Complete versus incomplete revascularization in patients with multivessel coronary artery disease treated with drug-eluting stents

Impact of Optimal Medical Therapy on Long-Term Outcomes After Myocardial Revascularization for Multivessel Coronary Disease

Although optimal medical therapy (OMT) after coronary revascularization is advocated for intensive secondary prevention, its criteria and effect on long-term outcomes are uncertain. Using data from the ASAN-Multivessel (Asan Medical Center-Multivessel Revascularization) registry, we identified 8,311 patients who underwent coronary artery bypass grafting (CABG) (n = 3,115) or percutaneous coronary intervention (PCI) (n = 5,196). OMT was defined as the combination of minimum of 3 medications in 4 drug classes (antiplatelet drugs, statins, β blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). Two primary outcomes were all-cause mortality and serious composite outcome of death, spontaneous myocardial infarction, or stroke at 10 years. Of 8,311 patients, 4,321 (52.0%) followed OMT. In the 3,397 propensity-score-matched cohort, OMT status compared with non-OMT status was significantly associated with a lower risk of all-cause mortality (10.7% vs 18.7%; hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.47 to 0.65) and serious composite outcome (14.5% vs 22.5%, HR 0.635, 95% CI 0.55 to 0.73) at 10 years. The association on 10-year mortality was more prominent in the PCI group (HR 0.45, 95% CI 0.36 to 0.56) than in the CABG group (HR 0.72, 95% CI 0.58 to 0.90) with a significant interaction (p = 0.001). Overall findings were consistent using different OMT criteria (all 4 types of medications). In conclusion, OMT significantly lowered the risks of mortality and major cardiovascular events at 10 years in patients with multivessel revascularization. The OMT impact on mortality was more remarkable in the PCI group than in the CABG group. This work was registered at http://ClinicalTrials.gov (Identifier: NCT02039752).

Relationship Between the Completeness of Revascularization and Myocardial Injury in Patients Treated With Percutaneous Coronary Intervention

BACKGROUND

Clinical outcomes of patients suffering periprocedural myocardial injury and undergoing incomplete revascularization (IR) following percutaneous coronary intervention (PCI) has never been investigated.

OBJECTIVE

To investigate the relationship between different thresholds of post-PCI cardiac troponin (cTn) elevation and revascularization completeness in determining long-term clinical outcomes.

METHODS

Patients were stratified in tertiles according to preprocedural SYNTAX score (SS) (low: 0-6; medium: >6-11; high: >11) and residual SS (low: 0-4; medium: >4-8; high: >8). IR was defined by a rSS value >4. Three thresholds of myocardial injury were pre-specified: 5×, 35× and 70× 99th percentile upper reference limit (URL) increase of baseline cTn. Primary outcome was a composite of major adverse cardiac events (MACE) at two years of follow-up.

RESULTS

1061 patients undergoing PCI for stable coronary artery disease were enrolled. IR occurred in 249 (23.4 %) and major myocardial injury in 540 (50.9 %). Patients belonging to the highest tertile of SS showed an increased risk of experiencing IR and periprocedural myocardial injury. Two-year follow-up was available in 869. At multi-variate Cox's regression analysis, patients undergoing IR + cTn > 35 × URL and IR + cTn > 70 × URL showed an increased risk of MACE [HR 2.30 (1.19-4.41) and HR 3.20 (1.38-7.41); respectively].

CONCLUSIONS

Periprocedural myocardial injury is critically associated with MACE at two-year follow-up in patient treated with PCI who achieve IR. Despite conflicting evidence exists regarding the influence of periprocedural myocardial injury on clinical outcomes, patients undergoing IR seem to represent a high-risk subgroup.

Impact of Complete or Incomplete Revascularization for Left Main Coronary Disease: The Extended PRECOMBAT Study

Background

Whether complete revascularization (CR) or incomplete revascularization (IR) may affect long-term outcomes after PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease is unclear.

Objectives

The authors sought to assess the impact of CR or IR on 10-year outcomes after PCI or CABG for LMCA disease.

