Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease

Sequential composite BIMA grafting for 3v-CAD: factors that predict successful outcome of the one-inflow and two-inflow revascularization techniques

OBJECTIVE

The effect of one-inflow and two-inflow coronary surgical revascularization techniques inclosing skeletonized double mammary artery (BIMA) as T-graft on outcome is studied.

METHODS

Early ad mid-term outcome of complete BIMA revascularization (C-T-BIMA) versus left-sided BIMA with right-sided aorto-coronary bypass (L-T-BIMA + R-CABG) is quantified and analyzed by multivariate logistic regression, Cox-regression, and Kaplan-Meier analysis in a series of 204 consecutive patients treated for triple-vessel coronary disease (3v-CAD).

RESULTS

The L-T-BIMA + R-CABG technique (n = 104) enables higher number of total (4.02 ± 0.87 vs. 3.71 ± 0.69, p = 0.015) and right-sided (1.21 ± 0.43 vs. 1.02 ± 0.32, p = 0.001) coronary anastomoses, improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 ml, p < 0.0001) and bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p = 0.001), and enhances completeness of revascularization (84% vs.69%, p = 0.014) compared to C-T-BIMA strategy (n = 100), respectively. Although the incidence of MACCE was comparable in the two groups (8% vs.1.2%, p = 0.055), the progression of functional mitral regurgitation (FMR) was significantly lower after L-T-BIMA + R-CABG, then after C-T-BIMA (47% vs.64%, p = 0.017). The use of C-T-BIMA-technique (HR = 4.2, p = 0.01) and preoperative RCA occlusion (HR = 3.006, p = 0.023) predicted FMR progression, whereas L-T-Graft + R-CABG technique protected against it (X2 = 14.04, p < 0.0001) independent of the anatomic and clinical complexity (Syntax score I: HR = 16.2, p = 0.156, Syntax score II: HR = 1.901, p = 0.751), of early- (0.96% vs.2%, p = 0.617) and mid-term mortality (5.8% vs.4%, p = 0.748) when compared to C-T-BIMA, respectively.

CONCLUSIONS

The two-inflow coronary revascularization by L-T-BIMA + R-CABG better protects against FMR progression without increasing MACCE and mortality. Older patients with RCA occlusion and reduced LV-EF benefit most from the two-inflow L-T-BIMA + R-CABG technique. Younger 3v-CAD patients with normal LV-EF can preferentially be managed with the one-inflow C-T-BIMA; however, long-term outcome remains to be revealed.

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis

OBJECTIVES

The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.

RESULTS

From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.

CONCLUSIONS

No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

Surgical and percutaneous revascularization outcomes based on SYNTAX I, II, and residual scores: a long-term follow-up study

Background

The objective of this study was to evaluate the association of SYNTAX scores I, II, and residual with cardiovascular outcomes of patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and compare both procedures in a long-term follow-up.

Methods

This is a retrospective single-center study from the MASS registry at the Heart Institute of the University of São Paulo, Brazil in which 969 patients with stable coronary artery disease undergoing CABG (559) or PCI (410) were included. We assessed the SYNTAX scores I, II and residual in both interventions. Clinical endpoints were the first occurrence of a composite of overall death, myocardial infarction, stroke, or repeat revascularization (MACCE) and the total occurrence of each component of MACCE.

Results

In the CABG sample, SSI had a median of 23 (IQR 17–29.5), median SSII of 25.4 (IQR 19.2–32.8), and median rSS of 2 (IQR 0–6.5); in PCI SSI had a median of 14 (IQR 10–19.1), median SSII of 28.7 (IQR 23–34.2), and median rSS of 4.7 (IQR 0–9). Total of 174 events were documented and CABG patients had a lower rate of MACCE (15.6% vs. 21.2%; adjusted HR 1.98; 95% CI 1.13–3.47; P = 0.016) and repeat revascularization (3.8% vs. 11.5%; adjusted HR 4.35; CI 95% 1.74–10.85; P = 0.002) compared with PCI. No SYNTAX score tertile found a difference in death rate between procedures. In a multivariate analysis, the rSS was an independent predictor for MACCE (HR 1.04; 95% CI 1.01–1.06; P = 0.001). Regarding death, the only independent predictors were ejection fraction and renal function.

Conclusion

Surgical revascularization resulted in a more complete revascularization and lower rates of major cardiac or cerebrovascular events in a long-term follow-up. Also, grading the incompleteness of revascularization through the residual SYNTAX score identified a higher event rate, suggesting that complete revascularization is associated with a better prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01616-6.

