Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis

The association between preoperative multidisciplinary team care and patient outcome in frail patients undergoing cardiac surgery

OBJECTIVE

To evaluate the influence of preoperative multidisciplinary team (MDT) care on perioperative management and outcomes of frail patients undergoing cardiac surgery.

BACKGROUND

Frail patients are at increased risk for complications and poor functional outcome after cardiac surgery. In these patients, preoperative MDT care may improve outcomes.

METHODS

Between 2018 and 2021, 1168 patients aged 70 years or older were scheduled for cardiac surgery, of whom 98 (8.4%) frail patients were referred for MDT care. The MDT discussed surgical risk, prehabilitation, and alternative treatment. Outcomes of MDT patients were compared with 183 frail patients (non-MDT group) from a historical study cohort (2015-2017). Inverse probability of treatment weighting was used to minimize bias from nonrandom allocation of MDT versus non-MDT care. Outcomes were severe postoperative complications, total days in hospital after 120 days, disability, and health-related quality of life after 120 days.

RESULTS

This study included 281 patients (98 MDT and 183 non-MDT patients). Of the MDT patients, 67 (68%) had open surgery, 21 (21%) underwent minimally invasive procedures, and 10 (10%) received conservative treatment. In the non-MDT group, all patients had open surgery. Fourteen (14%) MDT patients experienced a severe complication versus 42 (23%) non-MDT patients (adjusted relative risk, 0.76; 95% CI, 0.51-0.99). Adjusted total days in hospital after 120 days was 8 days (interquartile range, 3-12 days) versus 11 days (interquartile range, 7-16 days) for MDT and non-MDT patients, respectively (P = .01). There was no difference in disability or health-related quality of life.

CONCLUSIONS

Preoperative MDT care for frail patients undergoing cardiac surgery is associated with alterations in surgical management and with a lower risk for severe complications.

Impacts of the SYNTAX score I, II and SYNTAX score II 2020 on left main revascularization

Patients with left main coronary artery disease (LMCAD) with a high SYNTAX score (SS) were excluded from randomized studies that comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). We sought to compare PCI and CABG in the real-world practice and investigate the impact of SS I, SS II, and SS II 2020 on clinical outcomes. In total, 292 Patients with LMCAD (173 PCI, 119 CABG) treated between 2017 and 2021 were enrolled. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, stroke, or myocardial infarction (MI). The mean SS I was high in both groups (PCI vs. CABG: 31.64 ± 11.45 vs. 32.62 ± 11.75, p = 0.660). The primary outcome occurred in 28 patients (16.2%) in the PCI group and in 19 patients (16.0%) in the CABG group without significant difference [adjusted hazard ratio, 95% CI = 0.98 (0.51-1.90), p = 0.97] over the follow-up period (26.9 ± 17.7 months). No significant difference was observed in all-cause mortality (11.6% vs. 11.8%, p = 0.93) or stroke rates (3.5% vs. 5.0%, p = 0.51) between groups. However, PCI was associated with higher MI (4.6% vs. 0.8%, p < 0.05) and revascularization rates (26% vs. 5.9%, p < 0.001). Prognostic value of the SS I, SS II and SS II 2020 on the primary outcome was not relevant in the PCI group. Among patients with LMCAD, PCI and CABG did not significantly differ in the composite endpoint of all-cause death, stroke, and MI. These results support the potential expansion of PCI indications in LMCAD management for whom are ineligible for CABG with complex coronary artery disease.

The association between fibrinogen levels and severity of coronary artery disease and long-term prognosis following percutaneous coronary intervention in patients with type 2 diabetes mellitus

Background

Fibrinogen is a potential risk factor for the prognosis of CAD and is associated with the complexity of CAD. There is limited research specifically investigating the predictive role of fibrinogen in determining the severity of CAD among patients with T2DM, as well as its impact on the prognosis following PCI.

Methods

The study included 675 T2DM patients who underwent PCI at the Third People's Hospital of Chengdu between April 27, 2018, and February 5, 2021, with 540 of them remaining after exclusions. The complexity of CAD was assessed using the SYNTAX score. The primary endpoint of the study was the incidence of MACCEs.

Results

After adjusting for multiple confounding factors, fibrinogen remained a significant independent risk factor for mid/high SYNTAX scores (SYNTAX score > 22, OR 1.184, 95% CI 1.022-1.373, P = 0.025). Additionally, a dose-response relationship between fibrinogen and the risk of complicated CAD was observed (SYNTAX score > 22; nonlinear P = 0.0043). The area under the receiver operating characteristic curve(AUROC) of fibrinogen for predicting mid/high SYNTAX score was 0.610 (95% CI 0.567-0.651, P = 0.0002). The high fibrinogen group (fibrinogen > 3.79 g/L) had a higher incidence of calcified lesions and an elevated trend of more multivessel disease and chronic total occlusion. A total of 116 patients (21.5%) experienced MACCEs during the median follow-up time of 18.5 months. After adjustment, multivariate Cox regression analysis confirmed that fibrinogen (HR, 1.138; 95% CI 1.010-1.284, P = 0.034) remained a significant independent risk factor for MACCEs. The AUROC of fibrinogen for predicting MACCEs was 0.609 (95% CI 0.566-0.650, P = 0.0002). Individuals with high fibrinogen levels (fibrinogen > 4.28 g/L) had a higher incidence of acute myocardial infarction (P < 0.001), MACCEs (P < 0.001), all-cause death (P < 0.001), stroke (P = 0.030), and cardiac death (P = 0.002). Kaplan-Meier analysis revealed a higher incidence of MACCEs in the high fibrinogen group (Log-Rank test: P < 0.001).

Conclusions

Elevated fibrinogen levels were associated with increased coronary anatomical complexity (as quantified by the SYNTAX score) and a higher incidence of MACCEs after PCI in patients with T2DM.