Methods

In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) 10-year extended study, the authors evaluated the effect of PCI and CABG on long-term outcomes according to completeness of revascularization. The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE) (composite of mortality from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization).

Results

Among 600 randomized patients (PCI, n = 300 and CABG, n = 300), 416 patients (69.3%) had CR and 184 (30.7%) had IR; 68.3% of PCI patients and 70.3% of CABG patients underwent CR, respectively. The 10-year MACCE rates were not significantly different between PCI and CABG among patients with CR (27.8% vs 25.1%, respectively; adjusted HR: 1.19; 95% CI: 0.81-1.73) and among those with IR (31.6% vs 21.3%, respectively; adjusted HR: 1.64; 95% CI: 0.92-2.92) (P for interaction = 0.35). There was also no significant interaction between the status of CR and the relative effect of PCI and CABG on all-cause mortality, serious composite of death, myocardial infarction, or stroke, and repeat revascularization.

Conclusions

In this 10-year follow-up of PRECOMBAT, the authors found no significant difference between PCI and CABG in the rates of MACCE and all-cause mortality according to CR or IR status. (Ten-Year Outcomes of PRE-COMBAT Trial [PRECOMBAT], NCT03871127; PREmier of Randomized COMparison of Bypass Surgery Versus AngioplasTy Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT], NCT00422968).

The role of circRNAs in the regulation of myocardial angiogenesis in coronary heart disease

During myocardial ischemia, timely reperfusion is critical to limit infarct area and the overall loss of cardiac contractile function. New treatment strategies need to be developed for patients who are neither able to receive interventional treatment nor suitable for surgical blood transport reconstruction surgery. Therapeutic angiogenesis is a promising approach that can be used to guide new treatment strategies. The goal of these therapies is to form new blood vessels or promote the maturation of existing vasculature systems, bypassing blocked arteries to maintain organ perfusion, thereby relieving symptoms and preventing the remodeling of bad organs. Non-coding RNAs (ncRNAs), including microRNAs (miRNAs), long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs), have been attracted much attention for their roles in various physiological and pathological processes. There is growing evidence that ncRNAs, especially circRNAs, play an important role in the regulation of cardiomyopathy angiogenesis due to its diversity of functions. Therefore, this article reviews the role and mechanisms of circRNA in myocardial angiogenesis to better understand the role of circRNAs in myocardial angiogenesis, which may provide useful insights and new revelations for the research field of identifying diagnostic markers and therapeutic approaches for the treatment of coronary artery disease.

Comparison of multiple risk scores in assessing medium-to long-term clinical outcomes in unstable angina / non-ST-elevation myocardial infarction patients undergoing multi vessel percutaneous coronary intervention: An observational, registry-based study in India

Objective

Post-revascularization mortality in multivessel coronary artery disease (MVCAD) has been explored via several risk scores. Here, we assessed and compared various risk scores in predicting medium to long-term clinical outcomes in unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients with MVCAD undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed a cohort of a tertiary care center registry enrolling patients in South India, Kerala, with MVCAD (N = 200) who had undergone PCI between 2010 and 2018. The outcomes evaluated were all-cause mortality and major adverse cardiac events (MACE). The risk scores assessed included SYNTAX score (SS), residual SYNTAX score (rSS), SYNTAX revascularization index (SRI), age, creatinine, and ejection fraction (ACEF) score, clinical SYNTAX score (cSS), and SYNTAX score II (SSII).

Results

Of the analyzed risk scores, SSII had the best predictive capability with the area under the curve (AUC) of 0.79 in c-statistics, followed by ACEF score and cSS with AUCs of 0.74 and 0.65, respectively for all-cause mortality (p < 0.01). Kaplan–Meier survival curves and multivariate analysis by Cox regression showed SSII with cut-offs of >35.15 and > 29.55 to be the only score associated with higher mortality and MACE, respectively.

Conclusions

In UA/NSTEMI patients with relatively less complex MVCAD treated by PCI, the SSII, ACEF and cSS risk scores could predict the outcomes better. The SSII showed the best predictive performance for all-cause mortality and MACE. Scores based on baseline and residual atherosclerotic burden (SS, rSS, and SRI) performed poorly in predicting the mortality and MACE.

