Complexity of atherosclerotic coronary artery disease and long-term outcomes in patients with unprotected left main disease treated with drug-eluting stents or coronary artery bypass grafting

Diagnostic accuracy of subendocardial vs. transmural myocardial perfusion defect for the detection of in-stent restenosis or progression of coronary artery disease after percutaneous coronary intervention

BACKGROUND

The ADVANTAGE study demonstrated in a cohort of stented patients a diagnostic accuracy of stress myocardial CT perfusion (CTP) significantly higher than that of coronary CT angiography (CCTA) for the detection of in-stent restenosis (ISR) or CAD progression vs. quantitative coronary angiography (QCA). This is a pre-defined subanalysis of the ADVANTAGE aimed at assessing the difference in terms of diagnostic accuracy vs. QCA of a subendocardial vs. a transmural perfusion defect using static stress CTP.

METHODS

We enrolled consecutive patients who previously underwent coronary stenting and were referred for QCA. All patients underwent stress CTP and rest CTP ​+ ​CCTA. The diagnostic accuracy of CCTA and CTP were evaluated in territory-based and patient-based analyses. We compared the diagnostic accuracy of "subendocardial" perfusion defect, defined as hypo-enhancement encompassing >25% but <50% of the transmural myocardial thickness within a specific coronary territory vs. "transmural" perfusion defect, defined as hypo-enhancement encompassing >50% of the transmural thickness.

RESULTS

In 150 patients (132 men, mean age 65.1 ​± ​9.1 years), the diagnostic accuracy of subendocardial vs. transmural perfusion defect in a vessel-based analysis was 93.5% vs. 87.7%, respectively (p ​< ​0.0001). The sensitivity and specificity of subendocardial vs. transmural defect were 87.9% vs. 46.9% (p ​< ​0.001) and 94.9% vs. 97.9% (p ​= ​0.004), respectively. In a patient-based analysis, the diagnostic accuracy of the subendocardial vs. transmural approach was 86.6% vs. 68% (p ​< ​0.0001).

CONCLUSIONS

This study shows that detection of a subendocardial perfusion defect as compared to a transmural defect is significantly more accurate to identify coronary territories with ISR or CAD progression.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

The Clinical Value of Syntax Scores in Predicting Coronary Artery Disease Outcomes

The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score (SS) hassignificantly improved angiographic risk stratification. By analyzing angiographic variables, this score characterizescoronary artery disease qualitatively and quantitatively. To date, combining this score with other non-angiographic clinicalscores has broadened perspectives regarding risk estimation, and future research on this topic appears promising.

Long-term clinical outcomes after a percutaneous coronary intervention with a drug-eluting stent in patients with unprotected left main coronary artery disease excluded from clinical trials

BACKGROUND

Major randomized clinical trials assessing clinical outcomes in patients who underwent a percutaneous coronary intervention (PCI) for left main coronary artery disease excluded some high-risk subsets. Whether the effectiveness and safety of a percutaneous approach in this group of patients are comparable with those observed in clinical trials is unclear. We aimed to explore the long-term outcomes of contemporary drug-eluting stent (DES)-based revascularization for left main coronary artery disease in patients presenting with one or more clinical or angiographic characteristics who would have precluded inclusion in randomized trials.

PATIENTS AND METHODS

Between April 2003 and December 2011, 340 consecutive patients with unprotected left main coronary artery stenosis of at least 50% who underwent successful PCI with DES at Sejong General Hospital (Bucheon, Republic of Korea) were included in this retrospective study. Patients were classified into the exclusion group (group E; n=120) and the inclusion group (group I; n=220) according to the prespecified inclusion and exclusion criteria utilized in clinical trials.

RESULTS

During the median follow-up of 86 (52-114) months, major adverse cardiac or cerebrovascular events occurred in 69 (31.4%) patients in group I and 46 (38.3%) patients in group E (P=0.155). In the propensity score-matched population, group E was not associated with a higher incidence of major adverse cardiac or cerebrovascular events (hazard ratio: 1.42, 95% confidence interval: 0.76-2.65, P=0.758). Definite or probable stent thrombosis occurred in five patients of group I, with no cases in group E.

CONCLUSION

In our real-world registry, about a third of patients who underwent PCI for unprotected left main coronary artery stenosis had one or more high-risk characteristics or comorbid conditions that represent exclusion criteria of previous randomized trials. PCI using DES is feasible in these patients.

