/12/2020] [Indexed: 11/17/2022] Open
Abstract
Background Many studies have compared the outcomes of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) for complex coronary artery disease (CAD). However, no trials have focused on young patients (<45 years) with complex CAD. We conducted a retrospective evaluation to compare the outcomes of a second-generation drug-eluting stent (DES) and CABG in young patients with LM or three-vessel disease. Methods In young patients with complex CAD who underwent PCI or CABG, a Kaplan-Meier analysis and Cox regression before and after propensity score matching were used to compare major adverse cardiac and cerebrovascular events (MACCE), including myocardial infarction (MI), stroke, death, and repeat revascularization. Results During follow-up, MACCE occurred in 20.5% of patients in the PCI group and 8.6% of patients in the CABG group (hazard ratio (HR): 3.263, 95% confidence interval (CI): 1.379 to 7.722, p=0.007). Repeat revascularization occurred more frequently in the PCI group (18.9% vs. 3.7%, respectively, HR: 6.968, 95% CI: 2.036 to 23.842, p=0.002). There were no significant differences in the other endpoints. After propensity score matching, no conclusions were modified. Conclusions In young patients with LM or three-vessel disease, PCI showed a higher incidence of MACCE, which was mainly driven by repeat revascularization. However, this did not translate into hard endpoint differences. Therefore, PCI is an alternative treatment to CABG in young patients with complex CAD.
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231
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Alfonso F, Kastrati A. Ten-Year Follow-Up of Left Main Coronary Artery Revascularization: Still Equipoise Between Percutaneous Interventions and Surgery? Circulation 2020; 141:1447-1451. [PMID: 32223557 DOI: 10.1161/circulationaha.120.046154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (F.A.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, and the German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (A.K.)
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232
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Park DW, Ahn JM, Park H, Yun SC, Kang DY, Lee PH, Kim YH, Lim DS, Rha SW, Park GM, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB, Park SJ. Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Disease. Circulation 2020; 141:1437-1446. [DOI: 10.1161/circulationaha.120.046039] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
Long-term comparative outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents and coronary-artery bypass grafting (CABG) for left main coronary artery disease are highly debated.
Methods:
In the PRECOMBAT trial (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease), patients with unprotected left main coronary artery disease were randomly assigned to undergo PCI with sirolimus-eluting stents (n=300) or CABG (n=300) in 13 hospitals in Korea from April 2004 to August 2009. The follow-up was extended to at least 10 years for all patients (median, 11.3 years). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target-vessel revascularization).
Results:
At 10 years, a primary outcome event occurred in 29.8% of the PCI group and in 24.7% of the CABG group (hazard ratio [HR] with PCI vs CABG, 1.25 [95% CI, 0.93–1.69]). The 10-year incidence of the composite of death, myocardial infarction, or stroke (18.2% vs 17.5%; HR 1.00 [95% CI, 0.70–1.44]) and all-cause mortality (14.5% vs 13.8%; HR 1.13 [95% CI, 0.75–1.70]) were not significantly different between the PCI and CABG groups. Ischemia-driven target-vessel revascularization was more frequent after PCI than after CABG (16.1% vs 8.0%; HR 1.98 [95% CI, 1.21–3.21).
Conclusions:
Ten-year follow-up of the PRECOMBAT trial of patients with left main coronary artery disease randomized to PCI or CABG did not demonstrate significant difference in the incidence of major adverse cardiac or cerebrovascular events. Because the study was underpowered, the results should be considered hypothesis-generating, highlighting the need for further research.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifiers: NCT03871127 and NCT00422968.
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Affiliation(s)
- Duk-Woo Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Hanbit Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Sung-Cheol Yun
- Division of Biostatistics (S.-C.Y.), Asan Medical Center, Seoul, Korea
| | - Do-Yoon Kang
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Young-Hak Kim
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Do-Sun Lim
- Korea University Anam Hospital, Seoul (D.-S.L.)
| | | | | | | | - Hyo-Soo Kim
- Samsung Medical Center, Seoul, Korea (H.-C.G., H.-S.K.)