Impact of completeness of revascularisation on long-term outcomes in patients with multivessel disease undergoing PCI: CR versus IR outcomes in multivessel CAD

AIMS

We aimed to study long-term clinical outcomes in patients with multivessel disease (MVD) undergoing percutaneous coronary intervention (PCI) over the last 10 years with respect to the completeness of revascularisation at a tertiary care hospital.

METHODS AND RESULTS

A total of 2,960 consecutive MVD patients taken for PCI between 2008 to 2017 were enrolled in the study with baseline demographic, procedural, and follow-up details retrieved from custom-made departmental software. Of those, 2,598 patients with follow-up details constituted the study cohort. Complete revascularisation (CR) was achieved in 1,854 (71.4%) and incomplete revascularisation (IR) in 744 (28.6%) patients. Propensity matching was performed and 740 matched pairs identified in the two groups. The primary endpoint was survival free of any major adverse cardiovascular events (MACE) with each individual MACE event being a secondary endpoint. IR occurred more often in patients with acute coronary syndrome (64.1% vs 58.3%, p=0.003), complex lesion intervention (40.7% vs 29.6%, p<0.001) and in those with mean stent length ≥38 mm per vessel intervened (21.0% vs 13.5%, p<0.001). Median follow-up was 54 months (interquartile range: 31-84 months). After propensity matching, CR resulted in a better survival free of all adverse events, i.e., 86.4% vs 81.1% (HR 1.52, CI: 1.21-2.02; p<0.01). Individual MACE endpoints were, however, not statistically different between the groups.

CONCLUSIONS

In MVD patients undergoing PCI, CR results in better survival free of all adverse events including all-cause mortality, non-fatal MI, repeat revascularisation and recurrent angina.

Complete revascularization in stable multivessel coronary artery disease: A real world analysis from the British Columbia Cardiac Registry

BACKGROUND

More than half of patients undergoing percutaneous coronary intervention (PCI) have multivessel disease (MVD). The prognostic significance of PCI in stable patients has recently been debated, but little data exists about the potential benefit of complete revascularization (CR) in stable MVD. We investigated the prognostic benefit of CR in patients undergoing PCI for stable disease.

METHODS

We compared CR versus incomplete revascularization (IR) in 8,436 patients with MVD. The primary outcome was all-cause mortality at 5 years.

RESULTS

A total of 1,399 patients (17%) underwent CR during the index PCI procedure for stable disease. CR was associated with lower mortality (6.2 vs. 10.7%, p < .001) and lower repeat revascularization at 5 years (12.7 vs. 18.4%, p < .001). Multivariable-adjusted analyses indicated that CR was associated with lower mortality (HR = 0.73, 95% CI: 0.58-0.91, p = .005) and repeat revascularization at 5 years (HR = 0.78, 95% CI: 0.66-0.93, p = .005). These findings were also confirmed in propensity-matched cohorts. Subgroup analyses indicated that CR conferred survival in older patients, male patients, absence of renal disease, greater angina (CCS Class III-IV) and heart failure (NYHA Class III-IV) symptoms, and greater burden of coronary disease. In sensitivity analyses where patients with subsequent repeat revascularization events were excluded, CR remained a strong predictor for lower mortality (HR = 0.69, 95% CI: 0.54-0.89, p = .004).

CONCLUSIONS

In this study of stable patients with MVD, CR was an independent predictor of long-term survival. This benefit was specifically seen in higher risk patient groups and indicates that CR may benefit selected stable patients with MVD.

Angiographic Complete versus Clinical Selective Incomplete Percutaneous Revascularization in Heart Failure Patients with Multivessel Coronary Disease

Background

Patients with multivessel disease (MVD) often pursue complete revascularization (CR) during percutaneous coronary intervention (PCI) to improve prognosis. However, angiographic CR is not always feasible and is associated with some procedure-related complications in heart failure (HF) patients with MVD. Clinical selective incomplete revascularization (IR) may be reasonable for these high-risk patients, but its role in long-term outcomes remains uncertain.