Outcomes of Complex Percutaneous Cardiac Interventions in Women

Complex percutaneous cardiac intervention (PCI) is a growing procedure in modern day cath labs. The treated population is often older, with multiple comorbidities, complex coronary anatomy, left ventricular dysfunction, and possibly concomitant valvular heart disease and/or cardiogenic shock. As such, PCI of bifurcations, chronic total occlusions, and atherectomy coronary interventions are becoming more common. The outcomes in terms of acute procedural success, procedure-related complications, and long-term mortality or heart failure hospitalizations are important to consider. Unfortunately, to date there is a paucity of data identifying sex and gender disparities following such interventions. With respect to bifurcation lesions, women usually have more comorbidities with less complex coronary anatomy. However, despite less complex anatomy, women have a significantly increased risk of MI. These differences are also noted with left main stem and multivessel disease, during which women appear to have a trend towards worse outcomes following PCI compared with coronary artery bypass grafting. Randomized trials have revealed that women present with increased cardiovascular risk factors, which may contribute to adverse longer-term outcomes. Revascularization of women with concomitant valvular heart disease is particularly challenging because the existing data are conflicted on not only the indication, but also the timing of revascularization. Similarly, women undergoing PCI of calcified lesions with drug-eluting stents have a worse clinical profile and remain at increased ischemic risk. The lower incidence of coronary calcification in women, combined with the under-representation of women in randomized trials, poses a real challenge when attempting to address safety and survival benefit in women undergoing complex interventions. This warrants dedicated trials exploring the safety and efficacy of complex interventions in women.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease: An Updated Systematic Review and Meta-Analysis

Recently, both US and European guidelines have predominantly recommended coronary artery bypass grafting (CABG) as the preferred revascularisation method. However, emerging data have raised the possibility of percutaneous coronary intervention (PCI) being a viable and effective alternative. This meta-analysis sought to evaluate the latest insights from major clinical trials to ascertain whether PCI could be as effective as CABG in treating left main coronary artery (LMCA) disease. To achieve this, a comprehensive systematic search was conducted across databases, including Medline (via PubMed), Embase, Cochrane, and clinicaltrials.gov. The search spanned from the inception of these databases to August 20, 2022, and exclusively focused on randomized controlled trials (RCTs). Employing the random effects model, selected studies underwent rigorous analysis. The study outcomes encompassed a spectrum of factors such as all-cause mortality, major adverse cerebrovascular and cardiovascular events (MACCE), myocardial infarction (MI), stroke, and revascularisation procedures. The observation periods of interest included the 30-day mark, 1 year, 5 years, and 10 years. The analysis integrated six RCTs, revealing noteworthy patterns. In terms of all-cause mortality, PCI demonstrated non-inferiority to CABG across all observed time frames: 30 days (OR 0.6), 1 year (OR 0.77), 5 years (OR 1.41), and 10 years (OR 1.08). Analysis of MACCE outcomes favored PCI at 30 days and CABG at 5 years. The utilisation of the original five-year EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularisation) trial definition for MI highlighted higher MI rates for PCI compared to CABG (OR 1.66, P < 0.05). Intriguingly, when the subsequently released EXCEL data, aligned with the third universal MI definition, was incorporated, the five-year data consistently leaned towards CABG. Specifically, the PCI group exhibited 7.5% MI rates in contrast to the 3.6% in the CABG cohort (OR 2.19, P < 0.001). Concerning stroke, PCI proved advantageous at 30 days and 1 year while exhibiting no significant disparity at 5 and 10 years. Revascularisation procedures favoured CABG at one and five years, with comparability at the remaining time points. In summation, the outcomes of this comprehensive meta-analysis suggest that PCI could serve as a feasible alternative to CABG in the context of uncomplicated LMCA disease. It's worth noting that CABG might still hold an advantage for complex lesions.

Artificial intelligence in the autonomous navigation of endovascular interventions: a systematic review

Background

Autonomous navigation of catheters and guidewires in endovascular interventional surgery can decrease operation times, improve decision-making during surgery, and reduce operator radiation exposure while increasing access to treatment.

Objective

To determine from recent literature, through a systematic review, the impact, challenges, and opportunities artificial intelligence (AI) has for the autonomous navigation of catheters and guidewires for endovascular interventions.

Methods

PubMed and IEEEXplore databases were searched to identify reports of AI applied to autonomous navigation methods in endovascular interventional surgery. Eligibility criteria included studies investigating the use of AI in enabling the autonomous navigation of catheters/guidewires in endovascular interventions. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), articles were assessed using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). PROSPERO: CRD42023392259.

Results

Four hundred and sixty-two studies fulfilled the search criteria, of which 14 studies were included for analysis. Reinforcement learning (RL) (9/14, 64%) and learning from expert demonstration (7/14, 50%) were used as data-driven models for autonomous navigation. These studies evaluated models on physical phantoms (10/14, 71%) and in-silico (4/14, 29%) models. Experiments within or around the blood vessels of the heart were reported by the majority of studies (10/14, 71%), while non-anatomical vessel platforms "idealized" for simple navigation were used in three studies (3/14, 21%), and the porcine liver venous system in one study. We observed that risk of bias and poor generalizability were present across studies. No procedures were performed on patients in any of the studies reviewed. Moreover, all studies were limited due to the lack of patient selection criteria, reference standards, and reproducibility, which resulted in a low level of evidence for clinical translation.

Conclusion

Despite the potential benefits of AI applied to autonomous navigation of endovascular interventions, the field is in an experimental proof-of-concept stage, with a technology readiness level of 3. We highlight that reference standards with well-identified performance metrics are crucial to allow for comparisons of data-driven algorithms proposed in the years to come.

Systematic review registration

identifier: CRD42023392259.

Alirocumab effect on preventing periprocedural ischaemic events in coronary heart disease patients undergoing coronary stenting (APPEASE trial): study protocol of a multicentre, open-label, randomised controlled trial

INTRODUCTION

Percutaneous coronary intervention (PCI)-related myocardial infarction (type 4a MI) and major periprocedural myocardial injury have been demonstrated leading to poor prognosis of patients with coronary heart disease (CHD) undergoing elective PCI and still remain high occurrence even after the therapy of dual antiplatelet agents and statins. Proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab has been shown to be effectively in reducing the risk of acute MI (AMI). However, the effect of alirocumab on preventing PCI-related MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI remains uncertain.

METHODS AND ANALYSIS

Alirocumab effect on Preventing Periprocedural ischaemic Events in coronary heart diseAse patients undergoing coronary StEnting trial is a multicentre, open-label, randomised controlled trial aiming to determine whether alirocumab could reduce the incidence of type 4a MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI. In total, 422 non-AMI CHD patients planned to undergo elective PCI will be randomly assigned to receive standard pharmacotherapy of CHD (control group) or additional use of subcutaneous alirocumab 75 mg 1 day before procedure (alirocumab group). The primary outcome is type 4a MI or major periprocedural myocardial injury defined as high-sensitivity cardiac troponin elevating above 5×99 th percentile upper reference limit in 48 hours after PCI. Patients will continue receiving standard pharmacotherapy or additional biweekly subcutaneous alirocumab 75 mg for 3 months according to the initial randomisation group. We will follow up for 3 months and record all the major adverse cardiovascular events (MACEs). Incidence of PCI-related MI or major periprocedural myocardial injury, and MACE in 3 months after PCI will be compared between control group and alirocumab group.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University with approval number: (2022)02-140-01. The results of this study will be reported through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200063191.

Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review

The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

Long-term clinical outcomes of percutaneous coronary intervention for ostial left main coronary artery disease

BACKGROUND

There are limited data regarding the long-term prognosis of percutaneous coronary intervention treatment for left main (LM) ostial stenosis.