Left main coronary artery disease: when and how to perform PCI?

Left main coronary artery (LMCA) disease has been reported in up to 10% of all patients with coronary artery disease (CAD) and in the majority of cases are associated with severe three-vessel CAD. Among patients with chronic coronary syndrome revascularization of significant LMCA disease improves prognosis, while there is a debate about which revascularization strategy, CABG surgery or percutaneous coronary interventions to use. We do a review of the available evidence about the impact of LMCA lesions on patient prognosis according to CAD extension and clinical presentation, the outcome after percutaneous or surgical revascularization, the procedural challenges of LMCA PCI and the available armamentarium to optimally treat this relevant population.

Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease

Severe stenosis of the left main coronary artery (LMCA) generally occurs as a result of atherosclerosis and compromises the blood supply to a wide area of myocardium, thereby increasing the risk of serious adverse cardiac events. Current revascularization strategies for patients with significant LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), both of which have a range of advantages and disadvantages. In general, PCI is associated with a lower rate of periprocedural adverse events and provides more rapid recovery, while CABG provides more durable revascularization. Most clinical trials comparing PCI and CABG for the treatment of LMCA disease have shown PCI to be non-inferior to CABG with respect to mortality and the serious composite outcome of death, myocardial infarction, or stroke in patients with low-to-intermediate anatomical complexities. Remarkable advancements in PCI standards, including safer and more effective stents, adjunctive intravascular imaging or physiologic evaluation, and antithrombotic treatment, may have contributed to these favorable results. This review provides an update on the current management of LMCA disease with an emphasis on clinical data and academic and clinical knowledge that supports the use of PCI in an increasing proportion of patients with LMCA disease.

Long-term outcomes following left main bifurcation stenting in Indian population-Analysis based on SYNTAX I and II scores

Background

Syntax 1 and recently Syntax 2 (SS2) scores are validated risk prediction models in coronary disease.

Objectives

To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2 (SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population.

Methods

Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test.

Results

Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5% at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7%). There were 4 deaths (3.8%). The mean left ventricular ejection fraction (LVEF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events.

Conclusions

Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LVEF was the most useful predictor of events after LM PCI.

Comparative determinants of 5-year cardiovascular event rates in patients with unprotected left main coronary artery disease

BACKGROUND

Diabetes mellitus (DM), low ejection fraction (EF), and the extent of coronary artery disease (CAD) have all been identified as predictors of cardiovascular events in multivessel disease, but their comparative contributions to future risk remain unclear in patients with unprotected left main coronary artery (ULMCA) disease. Through this study we aimed to categorize the risk for cardiovascular events in patients with ULMCA disease using simple clinical descriptors.

PATIENTS AND METHODS

Our study included a total of 5975 patients with ULMCA disease from the Interventional Research Incorporation Society-Left MAIN Revascularization registry who were treated with percutaneous coronary intervention (n=2850), coronary artery bypass grafting (n=2337), or medical therapy alone (n=608). We categorized the risk for cardiovascular events using simple clinical descriptors (DM, low EF, and the extent of CAD). The primary outcome was a major adverse cardiac or cerebrovascular event (MACCE) (i.e. death from any cause, stroke, myocardial infarction, or repeat revascularization).

RESULTS

Overall, the 5-year rate of MACCE was highest in the medical group, lower in the percutaneous coronary intervention group, and lowest in the coronary artery bypass grafting group (42.5, 25.7, and 19.9%, respectively; P<0.001). In multivariable modeling, the presence of DM [hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.12-1.40; P<0.001], low EF of 40% or less (HR: 1.83; 95% CI: 1.56-2.15; P<0.001), and the extent of CAD (HR: 1.14; 95% CI: 1.08-1.21; P<0.001) were independent predictors of MACCE; in addition, these factors were consistently associated with a significantly higher risk for MACCE, regardless of index treatment strategies.

CONCLUSION

Simple clinical descriptors can assist clinicians in identifying high-risk patients and in predicting future cardiovascular events within the broad range of risk factors for ULMCA disease.

The Predictive Value of the Syntax Score in Patients With Chronic Coronary Artery Disease Undergoing Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting: A Pilot Study

Objectives:

To evaluate the usefulness of the SYNTAX score (SS) in predicting 1-year clinical outcomes in a population of patients with chronic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Background:

Despite the proven prognostic value of the SS in patients with multivessel and/or left main (LM) CAD, its usefulness in other patient subsets remains uncertain.