- Seoul National University Hospital, Korea (H.-S.K.)
| | - In-Ho Chae
- Seoul National University Bundan Hospital, Seongnam, Korea (I.-H.C.)
| | - Yangsoo Jang
- Yonsei University Severance Hospital, Seoul, Korea (Y.J.)
| | - Myung-Ho Jeong
- Chonnam National University Hospital, Gwangju, Korea (M.-H.J.)
| | | | - Ki Bae Seung
- Catholic University of Korea, St. Mary’s Hospital, Seoul (K.B.S.)
| | - Seung-Jung Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
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van Zandvoort LJC, van Bommel RJ, Masdjedi K, Tovar Forero MN, Lemmert MM, Wilschut J, Diletti R, de Jaegere PPT, Zijlstra F, van Mieghem NM, Daemen J. Long-term outcome in patients treated with first- versus second-generation drug-eluting stents for the treatment of unprotected left main coronary artery stenosis. Catheter Cardiovasc Interv 2020; 95:1085-1091. [PMID: 31301161 DOI: 10.1002/ccd.28387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/01/2019] [Accepted: 06/22/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE AND BACKGROUND The study aim is to provide long-term clinical outcome after percutaneous coronary intervention (PCI) for unprotected left main coronary arteries (ULMCA) stenosis with the first-generation (1st -gen) drug-eluting stents (DES) in comparison to 2nd -gen DES, since this is largely unknown. METHODS Between May 2002, and December 2014, a consecutive series of 656 all-comer patients underwent a PCI for ULMCA stenosis at the Erasmus Medical Center. A total of 235 patients were treated with 1st -gen DES, while a total of 421 patients were treated with 2nd -gen DES. RESULTS Overall, the population consisted of 73% males and 58% presented with an acute coronary syndrome. Median follow-up time was 1,361 days (range from 0 to 5,031). At 5 years, the cumulative incidence of major adverse clinical events (the primary composite endpoint of all-cause death, any myocardial infarction or target lesion revascularization; MACE) did not differ between 1st - and 2nd -gen DES (36.8 vs. 38.6%, respectively, Log Rank p = .79, adjusted hazard ratio [HR] = 1.28 [95% confidence interval (CI) 0.94-1.74]). No difference was found in the individual endpoints of all-cause mortality (29.5 vs. 29% respectively, p = .88, adjusted HR = 1.19 [95% CI, 0.84-1.68]), target vessel myocardial infarction (5.0 vs. 8.4%, p = 0.17, adjusted HR = 1.75 [95% CI, 0.78-3.96]) and target lesion revascularization (8.1 vs. 9.8%, p = .94, adjusted HR = 1.16 [95% CI, 0.59-2.29]) between the 1st - and 2nd -gen DES cohorts, respectively. CONCLUSIONS In this large cohort of consecutive patients treated for ULMCA stenosis, no significant differences were found in the safety and efficacy of 1st versus 2nd -gen DES at 5 years follow-up.
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Affiliation(s)
| | - Rutger J van Bommel
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Kaneshka Masdjedi
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | | | - Miguel M Lemmert
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Peter P T de Jaegere
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Nicolas M van Mieghem
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
| | - Joost Daemen
- Department of cardiology, Thoraxcenter, Erasmus Medical Center, CA Rotterdam, The Netherlands
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Six months follow-up of protected high-risk percutaneous coronary intervention with the microaxial Impella pump: results from the German Impella registry. Coron Artery Dis 2020; 31:237-242. [DOI: 10.1097/mca.0000000000000824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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235
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Furtado RH, Bergmark B. Ejection fraction versus B‐type natriuretic peptide for revascularization strategy in left main disease: two sides of the same coin or a wooden nickel? Eur J Heart Fail 2020; 22:880-883. [DOI: 10.1002/ejhf.1717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Remo H.M. Furtado
- Albert Einstein Hospital São Paulo Brazil
- Instituto do Coração (Heart Institute) da Faculdade de Medicina da USP São Paulo Brazil
| | - Brian Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital Harvard Medical School Boston MA USA
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236
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Commentary: The left main controversy: Is this a real subgroup requiring custom clinical recommendations? J Thorac Cardiovasc Surg 2020; 163:108-110. [DOI: 10.1016/j.jtcvs.2020.04.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/20/2022]
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Tommaso CL. Stenting in unprotected left main coronary stenosis-"What no progress"? Catheter Cardiovasc Interv 2020; 95:1092-1093. [PMID: 32421241 DOI: 10.1002/ccd.28922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/11/2022]
Abstract
There does not appear to be a difference in patient outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis whether using first- or second-generation drug elutting stent. This is despite increase in patients having more adjunctive procedures such as intravascular imaging and newer generation antiplatelet agents. This single-center study provokes questions as to why there has not been improvement in outcomes.
