The adequacy of myocardial revascularization in patients with multivessel coronary artery disease

Quantitative analysis of myocardial blood flow in surgically revascularized and not revascularized myocardial segments. A pilot PET study

PURPOSE

To prospectively compare changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) in multivessel coronary artery disease (MVCAD) patients undergoing incomplete revascularization (IR) versus complete revascularization (CR) by coronary artery bypass grafting (CABG).

METHODS

Seven male patients (age 68 ± 9 years) with MVCAD underwent myocardial perfusion PET/CT with [13N]ammonia before and at least 4 months after CABG. Segmental resting and stress MBF as well as MFR were measured. Resting and during stress left ventricle ejection fraction (LVEF) were also calculated.

RESULTS

Three patients (43%) underwent CR and four (57%) IR. Among 119 myocardial segments, 101 (85%) were revascularized, and 18 (15%) were not. After CABG, stress MBF (mL/min/gr) and MFR are significantly increased in all myocardial segments, with a greater increase in the revascularized segments (p = 0.013). In both groups, LVEF significantly decreased during stress at baseline PET (p = 0.04), but not after CABG.

CONCLUSION

Stress MBF and MFR significantly improve after CABG in both revascularized and not directly revascularized myocardial segments. IR strategy may be considered in patients with high surgical risk for CR.

Long-term risk of new-onset arrhythmia in ST-segment elevation myocardial infarction according to revascularization status

AIMS

Emerging data show that complete revascularization (CR) reduces cardiovascular death and recurrent myocardial infarction in ST-segment elevation myocardial infarction (STEMI). However, the influence of revascularization status on development of arrhythmia in the long-term post-STEMI phase is poorly described. We hypothesized that incomplete revascularization (ICR) compared with CR in STEMI is associated with an increased long-term risk of new-onset arrhythmia.

METHODS AND RESULTS

Patients with STEMI treated with primary percutaneous coronary intervention (PPCI) at Copenhagen University Hospital, Rigshospitalet, Denmark, with CR or ICR were identified via the Eastern Danish Heart registry from 2009 to 2016. Using unique Danish administrative registries, the outcomes were assessed. The primary outcome was new-onset arrhythmia defined as a composite of atrial fibrillation/flutter (AF), sinoatrial block, advanced second- or third-degree atrioventricular block, ventricular tachycardia/fibrillation (VT), or cardiac arrest (CA), with presentation >7 days post-PPCI. Secondary outcomes were the components of the primary outcome and all-cause mortality. A total of 5103 patients (median age: 62.0 years; 76% men) were included, of whom 4009 (79%) and 1094 (21%) patients underwent CR and ICR, respectively. Compared with CR, ICR was associated with a higher risk of new-onset arrhythmia [hazard ratio (HR), 1.33; 95% confidence interval (CI), 1.07-1.66; P = 0.01], AF (HR, 1.29; 95% CI, 1.00-1.66; P = 0.05), a combined outcome of VT and CA (HR, 1.77; 95% CI, 1.10-2.84; P = 0.02) and all-cause mortality (HR, 1.27; 95% CI, 1.05-1.53; P = 0.01). All HRs adjusted.

CONCLUSION

Among patients with STEMI, ICR was associated with an increased long-term risk of new-onset arrhythmia and all-cause mortality compared with CR.

Coronary angiography- or fractional flow reserve-guided complete revascularization in multivessel disease STEMI: A Bayesian hierarchical network meta-analysis

AIMS

To identify the best strategy to achieve complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD).

METHODS AND RESULTS

We systematically reviewed the literature for randomized controlled trials (RCTs) comparing IRA-only PCI and CR guided by angiography or fractional flow reserve (FFR) in MVD-STEMI. Both frequentist (classical) and Bayesian network meta-analysis were performed, including a comparative hierarchy estimation of the probability to reduce the primary composite endpoint of all-cause death and new myocardial infarction (MI). We identified 11 RCTs, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the primary endpoint (OR: 0.73; 95%CI0.55-0.97). We observed non-significant difference between angiography and FFR guidance in reducing the primary endpoint (OR: 0.73, 95% CI 0.35-1.57). The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of all-cause death or new MI (SUCRA92%).

