Outcome of left main stem percutaneous coronary intervention in a UK nonsurgical center: A 5-year clinical experience

Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre

Background

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities.

Methods

Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded.

Results

A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations.

Conclusion

These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.

Interventional cardiologist perceptions about PCI without surgical backup-Results of an international survey

BACKGROUND

Percutaneous coronary intervention (PCI) without surgical backup is becoming increasingly common in the United States. Additionally, a recent SCAI expert consensus document has liberalized recommendations for performing PCI without cardiac surgery on site (SOS).

AIMS

The current study sought to understand practice patterns and operator preferences with regard to performing PCI without SOS.

METHODS

Two internet-based surveys were distributed to interventional cardiologists worldwide. Survey items asked about operator demographics, procedural preferences when performing PCI without SOS, self-judged personality traits, and history of malpractice.

RESULTS

Between March 2021 and May 2021, 517 interventional cardiologists completed the survey; 341 of whom perform elective PCI without SOS (no-SOS operators), and 176 who perform elective PCI with surgical backup (SOS operators). Most operators were male 473 (91.5%). There was a greater proportion of SOS operators in academic practice (86 vs. 75, p < 0.001) and greater proportion of no-SOS operators in hospital-owned practices (158 vs. 56, p < 0.001). Lesion characteristics (left main, chronic total occlusions, and need for atherectomy) were the most important procedural attributes for no-SOS operators, and international operators reported higher comfort levels with PCI on high-risk lesions. Cumulative personality profile scores were similar between SOS and no-SOS operators. SOS operators expressed more concern with legal ramifications of performing PCI without SOS (2.57 vs. 2.34, p = 0.049).

CONCLUSIONS

In the absence of surgical backup, lesion characteristics were the most important consideration for PCI patient selection for operators worldwide. Compared to the United States, international operators were more confident in performing high-risk PCI without surgical backup.

Left Main Stem Percutaneous Coronary Intervention: Does On-Site Surgical Cover Make a Difference?

BACKGROUND

Nonsurgical centers (NSC) contribute significantly to the capacity of overall percutaneous coronary intervention (PCI) in the United Kingdom. Although previous studies have demonstrated similar PCI outcomes in surgical centers (SC) versus NSC, it is unknown whether this applies to more complex procedures such as left main stem (LMS) PCI. We compared patient characteristics and outcomes of LMS PCI performed across SC and NSC in England and Wales.

METHODS

A retrospective analysis of procedures between January 2006 and March 2020 was performed using the British Cardiovascular Intervention Society database and stratified according to the surgical status of the center. The primary outcomes assessed were in-hospital major adverse cardiovascular and cerebrovascular events, all-cause mortality, and Bleeding Academic Research Consortium stage 3 to 5 bleeding.

RESULTS

Forty thousand seven hundred forty-four patients underwent LMS PCI during the period, of which 13 922 (34.2%) had their procedure performed at an NSC. The proportion of LMS PCI performed in NSC increased >2-fold (15.9% in 2006 to 36.7% in 2020). There was no association between surgical cover location and in-hospital mortality (odds ratio, 0.92 [95% CI, 0.69-1.22]), in-hospital major adverse cardiovascular and cerebrovascular events (odds ratio, 1.00 [95% CI, 0.79-1.25]), or emergency coronary artery bypass graft surgery (odds ratio, 1.00 [95% CI, 0.95-1.06]). NSC had lower Bleeding Academic Research Consortium 3 to 5 bleeding complications (odds ratio, 0.53 [95% CI, 0.34-0.82]).

CONCLUSIONS

There has been an increase in LMS PCI volumes at NSC, particularly elective LMS PCI. LMS PCI performed at NSC was not associated with increased mortality, in-hospital major adverse cardiovascular and cerebrovascular events, or emergency coronary artery bypass graft surgery, despite higher disease complexity.

Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease

Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.

Prevalence and Impact of High Bleeding Risk in Patients Undergoing Left Main Artery Disease PCI

OBJECTIVES

The aim of this study was to determine the prevalence and prognostic impact of high bleeding risk (HBR), as determined by the Academic Research Consortium HBR criteria, in real-world patients undergoing left main (LM) percutaneous coronary intervention (PCI).

BACKGROUND

LM PCI is often reserved for patients at increased risk for periprocedural adverse events. Patients at HBR represent a relevant percentage of this cohort, but their outcomes after LM PCI are still poorly investigated.

METHODS

All patients undergoing LM PCI between 2014 and 2017 at a tertiary care center were prospectively enrolled. Patients were defined as having HBR if they met at least 1 major or 2 minor Academic Research Consortium HBR criteria. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months.

RESULTS

Among 619 enrolled patients, 55.3% were at HBR. The rate of the primary endpoint was 4-fold higher in patients at HBR compared with those without HBR (20.5% vs 4.9%; HR: 4.43; 95% CI: 2.31-8.48), driven by an increased risk for all-cause death (HR: 3.88; 95% CI: 1.88-8.02) and MI (HR: 6.18; 95% CI: 1.83-20.9). Rates of target vessel or lesion revascularization and stent thrombosis were comparable in the 2 groups. Bleeding occurred more frequently in patients at HBR (HR: 3.77; 95% CI: 1.83-7.76). Consistent findings were observed after Cox multivariable regression adjustment.

CONCLUSIONS

Among patients undergoing LM PCI, those with HBR are at increased risk for all-cause death, MI, and bleeding. Conversely, rates of repeat revascularization and stent thrombosis were comparable, suggesting frailty and comorbidities as primary causes of worse outcomes in patients at HBR.