AIMS

The present study sought to investigate the long-term clinical outcomes and risk factors for adverse events in LM ostial lesions following drug-eluting stent implantation (DES) in a large cohort of an LM registry database.

METHODS

Patients presenting with LM coronary disease from January 2004 to December 2016 at Fuwai Hospital were included. The primary endpoint was target vessel failure (TVF), a composite endpoint of cardiac death, target vessel myocardial infarction and target vessel revascularisation. Cox proportional hazards models were constructed to identify independent predictors.

RESULTS

Among 4,625 LM patients, 627 (13.6%) patients were identified with LM ostial lesions. There were more female patients in the ostial group (31.3%), compared with the shaft (18.1%) and bifurcation groups (19.9%) (p<0.0001). Among patients with DES implantation, 3-year TVF occurred in 44 patients (7.5%) in the ostial group, which is comparable with the other two groups. Myocardial infarction (MI) was significantly lower in the ostial group (2.0%) compared with the bifurcation group (4.2%) (p=0.02), especially for MI events originating in the LM vessel (p=0.02). For patients with ostial LM disease who received percutaneous coronary intervention (PCI) treatment, procedural complications were an independent risk factor for long-term cardiac death or MI, while a more recent PCI proved to be a protective factor.

CONCLUSIONS

PCI treatment for ostial LM lesions achieved favourable long-term outcomes, with a similar MI risk compared with the mid-shaft group but a significantly lower risk of MI compared with the distal group.

Management of failed stenting of the unprotected left main coronary artery

Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease

Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.

Diagnostic and Therapeutic Strategies for Stable Coronary Artery Disease Following the ISCHEMIA Trial

Until recently, coronary revascularization with coronary artery bypass grafting or percutaneous coronary intervention has been regarded as the standard choice for stable coronary artery disease (CAD), particularly for patients with a significant burden of ischemia. However, in conjunction with remarkable advances in adjunctive medical therapy and a deeper understanding of its long-term prognosis from recent large-scale clinical trials, including ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), the approach to stable CAD has changed drastically. Although the updated evidence from recent randomized clinical trials will likely modify the recommendations for future clinical practice guidelines, there are still unresolved and unmet issues in Asia, where prevalence and practice patterns are markedly different from those in Western countries. Herein, the authors discuss perspectives on: 1) assessing the diagnostic probability of patients with stable CAD; 2) application of noninvasive imaging tests; 3) initiation and titration of medical therapy; and 4) evolution of revascularization procedures in the modern era.

Intraoperative visualization of a deformed left main stent during surgical aortic valve replacement

BACKGROUND

While coronary artery bypass grafting is typically considered first choice for the treatment of left main stenosis, there is a trend towards left main stenting due to a steadily aging population in western countries with a high operative risk and patients with single vessel coronary artery disease affecting the left main artery. Nevertheless left main stenting remains controversial, especially in patients with concomitant indications for open-heart surgery.

CASE PRESENTATION

We want to present a case of a 78-year-old male patient with high-grade aortic stenosis who underwent surgical aortic valve replacement at our heart center due to anatomical contraindications for transcatheter aortic valve replacement. Stenting of the left main coronary artery was performed three years earlier due to single vessel coronary artery disease while moderate aortic valve stenosis was under surveillance at the time of the intervention. Intraoperatively we found the stent to be deformed inside the left main coronary artery, covering nearly 25% of the coronary ostium. So injection of cardioplegia directly into this ostium, as we perform normally, was not possible without further damaging the stent and/or the opening of the ostium. We had to insert cardioplegia via the retrograde way, so via the coronary sinus.

CONCLUSION

While left main stenting can be reasonable for a specific population of patients, it should be used cautiously in patients with concomitant indications for open-heart surgery in the near future and a low perioperative risk profile.

Acute, periprocedural and longterm antithrombotic therapy in older adults: 2022 Update by the ESC Working Group on Thrombosis

The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults.

Coronary Stenting: Reflections on a 35-Year Journey

Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.

Left Main Disease

Traditionally, the treatment of left main coronary artery disease is recommended coronary artery bypass grafting because of its superior long-term outcomes compared with medical treatment and plain old balloon angioplasty. However, improvement of percutaneous coronary intervention technique and introduction of drug-eluting stent led to change of treatment strategy of left main coronary artery disease through cumulative data for revascularization that based on clinical evidence.

Coronary Artery Bypass Graft Surgery Brings Better Benefits to Heart Failure Hospitalization for Patients with Severe Coronary Artery Disease and Reduced Ejection Fraction

Objectives: We compared the outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) for revascularization in patients with reduced ejection fraction (EF) and severe coronary artery disease (CAD). Methods: Between February 2006 and February 2020, a total of 797 patients received coronary angiograms due to left ventricular EF ≤ 40% at our hospital. After excluding diagnoses of dilated cardiomyopathy, valvular heart disease, prior CABG, acute ST-segment myocardial infarction, and CAD with low Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score (≤22), 181 patients with severe coronary artery disease (CAD) with SYNTAX score >22 underwent CABG or PCI for revascularization. Vascular characteristics as well as echocardiographic data were compared between CABG (n = 58) and PCI (n = 123) groups. Results: A younger age (62 ± 9.0 vs. 66 ± 12.1; p = 0.016), higher new EuroSCORE II (8.6 ± 7.3 vs. 3.2 ± 2.0; p < 0.001), and higher SYNTAX score (40.5 ± 9.8 vs. 35.4 ± 8.3; p < 0.001) were noted in the CABG group compared to those in the PCI group. The CABG group had a significantly higher cardiovascular mortality rate at 1-year (19.6% vs. 5.0%, p = 0.005) and 3-year (25.0% vs. 11.4%, p = 0.027) follow-ups but a lower incidence of heart failure (HF) hospitalization at 1-year (11.1% vs. 28.2%, p = 0.023) and 3-year (3.6% vs. 42.5%, p = 0.001) follow-ups compared to those of the PCI group. Conclusions: Compared with PCI, revascularization with CABG was related to a lower incidence of HF hospitalization but a worse survival outcome in patients with severe CAD and reduced EF. CABG-associated reduction in HF hospitalization was more notable when SYNTAX score ≥33.

Delivery of miR-654-5p via SonoVue Microbubble Ultrasound Inhibits Proliferation, Migration, and Invasion of Vascular Smooth Muscle Cells and Arterial Thrombosis and Stenosis through Targeting TCF21

Background

Abnormal proliferation of vascular smooth muscle cells (VSMCs) is an important cause of vascular stenosis. The study explored the mechanism of inhibition of vascular stenosis through the molecular mechanism of smooth muscle cell phenotype transformation.