CONCLUSIONS

In patients with MVD-STEMI, CR is associated with a reduction in all-cause mortality and new MI compared with IRA-only PCI. Angio-guided CR is associated with the lowest risk of all-cause death or new MI, therefore the role of FFR-guidance in this setting is questionable.

CONDENSED ABSTRACT

Both frequentist and Bayesian network meta-analysis were performed to compare infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) and complete revascularization (CR) guided by angiography or fractional flow reserve (FFR) in multivessel disease (MVD) and acute ST-elevation myocardial infarction (STEMI). Eleven randomized controlled trials were identified, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the incidence of the composite endpoint of all-cause death and new myocardial infarction without significant difference in angio-guided and FFR-guided CR. The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of the composite endpoint and, therefore the role of FFR-guidance in this setting is questionable.

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.

A Prospective, observational, Italian multi-center registry of self-aPposing® cOronary Stents in patients presenting with ST-segment Elevation Myocardial InfarcTION: The iPOSITION registry

BACKGROUND

Primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) can be challenging for high thrombus burden and catecholamine-induced vasoconstriction. The Xposition-S stent was designed to prevent stent undersizing and minimize strut malapposition. We evaluated 1-year clinical outcomes of a nitinol, self-apposing®, sirolimus-eluting stent, pre-mounted on a novel balloon delivery system, in de novo lesions of patients presenting with STEMI undergoing pPCI.

METHODS

The iPOSITION is a prospective, multicenter, post-market, observational study. The primary endpoint, target lesion failure (TLF), was defined as the composite of cardiac death, recurrent target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR).

RESULTS

The study enrolled 247 STEMI patients from 7 Italian centers. Both device and procedural success occurred in 99.2% of patients, without any death, TV-MI, TLR, or stent thrombosis during the hospital stay and at 30-day follow-up. At 1 year, TLF occurred in 2.6%, cardiac death occurred in 1.7%, TV-MI occurred in 0.4%, and TLR in 0.4% of patients. The 1-year stent thrombosis rate was 0.4%.

CONCLUSIONS

The use of an X-position S self-apposing® stent is feasible in STEMI pPCI, with excellent post-procedural results and 1-year outcomes.

Effect of left ventricular ejection fraction on the prognostic impact of chronic total occlusion in a non-infarct-related artery in patients with acute myocardial infarction

BACKGROUND

Chronic total occlusion (CTO) in a non-infarct-related artery (IRA) in patients with acute coronary syndrome (ACS) is associated with a poor prognosis. However, whether the prognostic impact of non-IRA CTO differs according to left ventricular ejection fraction (LVEF) is unclear.

METHODS AND RESULTS

A total of 2060 consecutive acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) were classified into 2 groups according to their LVEF (reduced EF: LVEF < 50%, preserved EF: LVEF ≥ 50%) and further subdivided according to the presence of concomitant non-IRA CTO. In the reduced EF group, patients with CTO had a higher 1-year all-cause death rate (20.3% vs. 34.3%, P = 0.001) and major adverse cardiac event rate (MACE: 19.6% vs. 39.6%, P < 0.001) compared to those without CTO, but they were similar between patients with and without CTO in the preserved EF group. Non-IRA CTO was an independent predictor of all-cause death (HR 1.58, 95% CI 1.06-2.33, P = 0.02) and MACE (HR 1.67, 95% CI 1.14-2.46, P = 0.009) only in the reduced EF group. In addition, the outcomes of successful CTO-PCI seemed to be similar to those without CTO in the reduced EF group.

CONCLUSIONS

CTO in a non-IRA may contribute to a poor prognosis only in AMI patients with reduced LVEF.

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

The impact of the extent of side branch disease on outcomes following bifurcation stenting

OBJECTIVES

To define the impact of side branch (SB) lesion length on clinical outcomes after percutaneous coronary intervention (PCI) on bifurcation lesions.

BACKGROUND

The role of the SB lesion length remains questionable in PCI planning and its implication on clinical outcome is controversial.

METHODS

Data from the retrospective multicenter EBC-P2BiTO registry were analyzed. The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction excluding periprocedural, or stent thrombosis at 13 months median follow-up (IQR 11-28). By using propensity scores for inverse probability of treatment weighting (IPTW), the comparison of treatment groups was adjusted to correct for potential confounding.