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease

BACKGROUND

 High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR).

METHODS

 A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated.

RESULTS

 Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2-6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%.

CONCLUSION

 In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

SYNTAX score and coronary artery bypass graft surgery in Bangladesh

Background

The SYNTAX score is a helpful tool for determining the optimal myocardial revascularization strategy in complex coronary artery disease. The aim of this study was to assess whether the SYNTAX score predicts postoperative mortality in patients undergoing coronary artery bypass grafting.

Methods

The study included 1100 consecutive patients referred for coronary artery bypass graft surgery over a 4-year period. Angiographic data were interpreted by both experienced intervention cardiologists and cardiac surgeons. The patients were divided into three groups based on SYNTAX score tertiles: low ≤22 ( n =  560), intermediate 23–32 ( n =  360), and high ≥33 ( n =  180).

Results

Compared to patients with a low SYNTAX score, those with intermediate and high scores were significantly older ( p <  0.001), had a lower left ventricular ejection fraction ( p <  0.001), higher pulmonary artery pressure ( p <  0.001), and higher incidences of acute coronary syndrome and left main coronary artery disease. A significantly higher EuroSCORE ( p =  0.003) was also observed in patients with a higher SYNTAX score. Patients with intermediate and high SYNTAX scores had higher 5-year mortality rates (18.6% and 19.5%, respectively) than patients with low SYNTAX scores (9.5%, p <  0.05). In multivariate analysis, SYNTAX score was not an independent predictor of late mortality.

Conclusion

Although SYNTAX score is not independently predictive of late mortality in patients with complex coronary artery disease undergoing myocardial revascularization surgery, patients with lower SYNTAX scores had a lower mortality rate after coronary artery bypass graft surgery.

SYNTAX, STS and EuroSCORE – How good are they for risk estimation in atherosclerotic heart disease?

Tests that enable prediction of adverse outcome after surgical or nonsurgical intervention in cardiac patients are of great importance since they can help guide clinical decision making. The new evolving percutaneous therapeutic techniques combined with the currently available risk scoring systems require improved prediction models. In the context of steadily improving surgical techniques and perioperative care, on the one hand, and the inadequacy of regional patient data sets to provide generally applicable risk prediction base, on the other, there is need for adaption and recalibration of scoring systems some of which are partly outdated but still widely in use. The accuracy of predictive models depends on their proper application as well as the knowledge of their individual strengths and weaknesses. The EuroSCORE and the STS score take into consideration some risk factors associated with mortality, whereas the SYNTAX score relies solely on coronary anatomy and lesion characteristics. A combination of selected score components from the EuroSCORE, assessing the mortality risk, and those from the SYNTAX score, reflecting the coronary artery disease complexity, can be expected to yield more accurate results in estimating risk in individual patients. In this review, the predictive ability of the SYNTAX score, the STS score and the EuroSCORE will be discussed.

SYNTAX Score and Long-Term Outcomes: The BARI-2D Trial

BACKGROUND

The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease.

OBJECTIVES

This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.

METHODS

Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years.

RESULTS

A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p < 0.001). Among patients with low SYNTAX scores (≤22), major cardiovascular events did not differ significantly between revascularization and medical therapy, either in the CABG stratum (26.1% vs. 29.9%, p = 0.41) or in the PCI stratum (17.8% vs. 19.2%, p = 0.84). Among patients with mid/high SYNTAX scores, however, major cardiovascular events were lower after revascularization than with medical therapy in the CABG stratum (15.3% vs. 30.3%, p = 0.02), but not in the PCI stratum (35.6% vs. 26.5%, p = 0.12).

CONCLUSIONS

Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305).

Clinical SYNTAX score predicts outcomes of patients undergoing coronary artery bypass grafting

BACKGROUND

The SYNTAX score (SS) is a determinant of outcome in patients undergoing percutaneous coronary intervention. In addition, it has been recently shown that the clinical SYNTAX score (cSS), obtained by adding clinical variables to the SS, improves the predictive power of the resulting risk model. We assessed the hypothesis that the use of the cSS may predict outcomes of patients undergoing coronary artery bypass grafting (CABG).

METHODS

We measured the SYNTAX score in 874 patients undergoing isolated first time on-pump CABG. The clinical SYNTAX score was calculated at the time of the study using age, creatinine clearance and ejection fraction, the modified ACEF score, and analyses performed for major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality at 3-year follow-up.

