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Grines CL, Dupont A. Turndown for coronary artery bypass surgery: Never say never to revascularization. Catheter Cardiovasc Interv 2022; 100:367-368. [PMID: 36084192 DOI: 10.1002/ccd.30383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Abstract
In this issue of Catheterization and Cardiovascular Interventions, Farag et al. reported their experience comparing patients with acute coronary syndrome versus stable angina patients who were turned down for bypass surgery and subsequently treated with coronary stenting (1).
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Affiliation(s)
- Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | - Allison Dupont
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
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Farag M, Al-Atta A, Abdalazeem I, Salim T, Alkhalil M, Egred M. Clinical outcomes of percutaneous coronary intervention in high-risk patients turned down for surgical revascularization. Catheter Cardiovasc Interv 2022; 100:360-366. [PMID: 35775815 DOI: 10.1002/ccd.30318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022]
Abstract
AIMS There are limited data on outcomes of PCI in surgical turndown patientsespecially in those presenting with ACS. METHODS AND RESULTS A retrospective analysis of prospectively collected data of patients who were turned down for CABG and had PCI between 2013 and 2020. All consecutive patients (449), ACS (n = 245) and no-ACS (n = 204) were included. In-hospital complications occurred in 28 patients (6.2%). At 30 days, 27 patients (6.0%) died (18 patients in the ACS group [7.3%] vs. 9 patients in the no-ACS group [4.4%], p = 0.23). Following multivariate analysis, no significant difference in long-term mortality was observed between the two groups (median follow-up of 4 [2-6] years, hazard ratio [HR]: 1.08, 95% confidence interval [CI]: 0.75-1.58, p = 0.667). In propensity score-matched analysis, the adjusted mortality risk was also not different between the groups (HR: 0.74, 95% CI: 0.25-1.26, p = 0.374). Independent predictors of mortality included chronic kidney disease stage ≥ 3 (HR: 1.64, 95% CI: 1.13-2.39, p = 0.009), high European System for Cardiac Operative Risk Evaluation II (HR: 1.02, 95% CI: 1.00-1.05, p = 0.035), and laser atherectomy use (HR: 3.35, 95% CI: 1.32-8.54, p = 0.011). CONCLUSIONS PCI in surgical patients turndown patients appears safe. ACSpresentation was associated with more comorbid illnesses; however, afteradjustment, ACS did not independently confer additional risk of mortality.
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Affiliation(s)
- Mohamed Farag
- Cardiothoracic Department, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Clinical, Pharmaceutical and Biological Science, University of Hertfordshire, Hertfordshire, UK
| | - Ayman Al-Atta
- Cardiothoracic Department, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Tarik Salim
- Cardiothoracic Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Mohammad Alkhalil
- Cardiothoracic Department, Freeman Hospital, Newcastle upon Tyne, UK.,Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Newcastle upon Tyne, UK.,Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,School of Medicine, University of Sunderland, Sunderland, UK
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O'Neill WW, Anderson M, Burkhoff D, Grines CL, Kapur NK, Lansky AJ, Mannino S, McCabe JM, Alaswad K, Daggubati R, Wohns D, Meraj PM, Pinto DS, Popma JJ, Moses JW, Schreiber TL, Magnus Ohman E. Improved outcomes in patients with severely depressed LVEF undergoing percutaneous coronary intervention with contemporary practices. Am Heart J 2022; 248:139-149. [PMID: 35192839 DOI: 10.1016/j.ahj.2022.