Methods

Six hundred patients with HF and MVD submitted to PCI were enrolled. Major adverse cardiac events (MACEs) were defined as a composite of recurrent myocardial infarction, any revascularization, and all-cause mortality at 5 years.

Results

During a mean follow-up period of 3.7 ± 1.9 years, there was no significant difference in 5-year MACEs between selective IR and successful angiographic CR in HF patients with MVD. However, patients who failed CR had a significantly greater incidence of 5-year MACEs than those in the other two groups (failed CR: 46.4% vs. selective IR: 27.7% vs. successful CR: 27.8%, p < 0.001).

Conclusions

Long-term outcomes of selective IR were comparable with those of successful angiographic CR in HF patients with MVD. However, patients that failed CR showed 2.53-fold increased risk of MACEs compared to patients undergoing either selective IR or successful angiographic CR. A more comprehensive planning strategy should be devised before PCI in HF patients with MVD.

Therapeutic angiogenesis with exosomal microRNAs: an effectual approach for the treatment of myocardial ischemia

Therapeutic angiogenesis presents a potential approach for treating ischemic heart diseases especially in patients who are not appropriate candidates for traditional approaches of revascularization. This approach acts through inducing the neovascularization or maturation of pre-existing collateral vessels into functional arteries to bypass the blocked arteries and restore perfusion to ischemic myocardium. Successful stimulation of local angiogenesis can be established by the cross talk between stem cells, endothelial cells, and cardiomyocytes, which is mainly mediated by paracrine communication accompanied by secreted exosomes. Exosomes are extracellular vesicles carrying a complex of signaling molecules, such as microRNAs (miRs) that can modulate the function of recipient cells. Such particles have been indicated to exert cardioprotective role through providing signaling cues for angiogenesis, an effect ascribed mainly to their miRs content. Exosomal miRs-mediated therapeutic angiogenesis has been under drastic preclinical and clinical studies. In the current review, it was aimed to summarize pro-angiogenic exosomal miRs released by various cell types mediating angiogenesis, including stem cells, endothelial cells, and cardiomyocytes, which appear to exert a therapeutic effect on the myocardial ischemia. In brief, secreted exosomal miRs including miR-210, miR-23a-3p, miR-424, let-7f, miR-30b, miR-30c, miR-126, miR-21, miR-132, miR-130a-3p, miR-214, miR-378, miR-126, miR-133, and let-7b-5p could protect against myocardial ischemia through inducing cardiac angiogenesis and vascular regeneration resulting in the increase blood flow to ischemic myocardium.

Clinical outcomes of patients with multivessel coronary artery disease treated with robot-assisted coronary artery bypass graft surgery versus one-stage percutaneous coronary intervention using drug-eluting stents

A number of studies have reported on treatment outcomes of coronary stenting (PCI) for multivessel coronary artery diseases (MVD), and compared them with the conventional coronary artery bypass grafting (CABG). However, the clinical outcomes of robot-assisted CABG (R-CABG) in comparison with PCI in MVD patients have not been investigated.We recruited retrospectively MVD patients receiving R-CABG and PCI with drug-eluting stents for all vessels in one stage between January 2005 and December 2013 at our institution with at least 3 years of outcomes were retrospectively recruited and analyzed.A total of 638 MVD patients were studied. Among them, 281 received R-CABG, and 357 received PCI. Similar complete revascularizations were achieved in both groups (R-CABG: 40.2%, PCI: 41.5%, P = .751). The residual stenosis was 4.1 ± 4.4 in the R-CABG group, and comparably 3.5 ± 3.7 in the PCI group (P = .077). Patients in the R-CABG group were younger, with more severe coronary artery disease (CAD) and had more background risk factors. The in-hospital and long-term mortalities as well as the incidence of TLR, myocardial infarction (MI), stroke were all similar between groups. But the incidence of TVR and any revascularization were lower in the R-CABG group. The long-term mortality was predicted by age, left ventricular ejection fraction, and chronic kidney disease, but not by the revascularization modality, completeness of revascularization, nor residual SYNTAX scores. The last 3 factors were not predictors of long-term TLR, TVR, MI, and stroke.The in-hospital and long-term survival rates of MVD were similar for both the R-CABG and PCI groups. But the R-CABG group had rates of TVR and any revascularization lower than PCI. Revascularization modality, completeness of revascularization, and residual SYNTAX scores were not predictors of in-hospital and long-term mortalities, MI, and stroke in real-world practice. R-CABG was associated with lower rates of TLR and TVR, and is likely a safe and effective treatment and an alternative choice of PCI for MVD patients who have low surgical risks.