RESULTS

Among 1,252 patients, SB was normal in 489 (39%), diseased in 763 (61%) cases. MACE occurred in 68 patients (5.4%). The optimal discriminant SB lesion length for MACE was ≥10 mm, with an area under the curve of 0.71 (p < .01). The incidence of MACE was higher among patients with SB lesions ≥10 mm (8%) than with normal SB (4.1%) (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.5-5.3; p = .001, IPTW-adjusted) or SB lesions <10 mm (5.1%) (HR, 1.5; 95% CI, 1.1-3.3; p = .048, IPTW-adjusted), being similar between these last two groups.

CONCLUSIONS

In bifurcation PCI, SB lesion length ≥ 10 mm identifies patients at higher risk of MACE than those with <10 mm SB lesions and those without SB disease, considering that no differences were observed among these last two groups. Careful planning is mandatory when approaching bifurcations with long SB lesions.

Calcific lesion preparation for coronary bifurcation stenting

Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.

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.

Renal Dysfunction: How to Think About That in Acute Coronary Syndromes

PURPOSE OF REVIEW

Reduction of kidney function and heart disease frequently coexisted in the seam patient. The relation between renal and heart function is quite complex and bring out some unresolved questions about diagnosis (mostly related to the biomarkers levels interpretation), pharmacological therapy (mostly related to drugs kinetics and efficacy), and non-pharmacological therapy.

RECENT FINDINGS

Patients with kidney dysfunction (KD) are frequently excluded and underrepresented in the large trials. It is well-known that coronary revascularization reduces mortality also in KD patients presenting with acute coronary syndrome. However, acute kidney injury (AKI), primarily related at contrast medium administration, is worse prognosis. For this reason, prevention, early diagnosis, and effective therapy of ACK are key elements in assistance of these patients. In this context, recently, some new biomarkers of renal function have been proposed. Frequently, patients with acute coronary syndromes and kidney disease are undertreated, worsening their prognosis. Undertreatment and comorbidities associated with renal dysfunction explain the higher mortality of these patients.

Drug-eluting stent use after coronary atherectomy: results from a multicentre experience - The ROTALINK I study

AIMS

Until now, there is no medium- to long-term clinical evidence of the best treatment after rotational atherectomy.

METHODS

From the databases of seven high-volume centres, years 2005-2010, we retrospectively analysed the long-term outcome of patients who had undergone rotational atherectomy followed by plain-balloon angioplasty or implantation of drug-eluting stent (DES) or bare metal stent (BMS). Primary endpoint was the incidence of major adverse cardiovascular events (MACE: death, myocardial infarction, target-lesion-revascularization) at longest available follow-up.

RESULTS

In this registry, we enrolled 1397 patients with 1605 lesions, followed for 28.4 ± 21 months. DES-treated patients were more frequently diabetic, had more lesions treated and received a higher number of stents. In-hospital MACEs were significantly higher in DES patients (7.6 vs. 2.6 vs. 2.9%, respectively, P = 0.0001 for both), mainly due to a higher incidence of myocardial infarction (6.4 vs. 1.2 vs. 2.1%, P = 0.0001). The 2-year follow-up showed a significantly lower incidence of MACE in DES patients (15.1 vs. 24.2 vs. 20.8%, P = 0.001 for both), driven by a lower incidence of target-lesion revascularization (8 vs. 14.6 vs. 13.9%, P = 0.002). Myocardial infarction rate was lower in the DES group as well (0.4 vs. 3.1% in BMS, P = 0.001). At multivariate analysis, BMS implantation and balloon angioplasty were independent predictors of long-term MACE. DES implantation was associated with a lower risk of long-term myocardial infarction [hazard ratio 0.15, 95% confidence interval (95% CI) 0.04-0.67] and target-lesion revascularization (hazard ratio 0.42, 95% CI 0.21-0.82). Male sex and DES use were independent predictors of the absence of MACE.

CONCLUSION

After rotational atherectomy, DES implantation appears to be a preferable strategy, as it is associated with lower long-term MACE, despite an unexpected increase in periprocedural myocardial infarction.

Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

In multivessel coronary artery disease (MVCAD), myocardial revascularisation can be achieved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), with complete revascularisation on all diseased coronary segments or with incomplete revascularisation on selectively targeted lesions. Complete revascularisation confers a long-term prognostic benefit, but is associated with a higher rate of periprocedural events compared with incomplete revascularisation. In most patients with MVCAD, the main advantage of CABG over PCI is conferred by the achievement of more extensive revascularisation. According to current international guidelines, PCI is generally preferred in single-vessel disease, low-risk MVCAD or isolated left main disease; whereas CABG is usually recommended in patients with complex two-vessel disease, most patients with three-vessel disease and/or non-isolated left main disease. In patients with MVCAD, the choice on revascularisation modality should depend on a multifactorial evaluation, taking into account not only coronary anatomy, the ischaemic burden, myocardial function, age and the presence of comorbidities, but also the adequacy of myocardial revascularisation.

"One-Time" versus Staged Multivessel Intervention in Intermediate to Very High-Risk Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

Background and Objectives

To compare clinical outcomes of staged versus "one-time" percutaneous coronary intervention (PCI) in intermediate to very high-risk patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) and multivessel coronary disease (MVD).

Subjects and Methods

1531 NSTE-ACS patients with multivessel PCI and meeting the criteria of intermediate to very high risk were screened from a prospectively registered database obtained from General Hospital of Shenyang Military Region between 2008 and 2012. They were categorized into "one-time" PCI (n=859) and staged PCI (n=672) according to intervention strategy. The primary outcomes included a 3-year major adverse cardiac event (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularization.

Results

At 3 years, no significant differences in MACE (20.8% vs. 19.7%, p=0.608) and cardiac death/MI (7.1% vs. 9.1%, p=0.129) were observed between the two groups. After propensity score matching, there was no statistical significance in MACE (18.9% vs. 21.8%, p=0.249); whereas cardiac death/MI was significantly lower in the staged PCI group (7.0% vs.11.1%, p=0.033). Ninety-day landmark analysis showed that the staged PCI group had a lower 90-day incidence of MACE (1.2% vs. 3.3%, p= 0.037) and cardiac death/MI (0.7% vs. 2.6%, p=0.031). For the 90-day to 3-year follow-up period, the incidences of MACE (17.9% vs. 19.1%, p=0.641) and cardiac death/MI (6.3% vs. 8.7%, p=0.191) were similar in both groups.

Conclusion

In intermediate- to very high-risk NSTE-ACS patients with MVD, staged PCI is superior to "one-time" PCI in terms of cardiac death/MI.

Is it time to change how we think about incomplete coronary revascularization?

The optimal degree of revascularization for patients with chronic multivessel coronary artery disease remains an unsolved issue. Intuitively, complete revascularization decreases cardiovascular events and improves outcomes compared to incomplete procedures, but in recent years the concept of incomplete revascularization moved from a sub-optimal or a defective treatment towards the most appropriate revascularization technique in some categories of patients. A reasonable level of incomplete anatomic revascularization has been shown to be safe and achievable with both percutaneous (PCI) and surgical procedures (CABG), despite with different long-term outcomes. What are the mechanisms underlying the clinical benefits of an incomplete revascularization and what are the factors explaining the discrepancy in the long-term clinical outcomes between the two modes of revascularization PCI and CABG? The biological consequences of coronary reperfusion might provide valuable hints in this context and at the same time cast new light on the way we think about incomplete revascularization.

Localizing factors in atherosclerosis

Atherosclerotic vascular disease is the leading cause of death worldwide. Although the entire vascular bed is constantly exposed to the same risk factors, atheromatous lesions present a distinct intra-individual pattern of localization and progression, being consistently more frequent in specific segments of the arterial vascular bed. This peculiar distribution may be related to selective sensitivity of such locations to the influence of risk factors or to histopathological and flow differences, and has relevant clinical implications, as the prognosis of the disease varies according to localization. We here review the theories that have been formulated to explain such preferential locations, as its understanding can be useful to pursue diagnostic screening strategies and focused preventive measures.

Rotational atherectomy in very long lesions: Results for the ROTATE registry

BACKGROUND

Rotational atherectomy (RA) is relatively contraindicated in patients with lesions ≥25 mm of length. Aim of this study was to evaluate RA safety and efficacy in this subset of patients with new technology and devices.