Methods:

This was a prospective single centre cohort study conducted from September 2012 to November 2014 at the Nicosia General Hospital, Cyprus. Patients (n=140; 94% men and 6% women) with chronic CAD undergoing revascularization with either PCI or CABG were evaluated.

Results:

At 1-year, angina occurred in 20 patients (14.3%), myocardial infarction (MI) in 3 patients (2.1%), repeat revascularization procedures in 9 patients (6.4%) and death in 12 patients (8.6%). The SS independently predicted angina (p=0.024) but was not predictive of MI (p=0.964), death (p=0.292) or repeat revascularization (p=0.069).

Conclusion:

In this patient population, the SS predicted angina in the year following revascularization but was not predictive of MI, death or repeat revascularization.

Coronary lesion complexity assessed by SYNTAX score in 256-slice dual-source MDCT angiography

PURPOSE

The SYNTAX Score (SS) has an important role in grading the complexity of coronary artery disease (CAD) in patients undergoing revascularization. Noninvasive determination of SS prior to invasive coronary angiography (ICA) might optimize patient management. We aimed to evaluate the agreement between ICA and multidetector computed tomography (MDCT) while testing the diagnostic effectiveness of SS-MDCT.

METHODS

Our study included 108 consecutive patients who underwent both MDCT angiography with a 256-slice dual-source MDCT system and ICA within 14±3 days. SS was calculated for both ICA and MDCT coronary angiography. Spearman's rank correlation coefficient was used to evaluate the association of SS-MDCT with SS-ICA, and Bland-Altman analysis was performed.

RESULTS

The degree of agreement between SS-ICA and SS-MDCT was moderate. The mean SS-MDCT was 14.5, whereas the mean SS-ICA was 15.9. After dividing SS into three groups (high [≥33], intermediate [23-32], and low [≤22] subgroups), agreement analysis was repeated. There was a significant correlation between SS-MDCT and SS-ICA in the low SS group (r=0.63, P = 0.043) but no significant correlation in the high SS group (r=0.036, P = 0.677). The inter-test agreement analysis showed at least moderate agreement, whereas thrombotic lesions and the type of bifurcation lesion showed fair agreement.

CONCLUSION

The calculation of SS-MDCT by adapting SS-ICA parameters achieved nearly the same degree of precision as SS-ICA and was better than SS-ICA, especially in the low SS group.

SYNTAX score-0 patients: risk stratification in nonobstructive coronary artery disease

BACKGROUND

The complexity of coronary artery disease (CAD) is a predictor of cardiovascular events in patients with >50 % diameter stenosis as determined by SYNTAX score. Here, we compare the Gensini score to SYNTAX in patients with CAD as well as apply the Gensini score in patients with nonobstructive CAD (NOB-CAD), defined by ≤50 % diameter stenosis, were the SYNTAX score cannot be utilized to define future risk.

METHODS

The AtheroGene study enrolled 2316 patients [861/37.2 % with acute cardiovascular syndrome (ACS) and 1500/62.8 % with stable CAD (SCAD)]. Of these, 1966 had obstructive CAD (OB-CAD) with SYNTAX and Gensini scores available and 291 events with either cardiovascular mortality or non-fatal myocardial infarction were recorded. Furthermore, 350 patients had NOB-CAD with only Gensini score and 36 events. Median follow-up time was 4.9 years.

RESULTS

In the OB-CAD cohort the SYNTAX and the Gensini score predicted outcome. Kaplan-Meier curve analysis with the dichotomized Gensini score showed a significant result (p = 0.04) in the NOB-CAD cohort. Cox Regression analysis after adjustment showed a hazard ratio (HR) of 1.33 and p = 0.04 for the Gensini score in the NOB-CAD cohort. Receiver operating characteristic curve (ROC) analysis provided the highest area under the curve (AUC) regarding the outcome for the Gensini score with 0.65 (p = 0.004). Comparing the SYNTAX and Gensini score in this cohort showed improved discrimination of patients with events by the Gensini score (p = 0.02).

CONCLUSION

The Gensini score predicted events in patients with ≤50 % diameter lesions. Utilization of this score is useful to define risk in NOB-CAD patients.

Potential Utility of the SYNTAX Score 2 in Patients Undergoing Left Main Angioplasty

Background

The revascularization strategy of the left main disease is determinant for clinical outcomes.