Methods

Coronary heart disease-related genes were screened by bioinformatics, and the target genes of miR-654-5p were predicted by dual-luciferase method and immunofluorescence method. miR-654-5p mimic stimulation and transfection of TCF21 and MTAP into cells. SonoVue microbubble sonication was used to deliver miR-654-5p into cells. Cell proliferation, migration, and invasion were detected by CCK-8, wound scratch, and Transwell. HE and IHC staining were performed to study the effect of miR-654-5p delivery via SonoVue microbubble ultrasound on vessel stenosis in a model of arterial injury. Gene expression was determined by qRT-PCR and WB.

Results

TCF21 and MTAP were predicted as the target genes of miR-654-5p. Cytokines induced smooth muscle cell proliferation, migration, and invasion and promoted miR-654-5p downregulation; noticeably, downregulated miR-654-5p was positively associated with the cell proliferation and migration. Overexpression of TCF21 promoted proliferation, invasion, and migration, and mimic reversed such effects. miR-654-5p overexpression delivered by SonoVue microbubble ultrasound inhibited proliferation, migration, and invasion of cells. Moreover, in arterial injury model, we found that SonoVue microbubble ultrasound transmitted miR-654-5p into the arterial wall to inhibit arterial thrombosis and stenosis, while TCF21 was inhibited.

Conclusion

Ultrasound delivery of miR-654-5p via SonoVue microbubbles was able to inhibit arterial thrombosis and stenosis by targeting TCF21.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives

For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Non-Protected Left Main Coronary Artery Disease: 1-Year Outcomes in a High Volume Single Center Study

Introduction: There is clear evidence of a significant reduction in all major cardiovascular adverse events (MACE) by coronary artery bypass grafting (CABG) in left main coronary artery stenosis (LMCS), but revascularization by percutaneous coronary artery intervention (PCI) shows an increasingly important role as an alternative to CABG. Several recent trials aiming to test the difference in mortality between the two types of revascularization found conflicting data. The aim of this study is to determine whether PCI is non-inferior to CABG with respect to the occurrence of MACE at 1 year in patients with significant LMCS. Material and methods: We prospectively enrolled 296 patients with chronic or acute coronary syndromes and significant LM stenosis. The angiography that recommended the revascularization procedure was used for the calculation of the Syntax II score, in order to classify the patients as low-, intermediate- or high-risk. Low- and high-risk patients were revascularized with either PCI or CABG, according to current guidelines, and were included in the subgroup S1. The second subgroup (S0) included intermediate-risk patients (Syntax II score 23–32), in whom the type of revascularization was chosen depending on the decision of the heart team or the patient preference. Patients were monitored according to the chosen mode of revascularization—PCI or CABG. LM revascularization was performed in all the patients. Clinical endpoints included cardiac death, myocardial infarction, need for revascularization and stroke. Patients were evaluated at 1 year after revascularization. Event rates were estimated using the Kaplan–Meier analysis in time to the first event. Results: At 1-year follow-up, a primary endpoint occurred in 35/95 patients in the CABG group and 37/201 in the PCI group. There were no significant differences between the 2 treatment strategies in the 1-year components of the end-point. However, a tendency to higher occurrence of cardiac death (HR = 1.48 CI (0.55–3.9), p = 0.43), necessity of repeat revascularization (HR = 1.7, CI (0.81–3.6), p = 0.16) and stroke (HR = 1.52, CI (1.15–2.93), p = 0.58) were present after CABG. Contrariwise, although without statistical significance, MI was more frequent after PCI (HR = 2, CI (0.78–5.2), p = 0.14). The Kaplan–Meier estimates in subgroups demonstrated the same tendency to higher rates for cardiac death, repeat revascularization and stroke after CABG, and higher rates of MI after PCI. Although without statistical significance, patients with an intermediate-risk showed a slightly lower risk of MACE after PCI than CABG. With the exception of dyslipidemia and gender, other cardiovascular risk factors were in favor of CABG (CKD, obesity). Conclusion: In patients with LMCS, PCI with drug-eluting stents was non-inferior to CABG with respect to the composite of cardiac death, myocardial infarction, repeat revascularization and stroke at 1 year, even in patients with intermediate Syntax II risk score.

Intelligent Algorithm-Based Multislice Spiral Computed Tomography to Diagnose Coronary Heart Disease

In this study, dictionary learning and expectation maximization reconstruction (DLEM) was combined to denoise 64-slice spiral CT images, and results of coronary angiography (CAG) were used as standard to evaluate its clinical value in diagnosing coronary artery diseases. 120 patients with coronary heart disease (CHD) confirmed by CAG examination were retrospectively selected as the research subjects. According to the random number table method, the patients were divided into two groups: the control group was diagnosed by conventional 64-slice spiral CT images, and the observation group was diagnosed by 64-slice spiral CT images based on the DLEM algorithm, with 60 cases in both groups. With CAG examination results as the standard, the diagnostic effects of the two CT examination methods were compared. The results showed that when the number of iterations of maximum likelihood expectation maximization (MLEM) algorithm reached 50, the root mean square error (RMSE) and peak signal to noise ratio (PSNR) values were similar to the results obtained by the DLEM algorithm under a number of iterations of 10 when the RMSE and PSNR values were 18.9121 dB and 74.9911 dB, respectively. In the observation group, 28.33% (17/60) images were of grade 4 or above before processing; after processing, it was 70% (42/60), significantly higher than the proportion of high image quality before processing. The overall diagnostic consistency, sensitivity, specificity, and accuracy (88.33%, 86.67%, 80%, and 85%) of the observation group were better than those in the control group (60.46%, 62.5%, 58.33%, and 61.66%). In conclusion, the DLEM algorithm has good denoising effect on 64-slice spiral CT images, which significantly improves the accuracy in the diagnosis of coronary artery stenosis and has good clinical diagnostic value and is worth promoting.

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5-year follow-up randomized controlled trials

AIMS

A 5-year survival of patients with unprotected left main (ULM) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.

METHODS AND RESULTS

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE [a composite endpoint of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization] along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to the use of first- vs. last-generation coronary stents. Subgroup comparisons were performed according to SYNTAX score (below or above 33) and to age (using cut-offs of each trial's subgroup analysis). Four RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation, and 1540 with last-generation stents. At 5-year rates of all-cause death did not differ [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.71-1.21], as those of CV death and stroke. Coronary artery bypass graft reduced rates of MACCE (OR 0.69, 95% CI 0.60-0.79), mainly driven by MI (OR 0.48, 95% CI 0.36-0.65) and revascularization (OR 0.53, 95% CI 0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of SYNTAX score (OR 0.76, 95% CI 0.59-0.97 for values < 32 and OR 0.63, 95% CI 0.47-0.84 for values ≥ 33) while was not evident for 'younger' patients (OR 0.83, 95% CI 0.65-1.07 vs. OR 0.65, 95% CI 0.51-0.84 for 'older' patients).