RESULTS

The mean age of the study population was 70.9 ± 8.1 years, and the median cSS 14.2 (range 2.1-286.5). The ROC curve analysis showed that a cSS >14.5 (81.4% sensitivity and 67.8% specificity) was a reliable tool in discrimination of patients for the occurrence of MACCE (AUC 0.78) and all-cause mortality (AUC 0.74). Kaplan-Meier survival analysis confirmed that patients belonging to higher cSS quartiles have poorer 3-year survival (P = .0001) and MACCE-free survival (P = .0001), with respect to those with lower cSS.

CONCLUSIONS

This observational study has shown that the clinical SYNTAX score, incorporating the lesion-based SS and clinical-based ACEF score, predicted mid-term adverse outcomes of patients undergoing CABG and may play an important role in the risk stratification of this population. Further studies are needed to confirm these findings.

Risk Stratification for Percutaneous Coronary Intervention

The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is a semiquantitative angiographic score developed to prospectively characterize the disease complexity of the coronary vasculature. With more than 50 validation studies, the SYNTAX score is the most-studied risk model in the setting of percutaneous coronary intervention. In this article, the evolutionary journey of the SYNTAX score is reviewed, with emphasis on its sequential modifications and adaptations, now culminating in the development and validation of the SYNTAX score II.

SYNTAX score predicts postoperative atrial fibrillation in patients undergoing on-pump isolated coronary artery bypass grafting surgery

Objective:

Atrial fibrillation (AF) is the most common arrhythmia following coronary artery by-pass graft surgery (CABG). The value of SYNTAX score to predict postoperative atrial fibrillation (PoAF) has not been clearly addressed. We aimed to evaluate this relationship in patients undergoing isolated CABG.

Methods:

This study was designed as a single-center, non-randomized, observational, prospective study. Ninety-four patients undergoing isolated on-pump CABG, who had sinus rhythm and were older than 18 years, were enrolled. Demographic characteristics of the patients were recorded; SYNTAX score was calculated preoperatively for each patient. The univariate and multivariate logistic regression analysis were used to determine for predictors of PoAF.

Results:

The median SYNTAX score of the enrolled patients was 21, (56–5). PoAF was observed in 31 (33.3%) patients. Univariate logistic regression showed that age, chronic obstructive pulmonary disease (COPD), red blood cell distribution width (RDW), urea, initial troponin I, peak postoperative troponin I, interventricular septum, left atrial diameter, and SYNTAX score were significantly associated with the frequency of PoAF following CABG. An independent association was identified with age [b 0.088, p:0.023, OR: 1.092, 95% CI (1.012–1.179)], COPD [(b: 2.222, p:0.003, OR: 9.228, 95% CI (2.150–39.602)], and SYNTAX score [(b: 0.130, p:0.002, OR: 1.139, 95% CI (1.050–1.235)].

Conclusion:

This study showed that a higher SYNTAX score was related to more frequent PoAF in patients undergoing isolated on-pump CABG.

Predictive Ability of the SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery Score II for Long-term Mortality in Patients with Three-vessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention Treated with Second-generation Drug-eluting Stents

Background:

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery Score II (SS-II) can well predict 4-year mortality in patients with complex coronary artery disease (CAD), and guide decision-making between coronary artery bypass graft surgery and percutaneous coronary intervention (PCI). However, there is lack of data regarding the utility of the SS-II in patients with three-vessel CAD undergoing PCI treated with second-generation drug-eluting stents (DES). The purpose of the present study was to evaluate the ability of the SS-II to predict long-term mortality in patients with three-vessel CAD undergoing PCI with second-generation DES.

Methods:

Totally, 573 consecutive patients with de novo three-vessel CAD who underwent PCI with second-generation DES were retrospectively studied. According to the tertiles of the SS-II, the patients were divided into three groups: The lowest SS-II tertile (SS-II ≤20), intermediate SS-II tertile (SS-II of 21–31), and the highest SS-II tertile (SS-II ≥32). The survival curves of the different groups were estimated by the Kaplan–Meier method. Univariate and multivariate Cox proportional hazard regression analyses were performed to evaluate the relationship between the SS-II and 5-year mortality. The performance of the SS-II with respect to predicting the rate of mortality was studied by calculating the area under the receiver operator characteristic (ROC) curve. The predictive ability of the SS-II for 5-year mortality was evaluated and compared with the SS alone.

