The Impact of Complete Revascularization on Long-Term Survival Is Strongly Dependent on Age

Evaluation of a Structuralized Sick-Leave Programme Compared with usual Care Sick-Leave Management for Patients after an Acute Myocardial Infarction

OBJECTIVE

To compare a structuralized sick-leave programme with usual care sick-leave management in patients after an acute myocardial infarction. We hypothesize that a structured sick-leave programme will yield a faster return to work without negatively affecting quality of life.

METHODS

Patients admitted to Oslo University Hospital due to an acute myocardial infarction were included in the study. Patients were randomized into an intervention group or a conventional care group. Patients randomized to the intervention group were provided with a standard programme with full-time sick leave for 2 weeks after discharge and then encouraged to return to work. The sick leave of the conventional group was mainly managed by their general practitioner.

RESULTS

A total of 143 patients were included in the study. The conventional care group had a mean of 20.4 days absent from work, while that of the intervention group was significantly lower, with a mean of 17.2 days (p < 0.001) absent. There was no significant change in quality of life between the groups.

CONCLUSION

These findings strengthen the case for structuralized follow-up of patients with acute myocardial infarction, as this will have positive economic consequences for the patient and society as a whole, without making quality of life worse. Further investigation, with a larger study population, is warranted to determine the extent of health benefits conferred by early return to work.

Prognostic stratification of older patients with multivessel coronary artery disease treated with percutaneous transluminal coronary angioplasty based on clinical and biochemical measures: protocol for a prospective cohort study

INTRODUCTION

The incidence of acute coronary syndrome is rising in step with the growth of life expectancy. An increase in the age of patients with coronary artery disease has been related to in-hospital mortality, which has seen an upsurge over a short period of time. However, there is no consensus about the percutaneous coronary angioplasty strategy to follow for older patients with multivessel coronary artery disease (MVCAD). Complete revascularisation (CR) or incomplete revascularisation (ICR) strategy depends on prognosis but this has not yet been accurately described because of geriatric conditions and comorbidities. The aim of this study is to evaluate changes of clinical and biochemical parameters in older patients with MVCAD undergoing revascularisation and to establish a prognostic stratification model for CR and ICR.

METHODS AND ANALYSIS

This observational, longitudinal, prospective study will include 150 patients with MVCAD and subsequent revascularisation who attend the Hospital Universitario Virgen de la Victoria (Málaga, Spain). Because of the dropout rates, 180 patients will be recruited at the beginning. Sociodemographic characteristics, clinical and angiographic parameters, and biochemical variables, such as cardiovascular, metabolic, inflammatory, stress oxidative biomarkers, will be collected in the admission for coronary revascularisation and three follow-ups at 6, 12 and 18 months. Statistical analyses will be conducted with these data using CR and ICR as the primary exposure variable. Relevant explanatory variables will be selected from a predictive model for their inclusion in a prognostic stratification model. The primary outcome measures will be major adverse cardiovascular events.

ETHICS AND DISSEMINATION

Protocols and patient information have been approved by the regional research ethics committee (CEIm Provincial de Málaga-PEIBA (PI0131/2020). The results will be disseminated in international peer-reviewed journals, presented at conferences in Cardiology and Gerontology, and sent to participants, medical and health service managers, clinicians and other researchers.

What does complete revascularization mean in 2021? - Definitions, implications, and biases

PURPOSE OF REVIEW

Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives.

RECENT FINDINGS

When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks.

SUMMARY

Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.

Population-Based Multilevel Models to Estimate the Management Strategies for Acute Myocardial Infarction in Older Adults with Dementia

Background

Acute myocardial infarction (AMI) management strategies, involving treatment and post-care, are much more difficult for patients with dementia. This study investigated the factors influencing the use of invasive procedures and long-term care in the management strategies for AMI patients with dementia and the factors associated with these patients' survival.

Methods

This multilevel study combined information from two databases, namely later-stage elderly healthcare insurance and long-term care insurance claims, from 2013 to 2019. Of 214,963 individuals with dementia, we identified 13,593 patients with AMI. The primary outcomes were the use of invasive procedures for treatment and long-term care for post-care management. Survival outcomes were also measured over a 6-year period, adjusting for individual- and regional-level characteristics in multilevel models.

Results

A total of 1954 (14.38%) individuals received an invasive procedure during treatment, and 7850 (87.18%) used long-term care for post-care management after AMI. After multivariate adjustment, patients aged ≥ 85 years and women were less likely to receive invasive procedures and more likely to use long-term care. Patients undergoing invasive procedures had a lower use of long-term care. Better survival outcome was significantly associated with invasive management and long-term care, regardless of the type of care.