CONCLUSION

For patients with ULM disease followed-up for 5 years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. Coronary artery bypass graft reduced risk of MI, revascularization, and MACCE especially in older patients and in those with complex coronary disease and a high SYNTAX score.

The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery

The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.

Expansion Capacity of Drug-Eluting Stents in Patients with Left Main Coronary Artery Disease: An Intravascular Ultrasound Guided Study

Aims: The aim of this study was to assess the expansion capacity ofcurrent commercially available Drug Eluting Stents (DES) with nominaldiameters of 3.5-4.0mm in patients with Left Main disease.Materials and Methods: This study was conducted on 50Patients who underwent percutaneous coronary intervention(PCI)for Left Main disease at Benha university hospitals and NationalHeart Institute. PCI was done with Drug Eluting Stents(DES) with large diameters of 3.5-4mm and post dilatation wasdone with non-compliant (NC) balloons with diameters of 4.5-5mm. Intravascular ultrasound (IVUS) was used to measuremaximal stent diameter and area.Results: Three commercially available DESs were used in ourstudy; XIENCE Xpeditionᵀᴹ, Ultimasterᵀᴹ and Onyxᵀᴹ. Maximal stentdiameter was 4.5±0.3mm and diameter expansion index was0.96±0.05. Maximal stent area was 14.67±2.06mm² and area expansionindex was 0.86±0.07mm². On IVUS images, significantlymore calcification< 90 ̊ was detected in the group with expansionindex ˂ 0.85 (68.4 percent versus 25.8%, P=0.003) comparedto the group with expansion index >0.85. We found that DESswith diameters of 3.5-4.0mm can be expanded up to diameter of5.3mm after post-dilation. No complications were reported in thestudied patients, including perforation or stent fracture.Conclusion: Current DESs with nominal diameters of 3.5-4.0mmcan be safely and effectively over-expanded to reach the predicteddiameters in the left main, but the presence of calcification>90 may affect the achievement of the predicted area.

Single or multiple arterial bypass graft surgery vs. percutaneous coronary intervention in patients with three-vessel or left main coronary artery disease

AIM

The aim of this study was to compare long-term all-cause mortality between patients receiving percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) using multiple (MAG) or single arterial grafting (SAG).

METHODS AND RESULTS

The current study is a post hoc analysis of the SYNTAX Extended Survival Study, which compared PCI with CABG in patients with three-vessel (3VD) and/or left main coronary artery disease (LMCAD) and evaluated survival with ≥10 years of follow-up. The primary endpoint was all-cause mortality at maximum follow-up (median 11.9 years) assessed in the as-treated population. Of the 1743 patients, 901 (51.7%) underwent PCI, 532 (30.5%) received SAG, and 310 (17.8%) had MAG. At maximum follow-up, all-cause death occurred in 305 (33.9%), 175 (32.9%), and 70 (22.6%) patients in the PCI, SAG, and MAG groups, respectively (P < 0.001). Multiple arterial grafting [adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.49-0.89], but not SAG (adjusted HR 0.83, 95% CI 0.67-1.03), was associated with significantly lower all-cause mortality compared with PCI. In patients with 3VD, both MAG (adjusted HR 0.55, 95% CI 0.37-0.81) and SAG (adjusted HR 0.68, 95% CI 0.50-0.91) were associated with significantly lower mortality than PCI, whereas in LMCAD patients, no significant differences between PCI and MAG (adjusted HR 0.90, 95% CI 0.56-1.46) or SAG (adjusted HR 1.11, 95% CI 0.81-1.53) were observed. In patients with revascularization of all three major myocardial territories, a positive correlation was observed between the number of myocardial territories receiving arterial grafts and survival (Ptrend = 0.003).

CONCLUSION

Our findings suggest that MAG might be the more desirable configuration for CABG to achieve lower long-term all-cause mortality than PCI in patients with 3VD and/or LMCAD.

TRIAL REGISTRATION

Registered on clinicaltrial.gov. SYNTAXES: NCT03417050 (https://clinicaltrials.gov/ct2/show/NCT03417050); SYNTAX: NCT00114972 (https://www.clinicaltrials.gov/ct2/show/NCT00114972).

Risk factors for in-hospital mortality after coronary artery bypass grafting in Colombia

BACKGROUND

To determine the factors associated with in-hospital mortality after a coronary artery bypass (CABG) in a high-complexity clinic in the city of Santiago de Cali.

METHODS

A retrospective case-control analytical study was performed. Cases were defined as adult patients that had undergone CABG and died within 30 days of the surgery. Patients aged ≥18 years that had undergone isolated surgeries, i.e. procedures without other interventions combined, were included. This study excluded patients that had missing data in their medical records, had previously been in a state of coma, or had previously undergone cardiac surgery other than a bypass procedure. Exposure variables were measured at three stages: preoperative, intraoperative, and postoperative.

RESULTS

The study included 77 cases and 308 controls. The most common cause of death was cardiogenic shock (53.2%), followed by sepsis (27.3%). The multinomial logistic regression model revealed an association of in-hospital mortality with preoperative variables of age >75 years (odds ratio [OR] 2.5, 95% confidence interval [CI95%]: 1.1-5.8, p = 0.032), low socioeconomic status (OR 2.3, CI95%: 1.1-5.2, p = 0.034), heart failure (HF) (OR 3.2, CI95%: 1.5-7.0, p = 0.002), unstable angina (OR 4.2, CI95%: 1.9-9.0, p = 0.000), acute myocardial infarction (AMI) ≤7 days (OR 3.9, CI95%: 1.1-13.7, p = 0.037), chronic kidney insufficiency (CKI) (OR 2.9, CI95%: 1.2-7.0, p = 0.018), peripheral vascular disease (PVD) (OR 2.8, CI95%: 1.2-6.8, p = 0.019), and urgent/emergent surgery (OR 8.2, CI95%: 2.0-34.5, p = 0.004). Of the intraoperative variables, the model showed an association between the use of inotropic agents (OR 2.8, CI95%: 1.3-6.4, p = 0.011) and cardiogenic shock (OR 50.6, CI95%: 7.5-339, p = 0.000).

CONCLUSIONS

This study identifies the factors during preoperative and intraoperative periods that are associated with in-hospital mortality in patients that have undergone CABG.