Results:

The overall SS-II was 27.6 ± 9.0. Among patients in the lowest, intermediate and the highest SS-II tertiles, the 5-year rates of mortality were 1.6%, 3.2%, and 8.6%, respectively (P = 0.003); the cardiac mortality rates were 0.5%, 1.9%, and 5.2%, respectively (P = 0.014). By multivariable analysis, adjusting for the potential confounders, the SS-II was an independent predictor of 5-year mortality (hazard ratio: 2.45, 95% confidence interval: 1.38–4.36; P = 0.002). The SS-II demonstrated a higher predictive accuracy for 5-year mortality compared with the SS alone (the area under the ROC curve was 0.705 and 0.598, respectively).

Conclusion:

The SS-II is an independent predictor of 5-year mortality in patients with three-vessel CAD undergoing PCI treated with second-generation DES, and demonstrates a superior predictive ability over the SS alone.

Usefulness of the Logistic Clinical Syntax Score in Prediction of Saphenous Vein Graft Failure in Patients Undergoing Coronary Artery Bypass Grafting

We investigated the association between the preoperative logistic clinical syntax score (log CSS), saphenous vein graft (SVG) patency, and major adverse cardiac and cerebrovascular events (MACCEs) after coronary artery bypass surgery (CABG). Of 1875 patients undergoing isolated CABG between 2009 and 2011, 267 patients, who later underwent coronary angiography, were included in the study. The primary end point was at least 1 graft occlusion on the follow-up coronary angiogram. The secondary end point was a composite of MACCE. In multivariate analysis, log CSS was found as a strong predictor of SVG failure (odds ratio [OR] 0.66, 95% confidence interval [CI]: 0.46-0.94, P = .02; and OR: 2.21, 95% CI: 1.02-4.75, P = .04, respectively): log CSS was also associated with MACCE ( P = .001 and P < .001, respectively). The addition of clinical parameters to the anatomical SYNTAX score, termed as “log CSS”, augmented the accuracy and reliability of the prediction of SVG failure and MACCE in patients undergoing CABG.

Pentraxin 3 Is Highly Specific for Predicting Anatomical Complexity of Coronary Artery Stenosis as Determined by the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Score

Background and Objectives

The aim of this study was to examine the hypothesis that pentraxin 3 (PTX3) can have a diagnostic value for predicting anatomical complexity of coronary artery stenosis as measured by the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score.

Subjects and Methods

We investigated the association of systemic arterial PTX3 with SYNTAX score among 500 patients with ischemic heart disease assigned to medical treatment (251), percutaneous coronary intervention (PCI) (197), or coronary artery bypass graft (CABG) (52).

Results

The clinical judgment of the cardiologists was near-perfectly concordant with the SYNTAX score. Mean {99% confidence intervals (CIs)} SYNTAX scores were 5.8 (5.1-6.6), 18.4 (17.1-19.8), and 33.2 (32.8-33.6) in patients assigned to medical therapy, PCI, and CABG, respectively. The AROC (95% CIs) for discriminating between patients with and without a high SYNTAX score (>23) was 0.920 (0.895-0.946) for systemic arterial levels of PTX3. As the systemic arterial level of PTX3 increased, the SYNTAX scores also increased almost in a curvilinear fashion, with the value corresponding to the SYNTAX score of 23 being 0.29 ng · dL^-1. This cutpoint achieved a sensitivity of 0.66 (0.57-0.74), a specificity of 0.94 (0.91-0.96), a positive predictive value of 0.79 (0.70-0.87), and a negative predictive value of 0.89 (0.85-0.92).

Conclusion

We observed that systemic arterial levels of PTX3 were associated with the SYNTAX score in a curvilinear fashion. The discriminatory power of systemic arterial levels of PTX3 for a high SYNTAX score was excellent. The interesting finding of this study was the near perfect concordance between the decisions made by the cardiologists based on their clinical judgment and the SYNTAX score. The systemic arterial PTX3 level of 0.29 ng · dL^-1 was highly specific for diagnosing complex coronary artery stenosis.

Serum neutrophil gelatinase-associated lipocalin levels are correlated with the complexity and the severity of atherosclerosis in acute coronary syndrome

Objective:

Neutrophil gelatinase-associated lipocalin (NGAL) is a novel inflammatory marker that is released from neutrophils. In this study, we evaluated the correlation between serum NGAL level and clinical and angiographic risk scores in patients diagnosed with non-ST elevation acute coronary syndrome (NSTE-ACS).