Long-term outcomes after percutaneous coronary intervention relative to bypass surgery in diabetic patients with multivessel coronary artery disease according to clinical presentation

BACKGROUND

For diabetic patients with multivessel coronary artery disease (MVD), limited data exist on the long-term outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) according to clinical presentation [stable coronary artery disease (SCAD) or non-ST-elevation acute coronary syndrome (NSTE-ACS)].

PATIENTS AND METHODS

From a Korean multicenter registry, we analyzed 1135 diabetic patients with MVD treated with PCI (n = 660) or CABG (n = 475). After propensity score matching, 8-year major adverse cardiovascular and cerebrovascular events [MACCE; composite of all-cause death, myocardial infarction (MI), or stroke] were compared between PCI and CABG according to clinical presentation.

RESULTS

After matching, MACCE was not different between PCI and CABG for SCAD patients [15.6 vs. 17.2%, hazard ratio (HR)  = 0.94, 95% confidence interval (CI)  = 0.55-1.63, P = 0.837], whereas it was higher in PCI than in CABG for NSTE-ACS patients (31.1 vs. 22.4%, HR = 1.63, 95% CI = 1.03-2.59, P = 0.036), mainly driven by the higher MI occurrence (HR = 2.18, 95% CI = 1.04-4.59, P = 0.035). A significant interaction between revascularization strategy and clinical presentation was observed for MACCE (P-interaction = 0.022). However, when PCI was further classified according to revascularization completeness, the treatment gap between PCI and CABG with respect to MI in NSTE-ACS patients was improved by complete-revascularization PCI.

CONCLUSION

Among diabetic patients with MVD, the long-term outcomes of PCI versus CABG differed according to clinical presentation. CABG may be more beneficial for NSTE-ACS patients with MVD in reducing MACCE and MI, whereas PCI was as effective as CABG for SCAD patients with MVD. Therefore, clinical presentation must be considered when choosing revascularization strategies in these patients.

Surgical Revascularization of Chronically Occluded Coronary Arteries—What You See Is What You Get?

Background Revascularization strategy in coronary artery bypass grafting (CABG) surgery usually depends on coronary dimension and stenosis severity. Little is known about the relation of preoperative evaluation of scarcely or invisibly chronic occluded coronary arteries (chronic total occlusion [CTO]) and revascularization rate or anastomosis quality. We aimed to evaluate the success rates of CTO revascularization in CABG surgery and determine the influence of coronary lumen visibility and collateralization in preoperative angiograms on revascularization rates, bypass blood flow, and target vessel diameter.

Method Preoperative coronary angiograms were evaluated for 938 consecutive patients who underwent isolated CABG surgery between 2014 and 2016 and screened for occluded coronary arteries. The occluded vessels were scored for visibility using the Rentrop grading of collateral filling. Intraoperatively, dimensions of the occluded arteries were measured using conventional vessel probes, and anastomosis quality was assessed by transit time flow measurement.

Results A total of 404 (43.1%) patients were identified with at least one CTO. Revascularization rates differed from 96.2% in the left anterior descending artery, to 85.0% in left circumflex artery-dependent vessels, and 78.8% in right coronary artery territory. Coronary visibility and grade of collateralization in the preoperative angiogram had no influence on intraoperatively measured coronary diameter. Bypass blood flow in grafts revascularizing CTOs lacking collateralization were not significantly lower than those grafts leading to CTOs with higher Rentrop scores.

Conclusion Preoperative coronary assessment often differs from intraoperative findings. Our study confirms that even patients with scarcely collateralized CTOs and impaired visibility in the coronary angiogram have a high chance of complete revascularization during CABG surgery.