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Affiliation(s)
- Carl L Tommaso
- Rush University Medical School, NorthShore University HealthSystem, Evanston, Illinois, USA
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239
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Percutaneous Coronary Intervention Complexity and Risk of Adverse Events in relation to High Bleeding Risk among Patients Receiving Drug-Eluting Stents: Insights from a Large Single-Center Cohort Study. J Interv Cardiol 2020; 2020:2985435. [PMID: 32405273 PMCID: PMC7196972 DOI: 10.1155/2020/2985435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/17/2020] [Indexed: 01/05/2023] Open
Abstract
Background/Aim The relation between complex percutaneous coronary intervention (PCI), high bleeding risk (HBR), and adverse events after coronary artery implantation of drug-eluting stents has been incompletely characterized. This study sought to investigate the ischemic and bleeding events after complex PCI including stratification according to HBR estimated by PARIS bleeding risk score. Methods Between January 2013 and December 2013, 10,167 consecutive patients undergoing PCI were prospectively enrolled in Fuwai PCI Registry. Complex PCI was defined when having at least one of the following characteristics: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, unprotected left main PCI, in-stent restenosis target lesion, and severely calcified lesion. The primary ischemic endpoint was major adverse cardiovascular events (MACE) (composite of cardiac death, myocardial infarction, definite/probable stent thrombosis, and target lesion revascularization), and primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. Results The median duration of follow-up was 29 months. In adjusted Cox regression analysis, patients having complex PCI procedures experienced higher risks of MACE (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.38–1.92; P < 0.001), compared with noncomplex PCI. In contrast, the risk of clinically relevant bleeding was statistically similar between the 2 groups (HR: 0.86 [0.66–1.11]; P = 0.238). There was no statistical interaction between HBR (PARIS bleeding score ≥8 or <8) and complex PCI in regard to MACE (adjusted Pinteraction = 0.388) and clinically relevant bleeding (adjusted Pinteraction = 0.279). Conclusions Patients who had undergone complex PCI resulted in substantially more ischemic events, without an increase in clinically relevant bleeding risk, and these associations did not seem to be modified by HBR status. More intensified antiplatelet therapy may be beneficial for patients with complex percutaneous coronary revascularization procedures.
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240
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Lee K, Ahn JM, Yoon YH, Kang DY, Park SY, Ko E, Park H, Cho SC, Park S, Kim TO, Lee PH, Lee SW, Park SW, Park DW, Park SJ. Long-Term (10-Year) Outcomes of Stenting or Bypass Surgery for Left Main Coronary Artery Disease in Patients With and Without Diabetes Mellitus. J Am Heart Assoc 2020; 9:e015372. [PMID: 32310027 PMCID: PMC7428513 DOI: 10.1161/jaha.119.015372] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Data are still limited regarding whether there are differential long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for left main coronary artery disease with or without diabetes mellitus (DM). Methods and Results Using the 10-year data from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry, we sought to examine the effect of DM on comparative outcomes after percutaneous coronary intervention or CABG in patients with unprotected left main coronary artery disease. The outcomes of interest were all-cause mortality; a composite of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization. The primary adjusted analyses were performed with the use of propensity scores and inverse-probability weighting. Of 2240 patients with left main coronary artery revascularization, 722 (32%) had DM. In the overall population, the adjusted 10-year risks of death and composite outcome were similar between percutaneous coronary intervention and CABG, irrespective of DM status (Pinteraction: 0.41, mortality; 0.40, composite outcome). However, in the cohort of bare-metal stents and concurrent CABG, we observed differential outcomes after stenting and CABG by DM status (Pinteraction: 0.09, mortality; 0.04, composite outcome), favoring CABG in patients with DM. In the cohort of drug-eluting stents and concurrent CABG, the better effect of CABG over stenting was narrowed in patients with DM without a significant interaction (Pinteraction: 0.63, mortality; 0.47, composite outcome). Conclusions In this cohort of patients with longest follow-up who underwent left main coronary artery revascularization, the clinical impact of DM favoring CABG over percutaneous coronary intervention has diminished over time from the bare-metal stent to the drug-eluting stent era. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02791412.