Conclusion

Age and sex determine the use of invasive procedures and long-term care after AMI among patients with dementia. AMI patients with dementia receiving invasive procedures and long-term care had better survival outcomes.

Complete surgical revascularization: Different definitions, same impact?

BACKGROUND

There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes.

METHODS

All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated.

EXCLUSION CRITERIA

emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes.

RESULTS

Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.

Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting?

The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.

Complete Revascularization in Acute and Chronic Coronary Syndrome

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

Impact of residual coronary atherosclerosis on transfemoral transcatheter aortic valve replacement

OBJECTIVES

This study reports on the clinical effects of complete vs incompletely revascularized coronary artery disease on transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a high prevalence of active coronary artery disease (CAD) in patients undergoing TAVR but preemptive revascularization remains controversial.

METHODS

Patients were categorized into three cohorts: complete revascularization (CR), incomplete revascularization of a major epicardial artery (IR Major), and incomplete revascularization of a minor epicardial artery only (IR Minor). When feasible, SYNTAX scoring was performed for exploratory analysis. Analyses were performed using Cox proportional hazard models and Kaplan-Meier method.

RESULTS

A total of 323 patients with active CAD were included. Adjusted outcomes showed that patients with IR Major had increased incidence of acute myocardial infarction (AMI) or revascularization compared with those in the CR cohort (HR 3.72, P = 0.048). No difference was noted in all-cause mortality or all-cause readmission rates. Exploratory secondary analysis with residual SYNTAX scores showed a significant interaction between disease burden and AMI/revascularization, as well as all-cause readmission. All-cause mortality remained unaffected based on residual SYNTAX scores.

CONCLUSIONS

This is a retrospective single-center study reporting on pre-TAVR revascularization outcomes in patients with active CAD. In this analysis, we found that patients undergoing TAVR benefited from achieving complete revascularization to abate future incidence of AMI/revascularization. Despite this finding, all-cause mortality remained unaffected. Future efforts should focus on the role of functional assessment of the coronaries, as well as the long-term effects of complete revascularization in a larger patient cohort.

The effect of completeness of revascularization during CABG with single versus multiple arterial grafts

INTRODUCTION

Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG).

METHODS

We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression.

RESULTS

Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]).

CONCLUSIONS

Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.

Transcatheter or surgical treatment of severe aortic stenosis and coronary artery disease: A comparative analysis from the Italian OBSERVANT study

BACKGROUND

To assess clinical outcomes of patients with concomitant severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) or surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG).

METHODS

Data were extracted from the multicenter OBSERVANT study. For the purposes of the present analysis, we included only patients with established stable CAD meeting any of the following inclusion criteria: 1) TAVI patients with CAD undergoing staged PCI or TAVI and PCI in the same session; 2) SAVR patients undergoing combined SAVR and CABG in the same session.

RESULTS

After propensity-score matching, a total of 472 patients (236 per group) were identified. Among TAVI patients, PCI was performed prior to the procedure in 217 patients (92.0%), whereas concomitant TAVI and PCI were performed in 19 patients (8.0%). At 3-year, there was no difference in survival between the two groups (KM estimate of freedom from death for SAVR and TAVI patients of 0.742 and 0.650, respectively; log-rank p-value of 0.105). The rate of MACCE was comparable between the two groups (KM estimate of freedom from MACCE for SAVR and TAVI patients of 0.683 and 0.582, respectively; log-rank p-value of 0.115).

CONCLUSIONS

In patients with associated severe AS and CAD, percutaneous treatment (TAVR and staged or concomitant PCI) was comparable to surgical treatment (SAVR and concomitant CABG) with respect to the early and mid-term risk of death from any cause, myocardial infarction, stroke and unplanned revascularization.

Heart rate prediction of outcome in heart failure following myocardial infarction depend on heart rhythm status an analysis from the high-risk myocardial infarction database initiative

BACKGROUND

Heart rate has been reported to be associated with adverse outcome in heart failure (HF) and myocardial infarction (MI), but conflicting evidence exists regarding its impact in patients with associated atrial fibrillation (AF).

OBJECTIVES

We investigated the differential impact of heart rate on clinical outcomes according to the presence or absence of AF in patients with reduced systolic function and/or HF after MI.

METHODS

We studied the association of heart rate with outcome using Cox-models in a merged dataset (n=28,771) of four randomized trials (CAPRICORN, EPHESUS, OPTIMAAL, and VALIANT).