Mortality of patients with previous stroke undergoing drug-eluting stent implantation

OBJECTIVE

Patients with previous stroke are increasing among patients receiving percutaneous coronary intervention (PCI) with drug-eluting stents (DES); however, data about the influence of previous stroke on patient outcomes are limited. We evaluated whether previous stroke is associated with increased risk for mortality in coronary artery disease.

PATIENTS AND METHODS

A total of 18 650 patients with coronary artery disease undergoing PCI with DES were enrolled. Databases from three real-world PCI registries were merged for a patient-level meta-analysis. The primary outcome was death from any cause. The secondary outcomes were death from a cardiac cause, myocardial infarction, stent thrombosis, stroke, or repeat revascularization.

RESULTS

Patients with previous stroke (n=1361), compared with those without previous stroke (n=17 289), were older and had a higher prevalence of risk factors or comorbidities. At a median follow-up of 47.0 months, patients with previous stroke had a higher risk for death from any cause [adjusted hazard ratio (HR)=1.623; 95% confidence interval (CI): 1.342-1.962; P<0.001], death from a cardiac cause (adjusted HR=1.686; 95% CI: 1.339-2.124; P<0.001), and stroke (adjusted HR=2.456; 95% CI: 1.853-3.255; P<0.001). There were no significant differences in the risks for myocardial infarction, stent thrombosis, or repeat revascularization.

CONCLUSION

Patients with previous stroke showed higher risks for all-cause death and stroke after PCI with DES than those without stroke. Previous stroke should be considered a risk factor for all-cause death and stroke in this patient population.

Prognostic impact of reducing myocardial ischemia identified using ECG-gated myocardial perfusion SPECT in Japanese patients with coronary artery disease: J-ACCESS 4 study

AIM

Whether myocardial ischemia identified using myocardial perfusion imaging (MPI) can be an alternative target of coronary revascularization to reduce the incidence of cardiac events remains unclear.

METHODS AND RESULTS

This multicenter, prospective cohort study aimed to clarify the prognostic impact of reducing myocardial ischemia. Among 494 registered patients with possible or definite coronary artery disease (CAD), 298 underwent initial pharmacological stress ^99mTc-tetrofosmin MPI before, and eight months after revascularization or medical therapy, and were followed up for at least one year. Among these, 114 with at least 5% ischemia at initial MPI were investigated. The primary endpoints were cardiac death, non-fatal myocardial infarction and hospitalization for heart failure. Ischemia was reduced ≥5% in 92 patients. Coronary revascularization reduced ischemia (n = 89) more effectively than medical therapy (n = 25). Post-stress cardiac function also improved after coronary revascularization. Ejection fraction significantly improved at stress (61.0% ± 10.7% vs. 65.4% ± 11.3%; p < 0.001) but not at rest (67.1% ± 11.3% vs. 68.3% ± 11.6%; p = 0.144), among patients who underwent revascularization. Rates of coronary revascularization and cardiac events among the 114 patients were significantly higher (13.6%, p = 0.035) and lower (1.1% p = 0.0053), respectively, in patients with, than without ≥5% ischemia reduction. Moreover, patients with complete resolution of ischemia at the time of the second MPI had a significantly better prognosis.

CONCLUSIONS

Reducing ischemia by ≥5% and the complete resolution of ischemia could improve the prognosis of patients with stable CAD.

Comparison of the Acute and Long-Term Outcomes of Patients With Multivessel Coronary Artery Disease After Angiographic Complete and Incomplete Revascularization With Drug-Eluting Stents

BACKGROUND

Data regarding the long-term outcomes of a large patient population with multivessel coronary artery disease (MV-CAD) after complete revascularization (CR) and incomplete revascularization (IR) with drug-eluting stent (DES) implantation are controversial. The objective of this study was to evaluate differences between the clinical outcomes of CR and IR in such patients.Methods and Results:A total of 1,502 patients with MV-CAD who received DES between April 2005 and August 2016 were enrolled in this study after propensity score matching. The CR group had 751 patients with 1,368 stents implanted in 1,215 lesions, and the IR group had 751 patients with 1,077 stents implanted in 948 lesions. The CR group had a similar rate of in-hospital major adverse cardiovascular events to the IR group (1.9% vs. 1.6%, P=0.844). Follow-up angiography at 9 months showed no significant difference between the 2 groups for restenosis. The CR group had a higher cardiovascular event-free survival rate than the IR group during a mean follow-up period of 71±62 months (81.8% vs. 72.0%, P<0.001). Kaplan-Meier survival analysis also showed better results in the CR group than in the IR group.