Objective

We sought to 1) validate and compare the performance of the SYNTAX Score 1 and 2 for predicting major cardiovascular events at 4 years in patients who underwent unprotected left main angioplasty and 2) evaluate the long-term outcome according to the SYNTAX score 2-recommended revascularization strategy.

Methods

We retrospectively studied 132 patients from a single-centre registry who underwent unprotected left main angioplasty between March 1999 and December 2010. Discrimination and calibration of both models were assessed by ROC curve analysis, calibration curves and the Hosmer-Lemeshow test.

Results

Total event rate was 26.5% at 4 years.The AUC for the SYNTAX Score 1 and SYNTAX Score 2 for percutaneous coronary intervention, was 0.61 (95% CI: 0.49-0.73) and 0.67 (95% CI: 0.57-0.78), respectively. Despite a good overall adjustment for both models, the SYNTAX Score 2 tended to underpredict risk. In the 47 patients (36%) who should have undergone surgery according to the SYNTAX Score 2, event rate was numerically higher (30% vs. 25%; p=0.54), and for those with a higher difference between the two SYNTAX Score 2 scores (Percutaneous coronary intervention vs. Coronary artery by-pass graft risk estimation greater than 5.7%), event rate was almost double (40% vs. 22%; p=0.2).

Conclusion

The SYNTAX Score 2 may allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery. Prospective studies are needed for further validation.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center

Objective:

Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery.

Methods:

A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student’s t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference.

Results:

Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group.

Conclusion:

This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.

Dedicated bifurcation paclitaxel-eluting stent BiOSS Expert® in the treatment of distal left main stem stenosis

OBJECTIVES

The aim of this study was to assess prospectively the effectiveness and safety profile of distal left main stem (LMS) stenosis treatment with dedicated bifurcation paclitaxel-eluting stent BiOSS Expert®.

BACKGROUND

Angioplasty of distal LMS stenosis is always a high-risk procedure, and optimal treatment is uncertain.

METHODS

This was a prospective international 2-center study, which enrolled patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) or stable angina with distal left main stenosis. All patients were treated with the dedicated bifurcation stent BiOSS Expert®. Provisional T-stenting was the obligatory strategy. Angiographic control was performed after 12 months. The primary end-point was cumulative rate of death, myocardial infarction (MI), and target lesion revascularization (TLR) at 12 months. Angiographic end-points included late lumen loss, percent diameter stenosis, and binary restenosis rate.

RESULTS

A total of 54 patients with distal LMS stenosis were enrolled. Seven patients (13%) were enrolled during NSTE-ACS, 77.8% were hypertensive, 27.8% were diabetic, 51.9% had previous MI, 53.7% underwent prior percutaneous coronary intervention, and 16.7% coronary artery bypass graft. The mean SYNTAX score was 21.52 ± 6.50. The device success rate was 100%. The mean BiOSS Expert stent parameters were as follows: 4.07 ± 0.26 mm × 3.36 ± 0.26 mm × 16.61 ± 1.72 mm and in side branch the other stent (classical drug-eluting stent) was implanted in 25.9% of cases. The overall TLR was 9.3%. There were no death, stent thrombosis, or acute MI. In the univariate regression analysis, the only factor associated with higher risk for TLR was the SYNTAX score value.

CONCLUSIONS

The dedicated bifurcation stent BiOSS Expert® proved to be a feasible device, with promising safety and long-term clinical effectiveness in the treatment of distal LMS stenosis.

Outcomes of coronary artery interventions: comparing coronary artery bypass surgery and percutaneous coronary intervention in patients with unprotected left main stenosis

PURPOSE

The purpose of this integrative review is to examine the existing literature comparing short- and long-term outcomes of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (ULMCA) stenosis. CABG has long been considered the standard of treatment for ULMCA stenosis; however, advancements in the use of PCI have made it a viable alternative treatment option.

DATA SOURCES

Sixteen articles were selected from a literature search using the PubMed database, with at least 1 year of follow-up and adjustment for established risk factors.

CONCLUSIONS

The majority of studies found CABG and PCI with stenting to be comparable and equally safe treatment strategies for patients with ULMCA stenosis. Some studies found that PCI had a significantly lower risk for adverse events and mortality compared to CABG. However, a large number of studies found that PCI had a higher rate of target vessel restenosis.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses have become a prominent and influential part of the healthcare delivery system. As such, advanced practice nurses should be educated on the current research about coronary artery interventions so that they may better screen, treat, and manage this patient population.