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/16/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Contemporary practices for hemodynamically supported high-risk percutaneous coronary intervention have evolved over the last decade. This study sought to compare outcomes of the prospective, multicenter, PROTECT III study to historic patients treated with Impella in the PROTECT II randomized controlled trial. METHODS Of 1,134 patients enrolled in PROTECT III from March 2017 to March 2020, 504 were "PROTECT II-like" (met eligibility for PROTECT II randomized controlled trial) and are referred to as PROTECT III for comparative analysis. Major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause mortality, stroke/transient ischemic attack, myocardial infarction, and repeat revascularization, were compared at hospital discharge and 90 days. RESULTS Compared with PROTECT II (N = 216), PROTECT III patients were less often Caucasian (77.1% vs 83.8%, P = .045), with less prior CABG (13.7% vs 39.4%; P < .001) and prior myocardial infarction (40.7% vs 69.3%; P < .001). More PROTECT III patients underwent rotational atherectomy (37.1% vs 14.8%, P < .001) and duration of support was longer (median 1.6 vs 1.3 hours; p<0.001), with greater improvement achieved in myocardial ischemia jeopardy scores (7.0±2.4 vs 4.4±2.9; P < .001) and SYNTAX scores (21.4±10.8 vs 15.7±9.5; P < .001). In-hospital bleeding requiring transfusion was significantly lower in PROTECT III (1.8% vs 9.3%; P < .001), as was procedural hypotension (2.2% vs 10.1%; P < .001) and cardiopulmonary resuscitation or ventricular arrhythmia (1.6% vs 6.9%; P < .001). At 90 days, MACCE was 15.1% and 21.9% in PROTECT III and PROTECT II, respectively (p=0.037). Following propensity score matching, Kaplan-Meier analysis showed improved 90-day MACCE rates in PROTECT III (10.4% vs 16.9%, P = .048). CONCLUSIONS The PROTECT III study demonstrates improved completeness of revascularization, less bleeding, and improved 90-day clinical outcomes compared to PROTECT II for Impella-supported high-risk percutaneous coronary intervention among patients with severely depressed LVEF.
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Affiliation(s)
| | - Mark Anderson
- Hackensack University Medical Center, Hackensack, NJ
| | | | | | | | | | | | | | | | | | - David Wohns
- Spectrum Health, Frederik Meijer Heart and Vascular Institute, Grand Rapids, MI
| | | | - Duane S Pinto
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Jeffrey J Popma
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Achim A, Marc M, Ruzsa Z. Surgical Turned-Downed CHIP Cases—Can PCI Save the Day? Front Cardiovasc Med 2022; 9:872398. [PMID: 35463754 PMCID: PMC9021524 DOI: 10.3389/fcvm.2022.872398] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/21/2022] [Indexed: 01/19/2023] Open
Abstract
Current guidelines, rarely if at all, address decision-making for revascularization when bypass surgery is not a possibility for high-risk cases. Patients who are surgically turned down are routinely excluded from clinical trials, even though they remain symptomatic. Furthermore, the reasons for surgical ineligibility are often times not captured in standardized risk models. There is no data regarding health status outcomes following PCI procedures in these patients and the ultimate question remains whether the benefits of PCI outweigh its risks in this controversial subpopulation. When CHIP (Complex High risk Indicated Percutaneous coronary interventions) is selected for these very complex individuals, there is no unanimity regarding the goals for interventional revascularization (for instance, the ambition to achieve completeness of revascularization vs. more targeted or selective PCI). The recognition that, worldwide, these patients are becoming increasingly prevalent and increasingly commonplace in the cardiac catheterization labs, along with the momentum for more complex interventional procedures and expanding skillsets, gives us a timely opportunity to better examine the outcomes for these patients and inform clinical decision-making.