Methods:

Forty-seven random NSTE-ACS patients and 45 patients with normal coronary arteries (NCA) who underwent coronary angiography were enrolled in the study. GRACE risk score and SYNTAX and Gensini risk scores were used, respectively, for the purpose of clinical risk assessment and angiographic risk scoring. Serum NGAL level was measured via ELISA in peripheral blood samples obtained from the patients at the time of admission.

Results:

Serum NGAL level was significantly higher in the NSTE-ACS group compared to the control group (112.3±49.6 ng/mL vs. 58.1±24.3 ng/mL, p<0.001). There was a significant positive correlation between serum NGAL levels and the GRACE (r=0.533 and p<0.001), SYNTAX (r=0.395 and p=0.006), and Gensini risk scores (r=0.575 and p<0.001). The intermediate-high SYNTAX (>22) group had statistically significantly higher serum NGAL levels compared to the low SYNTAX (≤22) group (143±29.5 ng/mL vs. 98.7±43.2 ng/mL, p=0.001).

Conclusion:

NGAL level was positively correlated with lesion complexity and severity of coronary artery disease in patients with NSTE-ACS. Serum NGAL levels on admission are associated with increased burden of atherosclerosis in patients with NSTE-ACS.

EuroSCORE II with SYNTAX score to assess risks of coronary artery bypass grafting outcomes

OBJECTIVES

We evaluated the usefulness of the combination of European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) and SYNergy between percutaneous intervention with TAXus drug-eluting stents and cardiac surgery (SYNTAX) score in predicting risks associated with early and late outcomes after coronary artery bypass grafting (CABG).

METHODS

Between January 2010 and April 2012, 412 patients underwent isolated CABG at our institution. EuroSCORE II and SYNTAX score were calculated retrospectively, and their ability to predict early and long-term outcomes was evaluated. Patients were divided into four groups according to median EuroSCORE II and SYNTAX score: Group 1, low EuroSCORE II, low SYNTAX (n=103); Group 2, low EuroSCORE II, high SYNTAX (n=103); Group 3, high EuroSCORE II, low SYNTAX (n=99); and Group 4, high EuroSCORE II, high SYNTAX (n=107).

RESULTS

Operative death was not different among the groups; however, Group 4 had the highest major complication rate of the four groups (0 in Group 1, 2.9% in Group 2, 3.0% in Group 3 and 8.4% in Group 4; P=0.011). Multivariate analyses revealed that both high EuroSCORE II (odds ratio [OR]: 4.154; P=0.030) and high SYNTAX score (OR: 3.988; P=0.035) were independent predictors of postoperative major complications and that high EuroSCORE II was an independent predictor of late mortality (OR: 4.673; P=0.016) but high SYNTAX score was not (OR: 0.808; P=0.662). Actuarial survival rate at 3 years was the lowest in Group 4 (99.0±1.0% in Group 1, 97.7±1.6% in Group 2, 91.9±2.7% in Group 3 and 90.5±4.7% in Group 4; P=0.045).

CONCLUSIONS

The combination of EuroSCORE II and SYNTAX score was useful in predicting early major complications after CABG. In the long term, EuroSCORE II continued to be associated with late mortality, but SYNTAX score did not.

The CABG SYNTAX Score - an angiographic tool to grade the complexity of coronary disease following coronary artery bypass graft surgery: from the SYNTAX Left Main Angiographic (SYNTAX-LE MANS) substudy

AIMS

The SYNTAX Score (SXscore) has established itself as an important prognostic tool in patients undergoing percutaneous coronary intervention (PCI). A limitation of the SXscore is the inability to differentiate outcomes in patients who have undergone prior coronary artery bypass graft (CABG) surgery. The CABG SXscore was devised to address this limitation.

METHODS AND RESULTS

In the SYNTAX-LE MANS substudy 115 patients with unprotected left main coronary artery disease (isolated or associated with one, two or three-vessel disease) treated with CABG were prospectively assigned to undergo a 15-month coronary angiogram. An independent core laboratory analysed the baseline SXscore prior to CABG. The 15-month CABG SXscore was calculated by a panel of three interventional cardiologists. The CABG SXscore was calculated by determining the standard SXscore in the "native" coronary vessels ("native SXscore") and deducting points based on the importance of the diseased coronary artery segment (Leaman score) that have a functioning bypass graft anastomosed distally. Points relating to intrinsic coronary disease, such as bifurcation disease or calcification, remain unaltered. The mean 15-month CABG SXscore was significantly lower compared to the mean baseline SXscore (baseline SXscore 31.6, SD 13.1; 15-month CABG SXscore 21.2, SD 11.1; p<0.001). Reproducibility analyses (kappa [k] statistics) indicated a substantial agreement between CABG SXscore measurements (k=0.70; 95% CI [0.50-0.90], p<0.001), with the points deducted to calculate the CABG SXscore the most reproducible measurement (k=0.74; 95% CI [0.53-0.95], p<0.001). Despite the limited power of the study, four-year outcome data (Kaplan-Meier curves) demonstrated a trend towards reduced all-cause death (9.1% vs. 1.8%, p=0.084) and death/CVA/MI (16.4% vs. 7.0%, p=0.126) in the low compared to the high CABG SXscore group.