Critical evaluation of stents in coronary angioplasty: a systematic review

BACKGROUND

Coronary stents are routinely placed in the treatment and prophylaxis of coronary artery disease (CAD). Current coronary stent designs are prone to developing blockages: in-stent thrombosis (IST) and in-stent re-stenosis (ISR). This is a systematic review of the design of current coronary stent models, their structural properties and their modes of application, with a focus on their associated risks of IST and ISR. The primary aim of this review is to identify the best stent design features for reducing the risk of IST and ISR. To review the three major types of stents used in clinical settings today, determining best and relevant clinical practice by exploring which types and features of offer improved patient outcomes regarding coronary angioplasty. This information can potentially be used to increase the success rate of coronary angioplasty and stent technology in the future taking into account costs and benefits.

METHODS

Scientific databases were searched to find studies concerning stents. After the exclusion criteria were applied, 19 of the 3192 searched literature were included in this review. Studies investigating three major types of stent design were found: bare-metal stents (BMS), drug-eluting stents (DES) and bioresorbable stents (BRS). The number of participants varied between 14 and 1264. On average 77.4% were male, with a mean age of 64 years.

RESULTS

From the findings of these studies, it is clear that DES are superior in reducing the risk of ISR when compared to BMS. Conflicting results do not clarify whether BRS are superior to DES at reducing IST occurrence, although studies into newer BRS technologies show reducing events of IST to 0, creating a promising future for BRS showing them to be non-inferior. Thinner stents were shown to reduce IST rates, due to better re-endothelialisation. Scaffold material has also been shown to play a role with cobalt alloy stents reducing the risk of IST. This study found that thinner stents that release drugs were better at preventing re-blockages. Some dissolvable stents might be better at stopping blood clots blocking the arteries when compared to metal stents. The method and procedure of implanting the stent during coronary angioplasty influences success rate of these stents, meaning stent design is not the only significant factor to consider.

CONCLUSIONS

Positive developments in coronary angioplasty could be made by designing new stents that encompass all the most desirable properties of existing stent technology. Further work is needed to investigate the benefits of BRS in reducing the risk of IST compared to DES, as well as to investigate the effects of different scaffold materials on IST and ISR outcomes.

Pooled prevalence of three major cardiovascular risk factors in patients undergoing left main bifurcation stenting: a systematic review and meta-analysis

BACKGROUND

Prevalence of the major risk factors in patients with Left Main (LM) bifurcation disease has not been yet clearly assessed, although it would important for building up bifurcation computational models. We perform a systematic review and metaanalysis on the three major cardiovascular risk factors in patients treated for LM bifurcation disease using either single or 2-stent strategy.

MEHTODS

In accordance with the PRISMA guidelines, Cochrane Library, Embase, PubMed and Google Scholar were queried to locate articles published between January 2015 to October 2020, comparing single- versus 2-stent strategy and reporting the prevalence of arterial hypertension (HT), hyperlipidaemia (HyperL) and diabetes mellitus (DM).

RESULTS

Out of a total of 230 articles, 7 articles were included into the final analysis. A total of 4559 patients were enrolled: 2666 (58.4%, mean age 60.4 years, 2318 males) and 1933 patients (42.3%, mean age 64.8 years, 1763 males) received a single- and 2-stent stenting strategies, respectively. A random effect model revealed a pooled prevalence of HT, HyperL and DM in 69.4%, 38.9% and in 31% of cases, respectively. Prevalence of HT was lower in patients treated with single versus 2-stent strategy (63 versus 66.7% of patients, p=0.01) while HyperL and DM were more represented in single versus 2-stent strategy: 41.6 versus 34.1% (p<0.001), and 32.5 versus 31.8% of patients (p=0.61), respectively.

CONCLUSIONS

In patients with LM bifurcation disease undergoing either single or 2- stent strategy, HT, HyperL and DM are frequent comorbidities. In severe LM disease requiring 2-stent technique, HT is the most prevalent risk factor.

Procedural myocardial injury, infarction and mortality in patients undergoing elective PCI: a pooled analysis of patient-level data

AIMS

The prognostic importance of cardiac procedural myocardial injury and myocardial infarction (MI) in chronic coronary syndrome (CCS) patients undergoing elective percutaneous coronary intervention (PCI) is still debated.

METHODS AND RESULTS

We analysed individual data of 9081 patients undergoing elective PCI with normal pre-PCI baseline cardiac troponin (cTn) levels. Multivariate models evaluated the association between post-PCI elevations in cTn and 1-year mortality, while an interval analysis evaluated the impact of the size of the myocardial injury on mortality. Our analysis was performed in the overall population and also according to the type of cTn used [52.0% had high-sensitivity cTn (hs-cTn)]. Procedural myocardial injury, as defined by the Fourth Universal Definition of MI (UDMI) [post-PCI cTn elevation ≥1 × 99th percentile upper reference limit (URL)], occurred in 52.8% of patients and was not associated with 1-year mortality [adj odds ratio (OR), 1.35, 95% confidence interval (CI) (0.84-1.77), P = 0.21]. The association between post-PCI cTn elevation and 1-year mortality was significant starting ≥3 × 99th percentile URL. Major myocardial injury defined by post-PCI ≥5 × 99th percentile URL occurred in 18.2% of patients and was associated with a two-fold increase in the adjusted odds of 1-year mortality [2.29, 95% CI (1.32-3.97), P = 0.004]. In the subset of patients for whom periprocedural evidence of ischaemia was collected (n = 2316), Type 4a MI defined by the Fourth UDMI occurred in 12.7% of patients and was strongly associated with 1-year mortality [adj OR 3.21, 95% CI (1.42-7.27), P = 0.005]. We also present our results according to the type of troponin used (hs-cTn or conventional troponin).

CONCLUSION

Our analysis has demonstrated that in CCS patients with normal baseline cTn levels, the post-PCI cTn elevation of ≥5 × 99th percentile URL used to define Type 4a MI is associated with 1-year mortality and could be used to detect 'major' procedural myocardial injury in the absence of procedural complications or evidence of new myocardial ischaemia.

Long-Term Clinical Outcomes of Unprotected Left Main Percutaneous Coronary Intervention: A Large Single-Centre Experience

Aims

This study sought to report the 10-year clinical outcomes of patients who underwent unprotected left main (LM) percutaneous coronary intervention (PCI) in a large centre.

Methods and Results

A total of 913 consecutive patients who underwent unprotected LM PCI from January 2004 to December 2008 at Fu Wai Hospital were retrospectively analysed; the mean age was 60.0 ± 10.9 years, females accounted for 22% of patients, diabetes was present in 27.7% of patients, and an LM bifurcation lesion occurred in 82.9% of patients. During the median follow-up of 9.7 years, major adverse cardiac or cerebrovascular events (MACCEs) occurred in 25.6% (234) of patients, and the rates of all-cause death, myocardial infarction, and stroke were 14.9%, 11.0%, and 7.1%, respectively. Cardiac death occurred in only 7.9% of patients. The estimated event rate was 41.9% for death/myocardial infarction/any revascularization and 45.9% for death/MI/stroke/any revascularization. Definite/probable stent thrombosis occurred in 4.3% (39) of patients. According to the subgroup analysis, IVUS-guided PCI was associated with less long-term MACCEs. Further multivariate analysis identified that age and LVEF<40% were the only independent predictors for 10-year death. Age, LVEF<40%, creatinine clearance, and incomplete revascularization were independent predictors for death/MI, while a two-stent strategy, diabetes, a transradial approach, and the use of bare metal stents (BMSs) or first-generation drug-eluting stents (DESs) were not.