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Affiliation(s)
- Kyusup Lee
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Jung-Min Ahn
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Yong-Hoon Yoon
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Do-Yoon Kang
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Seo-Young Park
- Department of Clinical Epidemiology and Biostatistics Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Euihong Ko
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Hanbit Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Sang-Cheol Cho
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Sangwoo Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Tae Oh Kim
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Pil Hyung Lee
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Seung-Whan Lee
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Seong-Wook Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Duk-Woo Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Seung-Jung Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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241
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Bilateral internal thoracic artery grafting in patients with left main disease: a single-center experience. Coron Artery Dis 2020; 31:464-471. [PMID: 32271239 DOI: 10.1097/mca.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compared early and long-term outcomes between bilateral internal thoracic artery (BITA) grafting and single internal thoracic artery (SITA) grafting in patients with LM disease. METHODS We evaluated the outcomes of all patients with LM disease who underwent revascularization in our center during 1996-2011. Variables that were adjusted for in a multivariate analysis and in propensity matching included age, sex, comorbid diseases, repeat operation, the number of diseased vessels, other conduits used, the use of sequential grafting, the number of grafts constructed, and the operative era (1996-2000 vs. 2001-2011). RESULTS In total, 949 patients with LM disease underwent BITA grafting and 564 underwent SITA grafting during the study period. SITA patients were more often female and more likely to have comorbidities such as chronic obstructive pulmonary disease, ejection fraction <30%, recent myocardial infarction, diabetes, congestive heart failure, chronic renal failure, and peripheral vascular disease, and to have undergone an emergency operation. We found no statistically significant difference between the SITA and BITA groups in 30-day mortality (4.8% vs. 3.3%, P = 0.136), sternal wound infection (2.0% vs. 2.4%, P = 0.548), and stroke (3.2% vs. 4.4%, P = 0.234). BITA patients had improved long-term survival (70.1% vs. 52.0% p<0.001), median follow-up of 15 years. In multivariate analysis, after propensity score matching (477 matched pairs), this finding was not statistically significant (P = 0.135). CONCLUSION This study did not demonstrate a clear benefit of BITA grafts among patients with LM disease.
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Chai J, Wang K, Kong X, Pan C, Jiang W, Zhou W, Chen H, Xue F, Zhang L, Shen Z. Coronary artery bypass graft combined with liver transplantation in patients with advanced alcoholic liver cirrhosis: A case report. Exp Ther Med 2020; 19:3197-3202. [PMID: 32266015 PMCID: PMC7132228 DOI: 10.3892/etm.2020.8594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 08/30/2019] [Indexed: 11/17/2022] Open
Abstract
Performing cardiothoracic surgery on patients with advanced liver failure and liver cirrhosis is high-risk for patients. Coronary artery bypass grafting is the most effective treatment for patients with liver failure that is complicated with severe coronary heart disease, and who cannot be treated using coronary stent intervention. In the current study, one case of coronary artery bypass grafting combined with liver transplantation was assessed, with the patient exhibiting advanced alcoholic liver cirrhosis. A coronary artery bypass graft was performed to relieve angina pectoris. Following surgery, wound exudation, secondary infection, liver failure, pleuroperitoneal fluid leakage, hypoproteinemia and other adverse treatment results occurred, and the chest wound did not heal. Allograft liver transplantation was subsequently performed and, following surgery, the chest wound healed gradually after debridement, and the patient recovered.
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Affiliation(s)
- Junwu Chai
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Kai Wang
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Xiangrong Kong
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Cheng Pan
- Department of Liver Transplantation, Tianjin First Central Hospital, Tianjin 300192, P.R. China
| | - Wentao Jiang
- Department of Liver Transplantation, Tianjin First Central Hospital, Tianjin 300192, P.R. China
| | - Wei Zhou
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Honglei Chen
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Fenlong Xue
- Department of Cardiovascular Surgery, Tianjin First Central Hospital, Tianjin Clinical Research Center for Organ Transplantation, Tianjin, 300074, P.R. China
| | - Li Zhang
- Department of Liver Transplantation, Tianjin First Central Hospital, Tianjin 300192, P.R. China
| | - Zhongyang Shen
- Department of Liver Transplantation, Tianjin First Central Hospital, Tianjin 300192, P.R. China
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243
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Two-Year Outcomes after Left Main Coronary Artery Percutaneous Coronary Intervention in Patients Presenting with Acute Coronary Syndrome. J Interv Cardiol 2020; 2020:6980324. [PMID: 32327944 PMCID: PMC7166269 DOI: 10.1155/2020/6980324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives We aim to evaluate long-term outcomes after left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). Background PCI of the LMCA has been an acceptable revascularization strategy in stable coronary artery disease. However, limited studies on long-term clinical outcomes of LMCA PCI in ACS patients are available. Methods A total of 6429 consecutive patients with ACS undergoing PCI in Fuwai Hospital in 2013 were enrolled. Patients are divided into LMCA group and Non-LMCA group according to whether the target lesion was located in LMCA. Prognosis impact on 2-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed. Results 155 (2.4%) patients had target lesion in LMCA, while 6274 (97.6%) patients belong to the non-LMCA group. Compared with non-LMCA patients, LMCA patients have generally more comorbidities and worse baseline conditions. Two-year follow-up reveals that LMCA patients have significantly higher rate of cardiac death (2.6% vs. 0.7%, p = 0.034), myocardial infarction (7.1% vs. 1.8%, p < 0.001), in-stent thrombosis (4.5% vs. 0.8%, p < 0.001), and stroke (7.1% vs. 6.4%, p = 0.025). After adjusting for confounding factors, LMCA remains independently associated with higher 2-year myocardial infarction rate (HR = 2.585, 95% CI = 1.243-5.347, p = 0.011). Conclusion LMCA-targeted PCI is an independent risk factor for 2-year myocardial infarction in ACS patients.