RESULTS

At baseline, 3736 (13%) patients had AF. We identified a significant interaction between AF and heart rate, and a decreasing effect of heart rate with time, heart rate being less associated with outcome after 1year of follow-up (both p for interaction <0.001). We report associations with outcome separately in patients with and without AF. In addition, as neutral associations with outcome after 1year were estimated after adjustment on confounding factors, only association for the first year follow-up were provided. 10-bpm increase in heart rate conferred increased risk for all-cause mortality (1.27 [1.21 to 1.33], p<0.0001), CV-mortality (1.28 [1.22 to 1.34], p<0.0001), and HF-hospitalisation (1.25 [1.19 to 1.31], p<0.0001) in patients without AF. In contrast, in patients with AF, the incremental risk for 10-bpm increase in heart rate was attenuated for all-cause (1.14 [1.06 to 1.23], p=0.0007), CV-mortality (1.12 [1.03 to 1.22], p=0.006), and HF-hospitalisation (1.16 [1.07 to 1.26], p=0.0006, p for interaction with AF <0.001 for all outcomes).

CONCLUSIONS

In patients with reduced systolic function and/or HF post-MI, higher heart rate predicts increased major cardiovascular events during the first year following MI in patients without AF. This association is markedly attenuated in subjects with AF.

Quantification of Treatment Effect Modification on Both an Additive and Multiplicative Scale

Background

In both observational and randomized studies, associations with overall survival are by and large assessed on a multiplicative scale using the Cox model. However, clinicians and clinical researchers have an ardent interest in assessing absolute benefit associated with treatments. In older patients, some studies have reported lower relative treatment effect, which might translate into similar or even greater absolute treatment effect given their high baseline hazard for clinical events.

Methods

The effect of treatment and the effect modification of treatment were respectively assessed using a multiplicative and an additive hazard model in an analysis adjusted for propensity score in the context of coronary surgery.

Results

The multiplicative model yielded a lower relative hazard reduction with bilateral internal thoracic artery grafting in older patients (Hazard ratio for interaction/year = 1.03, 95%CI: 1.00 to 1.06, p = 0.05) whereas the additive model reported a similar absolute hazard reduction with increasing age (Delta for interaction/year = 0.10, 95%CI: -0.27 to 0.46, p = 0.61). The number needed to treat derived from the propensity score-adjusted multiplicative model was remarkably similar at the end of the follow-up in patients aged < = 60 and in patients >70.

Conclusions

The present example demonstrates that a lower treatment effect in older patients on a relative scale can conversely translate into a similar treatment effect on an additive scale due to large baseline hazard differences. Importantly, absolute risk reduction, either crude or adjusted, can be calculated from multiplicative survival models. We advocate for a wider use of the absolute scale, especially using additive hazard models, to assess treatment effect and treatment effect modification.

Clinical benefit of spironolactone in patients with acute decompensated heart failure and severe renal dysfunction: Data from the Korean Heart Failure Registry

BACKGROUNDS

We investigated the relationship between spironolactone use and all-cause mortality in acute decompensated heart failure (ADHF) patients with severe renal dysfunction. The clinical benefit of spironolactone in the treatment of heart failure (HF) has been described in several large randomized clinical trials. However, its clinical benefits have not been studied in hospitalized ADHF patients with severe renal dysfunction (estimated glomerular filtration rate [eGFR] <45 mL/min per 1.73 m(2)).

METHODS AND RESULTS

We retrospectively analyzed data from the Korean Heart Failure Registry. We included 1,035 ADHF patients with severe renal dysfunction. In Kaplan-Meier survival analysis, all-cause mortality in the spironolactone-treated group was significantly lower than that in the nonspironolactone group (18.1% vs 24.9%, respectively, log rank P = .028). However, spironolactone use was not an independent predictor after adjusting other HF risk factors (hazard ratio 0.974, 95% CI 0.681-1.392, P = .884) and after propensity score matching (P = .115). In subgroup analysis, the clinical benefit of spironolactone use was preserved in women, prehospital spironolactone use, the chronic kidney disease stage 3b (eGFR 30-44 mL/min per 1.73 m(2)), and the appropriate spironolactone use (eGFR ≥30 mL/min per 1.73 m(2) and K ≤5.0 mmol/L).

CONCLUSION

The spironolactone therapy was not beneficial in ADHF patients with severe renal dysfunction after multivariable adjusting and propensity score matching. However, we reassured the current HF guidelines for spironolactone use and the clinical benefit in chronic kidney disease stage 3b should be assessed in future clinical trial.