Conclusions

Unprotected LM PCI in a large cohort of consecutive patients in a single large centre demonstrated favourable long-term outcomes up to 10 years even with the use of BMSs and first-generation of DESs.

FGF-23 correlates with endocrine and metabolism dysregulation, worse cardiac and renal function, inflammation level, stenosis degree, and independently predicts in-stent restenosis risk in coronary heart disease patients underwent drug-eluting-stent PCI

Background

The present study aimed to assess the correlation of fibroblast growth factor (FGF)-23 expression with clinical characteristics, then further explore its value in predicting 2-year in-stent restenosis (ISR) risk in coronary heart disease (CHD) patients underwent percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

Methods

In this prospective, single-center, observational study, totally 214 CHD patients treated by PCI with DES were consecutively recruited, and peripheral blood samples were collected prior to PCI with DES for serum samples isolation. Following, FGF-23 level in the serum samples was detected via enzyme linked-immuno-sorbent Assay. The follow-up coronary angiography was performed at 1 year and 2 years after PCI or if suspected ISR symptoms occurred.

Results

FGF-23 was positively correlated with fasting blood-glucose, insulin resistance, serum creatinine, serum uric acid, LDL-C, high-sensitivity C-reactive protein, cardiac troponin I and N-terminal-proB-type natriuretic peptide, while was negatively associated with HDL-C and left ventricular ejection fraction (all P < 0.01). Furthermore, FGF-23 was positively correlated with hypercholesteremia, hyperuricemia and family history of CAD (all P < 0.05). However, it did not correlate with other chronic complications, biochemical indexes, lesion features or PCI parameters (all P > 0.05). Moreover, FGF-23 level was higher in 2-year ISR patients (n = 38) compared to 2-year non-ISR patients (n = 176) (P < 0.001), and receiver operating characteristic curve indicated that FGF-23 was of good value in predicting 2-year ISR risk (AUC 0.828, 95% CI 0.761–0.896).

Conclusion

FGF-23 correlates with endocrine and metabolism dysregulation, worse cardiac and renal function, inflammation level, stenosis degree of target lesion, and serves as an independent risk factor for 2-year ISR risk in CHD patients underwent PCI with DES.

Long-term outcomes of percutaneous or surgical treatment in left main disease

INTRODUCTION

Long-term efficacy and safety of either surgical or percutaneous treatment left main coronary artery disease treatment is lacking.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of the most updated randomized clinical trials that compared the efficacy of coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the Left Main Coronary Artery (LMCA) disease. It was also conducted a systematic search of PubMed, Google Scholar, reference lists of relevant articles, and Medline. The search utilized the following terms: "left main PCI versus CABG," "drug-eluting stents," "bypass surgery" and "left main stenting." The search of articles compatible with our inclusion and exclusion criteria was performed from inception through April 2020 and returned a combined total of 304 articles.

EVIDENCE SYNTHESIS

We identified 6 studies, providing data on 5812 patients. The mean follow-up was 6.7 years. PCI was associated with an increased risk of major vascular events (MACE) (IRR 1.24, 95% CI [1.03-1.67], P<0.01), and coronary revascularization (IRR 1.69, 95% CI [1.42-2.03], P<0.01) compared to CABG. Furthermore, all-cause death, MI and stroke events were not statistically different between the two therapeutic revascularization methodologies (IRR 1.06, 95% CI [0.90-1.24], P=0.47, IRR 1.35, 95% CI [0.84-2.16], P=0.03 and IRR 0.66, 95% CI [0.43-1.01], P=0.05, respectively).

CONCLUSIONS

LMCA PCI has an overall same survival compared to CABG in the long term follow-up. Nevertheless, MACE and revascularization events were more frequent in PCI compared to CABG.

Treatment with a dedicated bifurcation sirolimus-eluting cobalt-chromium stent for distal left main coronary artery disease: rationale and design of the POLBOS LM study

AIMS

The aim of this study is to demonstrate the non-inferiority of the BiOSS LIM C sirolimus-eluting cobalt-chromium bifurcation dedicated stent against the XIENCE stent regarding the patient-oriented composite endpoint (POCE) at 12 months among patients with left main coronary artery disease (LMCA).

METHODS AND RESULTS

The POLBOS LM study is a single-arm, prospective, multicentre study enrolling 260 patients (SYNTAX score ≤32) with a pre-specified performance goal based on the results of the EXCEL trial with contemporary percutaneous coronary intervention (PCI) for LMCA disease. Patient enrolment will comply with objective inclusion criteria of diameter stenosis ≥50% in the LMCA based on off-line quantitative coronary angiography (QCA) analysed by an independent core laboratory using dedicated bifurcation QCA software. The BiOSS LIM C is used for the treatment of LMCA disease with the same specific technical classification as for the BiOSS LIM (modified MADS classification) and the stent implantation is optimised by using pre-specified intravascular ultrasound criteria. The primary endpoint is POCE (a composite of all-cause death, stroke, any myocardial infarction, and any revascularisation) at 12 months.

CONCLUSIONS

The POLBOS LM study will indicate the efficacy of the BiOSS LIM C stent with contemporary PCI for distal left main bifurcation lesions in comparison with the XIENCE stent from the recent EXCEL trial, as a performance index.

Complete Revascularization in Acute and Chronic Coronary Syndrome

In patients with multivessel disease, complete revascularization (CR) is the most biologically plausible approach irrespective of definition or type or clinical setting (acute or chronic coronary syndrome [ACS or CCS]). It aims at minimizing residual ischemia, relieving symptoms and reducing the risk of future cardiovascular events. Large evidence supports CR benefits in ACS, predominantly ST-segment elevation myocardial infarction, except cardiogenic shock, although optimal assessment and timing remain debated. In patients with CCS, when revascularization is indicated, a functional CR should be attempted. Therefore, heart-team is crucial in selecting the ideal strategy for each patient to optimize decision-making.

Comparison of Percutaneous Coronary Intervention, Coronary Artery Bypass Grafting and Medical Therapy in Non-ST Elevation Acute Coronary Syndrome Patients With 3-Vessel Disease

BACKGROUND

The aim of this study is to compare the long-term prognosis of non-ST elevation acute coronary syndrome (NSTE-ACS) patients with 3-vessel disease (3VD) who underwent percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical therapy (MT).