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Gallo M, Blitzer D, Laforgia PL, Doulamis IP, Perrin N, Bortolussi G, Guariento A, Putzu A. Percutaneous coronary intervention versus coronary artery bypass graft for left main coronary artery disease: A meta-analysis. J Thorac Cardiovasc Surg 2020; 163:94-105.e15. [DOI: 10.1016/j.jtcvs.2020.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
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Gao C, Wang R, Sharif F, Takahashi K, Ono M, Hara H, Tomaniak M, Kawashima H, Modolo R, van Geuns RJM, Capodanno D, Byrne RA, Wijns W, Onuma Y, Serruys PW. The year in review: coronary interventions. EUROINTERVENTION 2020; 15:1534-1547. [DOI: 10.4244/eij-d-19-01124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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246
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A Hypothetical Vascular Stent with Locally Enlarged Segment and the Hemodynamic Evaluation. Cardiol Res Pract 2020; 2020:7041284. [PMID: 32185077 PMCID: PMC7060871 DOI: 10.1155/2020/7041284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/03/2020] [Indexed: 11/17/2022] Open
Abstract
Among the interventional stenting methods for treating coronary bifurcation lesions, the conventional treatments still have disadvantages, which include increased intervention difficulties or inadequate supply of blood flow to side branches and may alter the physiological function of downstream organs. Thus, the optimized design of stent geometry needs to be improved based on the specific shape of branches to minimize the complications of inadequate blood flow to the downstream organs and tissues. Our research used 3D modeling and fluid dynamics simulation to design and evaluate a new stent with locally enlarged segment by altering the proportion and length of enlarged surface area based on Bernoulli's equation. The aim is to increase the pressure and blood flow supply at side branches. According to series of blood flow simulations, the stent with 10% enlargement of surface area and length of 3 folders of stent diameter was assigned as the optimized design. The results revealed that by using this design, according to the simulation results, the average pressure on side branches increased at the rate of 43.6%, which would contribute to the adequate blood supply to the downstream organs. Besides, the average wall shear stress (WSS) at sidewalls increased at 9.2% while the average WSS on the host artery wall decreased at 14.1%. There is in the absent of noticeable rise in the total area of low WSS that blows the threshold of 0.5 Pa. Therefore, the present study provides a new method to optimize the hemodynamics features of stent for bifurcation arteries.
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247
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Cummings IG, Lucchese G, Garg S, Soni M, Majid AF, Marczin N, Panoulas V, Raja SG. Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study. Int J Surg 2020; 76:146-152. [PMID: 32173612 DOI: 10.1016/j.ijsu.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients. METHODS We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI. RESULTS 214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001). CONCLUSION Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.
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Affiliation(s)
- Ian G Cummings
- Department of Cardiac Surgery, Harefield Hospital, London, UK.
| | | | - Sheena Garg
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Manish Soni
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Akbar F Majid
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Nandor Marczin
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | | | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK
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248
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Chiarito M, Mehilli J. Left main coronary artery disease: when and how to perform PCI? Minerva Cardioangiol 2020; 68:405-414. [PMID: 32107900 DOI: 10.23736/s0026-4725.20.05198-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Left main coronary artery (LMCA) disease has been reported in up to 10% of all patients with coronary artery disease (CAD) and in the majority of cases are associated with severe three-vessel CAD. Among patients with chronic coronary syndrome revascularization of significant LMCA disease improves prognosis, while there is a debate about which revascularization strategy, CABG surgery or percutaneous coronary interventions to use. We do a review of the available evidence about the impact of LMCA lesions on patient prognosis according to CAD extension and clinical presentation, the outcome after percutaneous or surgical revascularization, the procedural challenges of LMCA PCI and the available armamentarium to optimally treat this relevant population.