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Affiliation(s)
- Alexandru Achim
- “Niculae Stancioiu” Heart Institute, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Klinik für Kardiologie, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland
- Division of Invasive Cardiology, 2nd Department of Internal Medicine, University of Szeged, Szeged, Hungary
- *Correspondence: Alexandru Achim
| | - Madalin Marc
- “Niculae Stancioiu” Heart Institute, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Zoltan Ruzsa
- Division of Invasive Cardiology, 2nd Department of Internal Medicine, University of Szeged, Szeged, Hungary
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Zein R, Patel C, Mercado-Alamo A, Schreiber T, Kaki A. A Review of the Impella Devices. Interv Cardiol 2022; 17:e05. [PMID: 35474971 PMCID: PMC9026144 DOI: 10.15420/icr.2021.11] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 12/01/2021] [Indexed: 01/14/2023] Open
Abstract
The use of mechanical circulatory support (MCS) to provide acute haemodynamic support for cardiogenic shock or to support high-risk percutaneous coronary intervention (HRPCI) has grown over the past decade. There is currently no consensus on best practice regarding its use in these two distinct indications. Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. The authors outline technical specifications of the individual Impella heart pumps and their accompanying technology, the Automated Impella Controller and SmartAssist, their indications for use and patient selection, implantation techniques, device weaning and escalation, closure strategies, anticoagulation regimens, complications, future directions and upcoming trials.
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Affiliation(s)
- Rami Zein
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Chirdeep Patel
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Adrian Mercado-Alamo
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Theodore Schreiber
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Amir Kaki
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
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Shields MC, Ouellette M, Kiefer N, Kohan L, Taylor AM, Ailawadi G, Ragosta M. Characteristics and outcomes of surgically ineligible patients with multivessel disease treated with percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:1223-1229. [PMID: 33533551 DOI: 10.1002/ccd.29508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/10/2020] [Accepted: 12/29/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI). BACKGROUND Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials. METHODS Out of 1,061 consecutive patients who underwent a non-emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1-year. RESULTS The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one-year outcomes. CONCLUSIONS Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one-year outcomes after PCI compared to the SYNTAX score.
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Affiliation(s)
- Mary C Shields
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Michelle Ouellette
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Nicholas Kiefer
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Luke Kohan
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Angela M Taylor
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Gorav Ailawadi
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
| | - Michael Ragosta
- The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia
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Nonemergent Percutaneous Coronary Intervention on an Unprotected Left Main Coronary Artery Supported with Impella® Heart Pump in Patients Ineligible for Surgical Revascularization. J Interv Cardiol 2019; 2019:9691753. [PMID: 31772553 PMCID: PMC6739763 DOI: 10.1155/2019/9691753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 03/07/2019] [Indexed: 01/22/2023] Open
Abstract
Objectives We sought to assess if ineligibility to coronary artery bypass grafting (CABG) constitutes a risk factor in patients who underwent a nonemergent unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with prophylactic Impella® heart pump support. Background ULMCA PCI in patients not deemed eligible for CABG is associated with significantly worse outcomes compared to ULMCA PCI in eligible patients. Methods Patients from the cVAD Registry and the PROTECT II trial who underwent a nonemergent ULMCA PCI were identified. We compared in-hospital mortality and major adverse cardiac and cerebrovascular event (MACCE) rates as well as 30-day survival and MACCE rates between CABG ineligible and CABG eligible patients. Results A total of 331 patients were included (293 Impella 2.5®, 38 Impella CP®); 227 were ineligible for CABG and 104 were eligible. Baseline characteristics were remarkable for a trend toward higher rate of chronic obstructive pulmonary disease in the ineligible patients. In-hospital mortality (3.52% vs. 5.77%; p=0.383) and MACCE (6.61% vs. 7.69%; p=0.816) rates as well as 30-day survival (92.0% vs. 93.4%; Log-Rank p-value =0.781) and MACCE (88.1% vs. 90.1%; Log-Rank p-value=0.648) rates were not different between the two groups. Conclusions The results of our study suggest that prophylactic Impella support appears to mitigate the risks inherent to surgical ineligibility in patients undergoing a nonemergent ULMCA PCI. Our results require further investigation.
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Ly HQ, Nosair M, Cartier R. Surgical Turndown: “What’s in a Name?” for Patients Deemed Ineligible for Surgical Revascularization. Can J Cardiol 2019; 35:959-966. [DOI: 10.1016/j.cjca.2019.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/05/2019] [Indexed: 12/22/2022] Open
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