CONCLUSIONS

Angiographic CR was associated with more favorable long-term cardiovascular outcomes than angiographic IR in patients with MV-CAD after DES implantation.

Long-term outcomes post chronic total occlusion intervention-implications of completeness of revascularization

BACKGROUND

Long term clinical outcomes post chronic total occlusion (CTO) intervention may depend not only on CTO success/failure alone but also on Completeness of revascularization.

OBJECTIVES

To determine long term outcomes post CTO intervention and relate them to both success versus failure and Complete Revascularization (CR) versus Incomplete Revascularization (IR).

METHODS

Consecutive patients taken up for CTO intervention with at-least one CTO vessel between Jan 2006 to Dec 2015 were included. Clinical, procedural and follow up details were recorded in a pre-specified custom made software. Primary endpoint of the study was survival free of major adverse event individual, death, myocardial infarction (MI), repeat revascularisation (percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) and recurrent or continued angina. Each individual adverse event was considered as a secondary end point.

RESULTS

A total of 632 patients were enrolled in study with follow up data available in 549 (86%) constituting the study group with 490 (89.3%) success and 59 (11.7%) failure. Complete revascularization (CR) was obtained in 410 (74.7%). Follow up was median 2.9 years with inter-quartile range 1.1-4.8 years. Kaplan Meier survival analysis showed a better EFS with both CTO success versus failure (P = 0.03)and CR versus IR (P = 0.017). Individual adverse outcomes however were not significantly different in CTO success versus failure group but significantly better when analyzed with respect to CR versus IR including death (P = 0.049) and recurrent angina (P = 0.024). Repeat intervention and MI were not different by either analysis.

CONCLUSIONS

Successful CTO PCI results in a better long term event free survival but the difference between the groups is more if analyzed with respect to completeness of revascularization rather than CTO success/failure alone.

Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged

PURPOSE OF REVIEW

This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization.

RECENT FINDINGS

STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.

Comparison of Outcomes of Coronary Artery Bypass Grafting Versus Drug-Eluting Stent Implantation in Patients With Severe Left Ventricular Dysfunction

The optimal revascularization strategy for patients with significant coronary artery disease (CAD) and severe left ventricular (LV) dysfunction (ejection fraction ≤35%) remains unclear. We compared the effects of coronary artery bypass surgery (CABG, n = 442) versus percutaneous coronary intervention (PCI) with drug-eluting stents (n = 469) on long-term mortality in 911 patients with significant CAD and severe LV dysfunction using large real-world registry data. Databases of 3 real-world registries were merged for a patient-level meta-analysis. Primary outcome was death from any cause; secondary outcomes were death from cardiac causes, myocardial infarction, stroke, or repeat revascularization. At a median follow-up of 37.3 months, the risk of all-cause death (adjusted hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.31 to 0.61; p <0.001) was significantly lower in the CABG group than in the PCI group after adjustment. Similar findings were observed with regard to the risks of death from cardiac cause (adjusted HR 0.49; 95% CI 0.33 to 0.73; p <0.001) and repeat revascularization (adjusted HR 0.08; 95% CI 0.03 to 0.20; p <0.001). However, there were no significant differences in the risks of myocardial infarction and stroke between the 2 groups. The superiority of CABG over PCI was particularly pronounced in patients receiving β blockers and angiotensin-converting enzyme inhibitor or angiotensin receptor blockers than those who are not. In conclusion, among patients with significant CAD and severe LV dysfunction, CABG showed a lower risk of all-cause death, cardiac-cause death, and repeat revascularization compared with PCI with drug-eluting stents.

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis.

Methods and Results

A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR.

Conclusion

CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.