CONCLUSIONS

In this pilot study the calculation of the CABG SXscore appeared feasible, reproducible and may have a long-term prognostic role in patients with complex coronary disease undergoing surgical revascularisation. Validation of this new scoring methodology is required.

Additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

This study evaluated additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). All six scores were calculated in 209 consecutive STEMI patients undergoing pPCI. Primary end-point was the major adverse cardiovascular event (MACE--composite of cardiovascular mortality, non-fatal myocardial infarction and stroke); secondary end point was cardiovascular mortality. Patients were stratified according to the SYNTAX score tertiles (≤12; between 12 and 19.5; >19.5). The median follow-up was 20 months. Rates of MACE and cardiovascular mortality were highest in the upper tertile of the SYNTAX score (p < 0.001 and p = 0.003, respectively). SYNTAX score was independent multivariable predictor of MACE and cardiovascular mortality when added to GRACE, TIMI, ZWOLLE, and PAMI risk scores. However, the SYNTAX score did not improve the Cox regression models of MACE and cardiovascular mortality when added to the CADILLAC score. The SYNTAX score has predictive value for MACE and cardiovascular mortality in patients with STEMI undergoing primary PCI. Furthermore, SYNTAX score improves prognostic performance of well-established GRACE, TIMI, ZWOLLE and PAMI clinical scores, but not the CADILLAC risk score. Therefore, long-term survival in patients after STEMI depends less on detailed angiographical characterization of coronary lesions, but more on clinical characteristics, myocardial function and basic angiographic findings as provided by the CADILLAC score.

Red cell distribution width and coronary artery bypass surgery

OBJECTIVES

The red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with coronary artery disease with or without heart failure. We sought to investigate the role of RDW in patients undergoing isolated coronary artery bypass graft surgery (CABG).

METHODS

Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Univariate and multivariate analysis was performed for in hospital mortality, long-term survival, length of hospital stay, length of intensive care unit stay and creatinine kinase muscle-brain (CKMB) release.

RESULTS

Overall mortality was 2.1% for all cases, N = 8615. Median follow up was 5.8 years. Univariate analysis demonstrated that the RDW has a significant effect on CKMB release, P = 0.001, in-hospital mortality, P < 0.0001, and long-term survival, P < 0.0001, but no significant effect on the ITU length of stay, P = 0.9, or hospital length of stay, P = 0.2. Multivariate analysis revealed that the RDW was a significant factor determining in-hospital mortality and long-term survival, but had no significant effect on CKMB release, ITU or hospital length of stay. Confounding factor analysis revealed that in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival.

CONCLUSIONS

The RDW is a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated CABG. The mechanism of association requires further study.

Integrating the Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score into practice: use, pitfalls, and new directions

Risk stratification is key in optimizing care of patients undergoing percutaneous coronary intervention (PCI). Score algorithms, in particular, are useful prognostic tools to select the most appropriate strategy of treatment and help patients and their families to get a better understanding of issues relevant to treatment strategies and subsequent risks. Most scores tested in the setting of PCI focus on clinical variables. The SYNTAX score is a semiquantitative angiographic score developed to prospectively characterize the disease complexity of the coronary vasculature. This scoring system has recently been assessed in numerous cohorts of patients undergoing coronary revascularization by PCI or bypass surgery. When using the SYNTAX score, however, physicians are still challenged with a labor-intensive calculation and conflicting results from validation studies. Understanding how the SYNTAX score works, for which patients it works best, and whether it predicts accurately enough for its purpose is of paramount importance to get the maximum benefit from its application. The present article provides an overview of the background and the currently available evidences on the use of the SYNTAX score in patients undergoing coronary revascularization along with its limitations.

SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main complex coronary disease

OBJECTIVE

The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events.

METHODS

All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders.

RESULTS

A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively).

CONCLUSIONS

SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.