METHODS AND RESULTS

From April 2002 to August 2013, the ROTATE registry included all consecutive patients undergoing RA in 8 centres. They were divided into shorter lesion group (SLG, lesions < 25 mm) and longer lesion group (LLG, lesions ≥ 25 mm). The angiographic success (AS) was the primary end point. Procedural complications (PC), a composite end point of procedural perforation, slow flow/no flow, and in-hospital major acute cardiovascular events (MACE), were secondary end points, along with death, nonfatal MI, target lesion revascularization, and MACE during follow-up. Sensitivity analysis was performed according to generation of DES. 1186 patients were included: 51.5% in SLG and 48.4% in LLG. Mean age was 70.4 ± 9.3 years, 64.5% were male. AS and PC did not differ between the two groups (93% vs 91%, p = 0.24 and 9.8 vs 9.4%, p = 0.84). During follow-up (27.6 ± 22.9 months), MACE did not differ between the two groups (28% vs 29.1%, p = 0.95). At multivariate analysis chronic kidney disease, male gender increased risk of MACE (HR 1.94, IQR 1.29-2.0, p = 0.01, HR 0.52, IQR 0.34-0.79, p = 0.01) while second-generation DES seemed protective (HR 0.53, IQR 0.31-0.88, p = 0.02). Data were confirmed at sensitivity analysis for second-generation DES (759 pts, 63.9%). No differences were found in this subpopulation between the two groups in term of AS, PC, and long-term MACE (93.6% vs 93.5%, p = 0.28, 11.9% vs 9.4%, p = 0.32 and 25.5% vs 23.9%, p = 0.72, respectively).

CONCLUSIONS

Treating coronary lesions ≥ 25 mm length with RA does not impact short- and long-term outcome, in particular, in patients with second-generation DES. © 2016 Wiley Periodicals, Inc.

Short- and Long-Term Patient Outcomes From Combined Coronary Endarterectomy and Coronary Artery Bypass Grafting: A Meta-Analysis of 63,730 Patients (PRISMA)

This meta-analysis aimed to compare the short- and long-term outcomes in patients undergoing combined coronary endarterectomy and coronary artery bypass grafting (CE + CABG) versus isolated CABG, and particularly to examine subgroup patients with high-risk profile and patients with diffuse disease in the left anterior descending artery (LAD).Studies published between January 1, 1970 and May 31, 2015 were searched in the literature databases, including Ovid Medline, Embase, PubMed, and ISI Web of Science.A total of 30 eligible studies including 63,730 patients were analyzed.Five authors extracted data from the included studies independently.Meta-analysis on the total patients revealed that CE + CABG was associated with significantly increased 30-day postoperative all-cause mortality compared with isolated CABG (OR = 1.86, 95% CI: 1.66-2.08, z = 10.99, P < 0.0001). Subgroup analysis on patients with high-risk profile and patients with diffuse disease in the LAD showed that 30-day mortality after CE + CABG was 2.6 folds (OR = 2.60, 95% CI: 1.39-4.86, z = 2.99, P = 0.003) and 3.93 folds (OR = 3.93, 95% CI: 1.40-11.0, z = 2.60, P = 0.009) of that after isolated CABG in the respective subgroup. In contrast, the mortality was comparable in CE + off-pump CABG and CE + on-pump CABG groups (OR = 0.53, 95% CI: 0.18-1.55, z = 1.16, P = 0.248). In addition, the incidences of perioperative myocardial infarction (MI) and 30-day postoperative complications, including low output syndrome (LOS), MI, ventricular tachycardia (VT), and renal dysfunction after CE + CABG were significantly higher than those after isolated CABG (all P < 0.05). In high-risk patient subgroup, CE + CABG significantly increased the incidences of postoperative LOS, MI, and renal function compared with isolated CABG (all P < 0.05). The incidence of perioperative myocardial after CE + CABG was 2.86 and 2.92 times of that after isolated CABG in high-risk patients and patients with diffuse disease in LAD, respectively. Analysis on the recent reports (published later than 2000) showed consistent results as the analysis including all the eligible reports. Long-term survival was comparable in CE + CABG and isolated CABG groups (hazardous ratio = 1.16, 95% CI: 0.32-4.22, z = 0.23, P = 0.819).CE + CABG appears to be associated with poor short-term outcomes, particularly in high-risk patients and patients with diffuse disease in the LAD.