METHODS AND RESULTS

Overall, 3,928 NSTE-ACS patients with 3VD were consecutively enrolled from April 2004 to February 2011 at Fu Wai Hospital. Patients were followed up for a median of 7.5 years, and were divided into PCI, CABG or MT groups according to their treatment. Compared with patients undergoing PCI, CABG patients had lower rates of myocardial infarction (MI), unplanned revascularization, major adverse cardiovascular and cerebrovascular events (MACCE) and a higher rate of stroke (all P<0.05). Compared with MT, PCI and CABG had lower incidences of all adverse outcomes (all P<0.05), except for a similar rate of stroke between PCI and MT. Kaplan-Meier analysis showed similar results. After adjusting for confounders, CABG was independently associated with a lower risk of cardiac death, revascularization and MACCE compared with PCI (all P<0.05). Compared with MT, PCI reduced long-term risk of death, whereas CABG reduced long-term risk of death, revascularization and MACCE events (all P<0.05).

CONCLUSIONS

In NSTE-ACS patients with 3VD, CABG is independently associated with a lower risk of long-term cardiac death, revascularization and MACCE compared with PCI. Patients who received MT alone had the highest risk of long-term MACCE.

Angiographic Results After Percutaneous Coronary Interventions in Ostial Versus Distal Left Main Lesions

PURPOSE

We sought to evaluate angiographic outcomes in ostial and distal LM lesions.

METHODS

176 patients with LM disease undergoing PCI were retrospectively included in this study. 9 months of angiographic and 12 months of clinical follow-up was obtained. Quantitative coronary analysis (QCA) was performed for all lesions, using an 11-segment model. Clinical endpoint measure was a composite endpoint of cardiac death, myocardial infarction and target lesion revascularization (TLR).

RESULTS

During 12 months follow up after successful PCI, the composite endpoint occurred more frequently in distal LM bifurcation lesions mainly driven by elevated TLR rates (14.1% in distal LM disease vs. 5.6% in ostial/midshaft LM disease, P = 0.20). Concordantly angiographic binary restenosis (8.2% compared to 0.0%) and late lumen loss (LLL, 0.42 ± 0.97 vs. 0.28 ± 0.34 mm) were increased in distal LM bifurcation lesions compared to ostial LM lesions. In distal lesions highest values for LLL were observed in segments adjacent to the bifurcation (0.37 ± 1.13 mm and 0.37 ± 0.73 mm). On cox proportional regression analysis the angiographic parameter LLL in a bifurcation segment (P = 0.03, HR 1.68 [1.1-2.7]) as well as presence of diabetes mellitus as a clinical parameter (P = 0.046, HR 2.77 [1.0-7.5]) were independent correlates for occurrence of MACE in distal LM bifurcations lesions.

CONCLUSION

PCI of ostial LM in accomplished with low LLL (0.28 ± 0.34 mm) and binary restenosis rates. In distal left main lesions highest rates for LLL and binary restenosis were observed in segments nearest to the bifurcation and rather focused on the main vessel (0.42 ± 0.97 mm).

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

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.

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

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.

Long-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery according to the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score

BACKGROUND

Percutaneous coronary intervention (PCI) of unprotected left-main coronary artery (uLMCA) is increasingly performed. Although it is recommended to calculate the SYNTAX score, if uLMCA PCI is considered, data of outcomes by the SYNTAX score are scarce, particularly among patients with high score (SYNTAX ≥ 33).

OBJECTIVE

To evaluate long-term outcomes of uLMCA PCI according to SYNTAX score in real-world practice.

METHODS

Patients following PCI of uLMCA throughout 2006-2018, in a tertiary hospital, were included and classified into three groups according to the SYNTAX I score. The primary outcome was three-year major adverse cardiac event (MACE) comprising all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), or coronary artery bypass surgery (CABG).

RESULTS

Overall 632 patients were analyzed, mean age 72.8 ± 11.5, males: 69%, classified as following: SYNTAX <22 (n = 225); SYNTAX 22-32 (n = 250) and SYNTAX ≥33 (n = 157). Patients with greater SYNTAX score had higher prevalence of diabetes mellitus, renal failure, peripheral arterial disease and stroke. Additionally, they had lower ejection fraction, greater EuroScore, and number of vessels involved. Procedural success rates were very high (>95%) and did not depend on the SYNTAX score. The rates of MACE and its components were significantly higher in patients with higher SYNTAX score. Multivariate analysis showed that SYNTAX score is an independent predictor of three-year MACE following uLMCA PCI [HRSYNTAX22-32 = 3 (95% confidence interval [CI]: 1.2-11.5), HRSYNTAX≥33 = 3.4 (95% CI: 1.8-13.3].

CONCLUSIONS

Despite the high success rates of uLMCA PCI in real-world patients with high SYNTAX score, the latter was significantly associated with worse three-year outcomes.

In-hospital outcome in patients presenting with acute coronary syndrome with left main coronary artery disease: A report from Japanese prospective multicenter percutaneous coronary intervention registry

BACKGROUND

Patients presenting with acute coronary syndrome (ACS) from left main (LM) disease are at a high risk for mortality despite recent advancement in devices and techniques during percutaneous coronary interventions (PCI). We aimed to evaluate patient characteristics, clinical presentations, and key clinical characteristics associated with adverse in-hospital outcomes among ACS patients undergoing LM-PCI.

METHODS

We retrospectively identified 280 LM-ACS patients (3.7 %) from 7608 ACS patients in the prospective multicenter Japan Cardiovascular Database-Keio Inter-Hospital Cardiovascular Studies registry from March 2009 to May 2016 and divided them into those with/without PCI/coronary artery bypass grafting. We compared baseline demographics, coronary lesion characteristics, PCI details, and short-term outcomes, including in-hospital mortality and periprocedural complications, between the two groups.

RESULTS

Among LM-ACS patients, 38.6 % presented with ST elevation myocardial infarction, 29.6 % with cardiogenic shock (CS), and 15.4 % with cardiac arrest. The observed in-hospital mortality rate was 18.9 % with presence of CS [odds ratio (OR): 10.16, 95 % confidence interval (CI): 4.51-22.91, p<0.001] and absence of prior revascularization (de novo patients; OR: 4.31, 95 % CI: 1.43-12.94, p=0.009) was independently associated with higher incidence of in-hospital mortality. Notably, the observed mortality rate was substantially higher among de novo patients than the predicted mortality rate with a contemporary risk model (observed: 25.1 %; predicted: 11.6 %).

CONCLUSIONS

Prior revascularization act as a protective factor among LM-ACS patients in the contemporary era of PCI. Further studies to detect those at higher risk for LM coronary lesion progression are needed to fully implement these findings into clinical practice.