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Affiliation(s)
- Mauro Chiarito
- Cardio Center, Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Julinda Mehilli
- Department of Cardiology, Munich University Hospital, Ludwig-Maximilians University, Munich, Germany - .,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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249
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Nguyen P, Seto A. Contemporary practices using intravascular imaging guidance with IVUS or OCT to optimize percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2020; 18:103-115. [PMID: 32077345 DOI: 10.1080/14779072.2020.1732207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction: Angiography is routinely used to perform percutaneous coronary intervention (PCI). However, angiography has many limitations that prevent accurate assessment of coronary lesions. The development and evolution of intravascular imaging have offset the limitations of angiography. Overwhelming evidence supports intravascular imaging guidance to optimize PCI results and studies have shown that it is associated with better outcomes. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are the most commonly used modalities and both have far greater spatial resolution compared with angiography. There are advantages and disadvantages to both IVUS and OCT, and the optimal modality will depend on patient factors and indications.Areas covered: This review will summarize clinical evidence and current practices in the use of intravascular imaging in PCI. Literature review from year 2000-2019 was completed via PubMed search using keywords.Expert commentary: Intravascular imaging is an essential tool in PCI that has outcome implications, but it is still underutilized. Proper image acquisition, accurate interpretation, and correct decision-making are needed for patients to benefit from imaging-guided PCI. Training and education are essential in successful utilization of imaging technology. High-definition IVUS is likely to gain favor as there is improved image resolution without the use of contrast.
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Affiliation(s)
- Peter Nguyen
- Cardiology, University of California, Irvine, CA, USA.,Cardiology, VA Long Beach Health Care System, Long Beach, CA, USA
| | - Arnold Seto
- Cardiology, University of California, Irvine, CA, USA.,Cardiology, VA Long Beach Health Care System, Long Beach, CA, USA
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Kosmidou I, Liu Y, Zhang Z, Redfors B, Kappetein AP, Serruys PW, Gersh BJ, Kandzari DE, Morice MC, Buszman PE, Bochenek A, Schampaert E, Sabik JF, Ben-Yehuda O, Stone GW. Incidence and Prognostic Impact of Atrial Fibrillation After Discharge Following Revascularization for Significant Left Main Coronary Artery Narrowing. Am J Cardiol 2020; 125:500-506. [PMID: 31813531 DOI: 10.1016/j.amjcard.2019.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
The incidence, recurrence rate, and prognostic significance of atrial fibrillation or flutter (AF) following hospital discharge after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) are unknown. We sought to determine the 3-year incidence and clinical impact of postdischarge AF in patients with LMCAD treated with PCI or CABG. In the EXCEL trial, 1,905 patients with LMCAD were randomized to PCI versus CABG. We analyzed the occurrence of postdischarge AF through 3 years and its time-adjusted association with adverse outcomes. A total of 1,802 patients without AF at baseline comprised the study cohort. Within 3 years, 227 episodes of AF occurred (29 [12.8%] in the PCI arm and 198 [87.2%] in the CABG arm, p <0.0001); of those, 63 (27.7%) occurred following discharge from the index hospitalization in 57 patients. In-hospital AF predicted postdischarge AF (hazard ratio [HR] 2.94, 95% confidence interval [CI] 1.42 to 6.10, p = 0.004). By multivariable analysis, time-updated postdischarge AF was an independent predictor of 3-year cardiovascular death (HR 4.91, 95% CI 1.92 to 12.60, p = 0.0009), stroke (HR 4.87, 95% CI 1.12 to 21.12, p = 0.035), and the composite outcome of death, stroke or myocardial infarction (HR 3.09, 95% CI 1.56 to 3.6-6.11, p = 0.001). Among patients with postdischarge AF, the rate of the primary composite outcome did not vary according to presence or absence of in-hospital AF (21.0% vs 23.8%, p = 0.78). In conclusion, postdischarge AF following CABG or PCI for LMCAD is associated with increased mortality and stroke. In-hospital atrial fibrillation is an independent predictor of AF following discharge.
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