Impact of age on early outcome after coronary bypass graft surgery using minimized versus conventional extracorporeal circulation

Background

Objective of this study was to evaluate the impact of age on comparative early outcomes after coronary artery bypass graft surgery (CABG) with minimized (MECC) and conventional extracorporeal circulation (CECC).

Methods

A retrospective age-, gender- and operation-matched cohort analysis between January 2005 and December 2010 with a total of 2274 patients undergoing CABG with MECC (n = 1137; 50%) or CECC was performed. Patients were stratified into 4 groups according to age: <59 years, 60–69 years, 70–79 years, and 80 years of age or older. Outcomes were compared within each age group. Patients with preoperative dialysis were excluded from analysis. Primary endpoint was 30-day mortality.

Results

Patients treated with CECC had a significantly higher mean logistic EuroSCORE (6.3% vs. 5.0%; p < 0.001), a slightly lower rate of preoperative myocardial infarction (46% vs. 51%; p = 0.01) and a higher rate of impaired renal function (eGFR < 60 mL/min/1.73 m2: 24% vs. 20%; p = 0.01) compared to MECC-patients. Left internal mammary artery was significantly used more often in MECC patients (93% vs. 86%; p < 0.001). Cardiopulmonary bypass and aortic-cross clamping time were significantly lower in the MECC group (p < 0.001). Overall 30-day mortality was significantly higher in patients treated with CECC (4.4% vs. 2.2%; p = 0.002). Within the different age groups mortality rates were not significantly different except for patients aged 60–69 years (4.5% vs. 1.8%; p = 0.03). Postoperative requirement of renal replacement therapy (4% vs. 2.2%; p = 0.01), respiratory insufficiency (9.9% vs. 6.6%; P = 0.004) and incidence of low cardiac output syndrome (3% vs. 1.2%; p = 0.003) were significantly increased in patients with CECC. Multivariate analysis identified age (p = 0.005; 95% CI 1.01 to 1.08; OR 1.05) among other parameters as an independent risk factor, whereas conventional extracorporeal circulation itself did not present as an independent risk factor for 30-day mortality.

Conclusions

In this matched study sample early outcome was significantly better in patients with MECC compared to CECC, irrespective of age. Prior myocardial infarction estimated GFR < 60 mL and waiving the use of LIMA were independent risk factors for 30-day mortality, which were more present in the CECC group.

Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients)

OBJECTIVES

Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD.

METHODS

This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index.

RESULTS

Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses.

CONCLUSIONS

The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.

Conduits for coronary bypass: strategies

Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.

Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts

OBJECTIVE

Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting.

METHODS

In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities.

RESULTS

In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients.

CONCLUSIONS

This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR.

Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice

OBJECTIVES

This study sought to assess in patients undergoing transcatheter aortic valve implantation (TAVI), the prevalence and impact of incomplete coronary revascularization defined as >50% coronary artery or graft diameter stenosis on visual assessment of the coronary angiogram.

BACKGROUND

TAVI is an established treatment option in elderly patients with aortic stenosis (AS) and a (very) high operative risk. Coronary artery disease (CAD) is often associated with AS.

METHODS

A single-center cohort of consecutive patients undergoing TAVI between November 2005 and June 2012 was evaluated for the presence of significant CAD. The decision to revascularize and pursue complete revascularization was made by heart team consensus.

RESULTS

A total of 263 consecutive patients with a mean age of 80 ± 7 years and 51% male underwent TAVI with a median follow-up duration of 16 months (interquartile range: 4.2 to 28.1 months). Significant CAD with myocardium at risk was present in 124 patients (47%), 44 of whom had had previous coronary artery bypass grafting (CABG), and the median SYNTAX score in the 81 patients without previous CABG was 9.00 (2.38 to 15.63). Staged percutaneous coronary intervention (PCI) was planned in 19 (15%) and concomitant PCI with TAVI in 20 (16%). The median post-procedural residual SYNTAX score of patients without prior CABG was 5.00 (0.13 to 9.88). Overall, 99 patients (37%) (61 with no CABG and 38 CABG patients) had incomplete revascularization after TAVI. Revascularization status did not affect clinical endpoints. Kaplan-Meier survival curves for patients with and without complete revascularization demonstrated a 1-year mortality of 79.9% versus 77.4% (p = 0.85), respectively.

CONCLUSIONS

In an elderly patient population undergoing TAVI for severe AS, a judicious revascularization strategy selection by a dedicated heart team can generate favorable mid-term outcome obviating the need for complete coronary revascularization.