The CABG SYNTAX Score - an angiographic tool to grade the complexity of coronary disease following coronary artery bypass graft surgery: from the SYNTAX Left Main Angiographic (SYNTAX-LE MANS) substudy

AIMS

The SYNTAX Score (SXscore) has established itself as an important prognostic tool in patients undergoing percutaneous coronary intervention (PCI). A limitation of the SXscore is the inability to differentiate outcomes in patients who have undergone prior coronary artery bypass graft (CABG) surgery. The CABG SXscore was devised to address this limitation.

METHODS AND RESULTS

In the SYNTAX-LE MANS substudy 115 patients with unprotected left main coronary artery disease (isolated or associated with one, two or three-vessel disease) treated with CABG were prospectively assigned to undergo a 15-month coronary angiogram. An independent core laboratory analysed the baseline SXscore prior to CABG. The 15-month CABG SXscore was calculated by a panel of three interventional cardiologists. The CABG SXscore was calculated by determining the standard SXscore in the "native" coronary vessels ("native SXscore") and deducting points based on the importance of the diseased coronary artery segment (Leaman score) that have a functioning bypass graft anastomosed distally. Points relating to intrinsic coronary disease, such as bifurcation disease or calcification, remain unaltered. The mean 15-month CABG SXscore was significantly lower compared to the mean baseline SXscore (baseline SXscore 31.6, SD 13.1; 15-month CABG SXscore 21.2, SD 11.1; p<0.001). Reproducibility analyses (kappa [k] statistics) indicated a substantial agreement between CABG SXscore measurements (k=0.70; 95% CI [0.50-0.90], p<0.001), with the points deducted to calculate the CABG SXscore the most reproducible measurement (k=0.74; 95% CI [0.53-0.95], p<0.001). Despite the limited power of the study, four-year outcome data (Kaplan-Meier curves) demonstrated a trend towards reduced all-cause death (9.1% vs. 1.8%, p=0.084) and death/CVA/MI (16.4% vs. 7.0%, p=0.126) in the low compared to the high CABG SXscore group.

CONCLUSIONS

In this pilot study the calculation of the CABG SXscore appeared feasible, reproducible and may have a long-term prognostic role in patients with complex coronary disease undergoing surgical revascularisation. Validation of this new scoring methodology is required.

Impact of the clinical syntax score on 5-year clinical outcomes after sirolimus-eluting stents implantation

The SYNTAX score stratifies risk among drug-eluting stent-treated patients and is based on lesion characteristics alone. The Clinical SYNTAX Score (CSS) combines the SYNTAX score with age, ejection fraction, and creatinine clearance. We assessed its ability to stratify long-term outcomes in sirolimus-eluting stents (SES)-treated patients. Between August 2004 and March 2005, 249 patients were treated with SES. Clinical follow-up was evaluated at more than 5 years. The CSS was available for 206 patients. More than 5-year clinical follow-up data (mean 2114 ± 107 days) and CSS (range 1-322, mean 35.3 ± 49.9, median 17.5) were available for 201 patients. We divided these scores into tertiles: CSS-LOW ≤ 9.5, 9.5 < CSS-MID ≤ 28, and CSS-HIGH > 28. CSS-HIGH was associated with a higher death rate (CSS-LOW 9.0 %, CSS-MID 11.9 %, CSS-HIGH 41.8 %; log-rank p < 0.001) and major adverse cardiovascular events (MACE) (CSS-LOW 29.8 %, CSS-MID 35.8 %, CSS-HIGH 61.2 %; log-rank p = 0.004). Independent predictors for death were hemodialysis [hazard ratio (HR) 3.82; p < 0.001], age (HR 1.67; p = 0.003), ejection fraction (HR 0.98, p = 0.012) and CSS (HR 1.73, p = 0.028), and those for MACE were hemodialysis (HR 2.53, p = 0.002) and CSS (HR 1.40, p = 0.028). Areas under the curve for the SYNTAX score and CSS for death were 0.60 and 0.78 (p < 0.001), whereas those for MACE were 0.58 and 0.68 (p < 0.001), respectively. The CSS predicts long-term outcomes among SES-treated patients better than the SYNTAX score.

Very long-term outcomes after percutaneous coronary intervention with bare metal stents for unprotected left main coronary artery disease

AIMS

The aim of this study was to evaluate very long-term clinical outcomes and potential predictors after percutaneous coronary intervention (PCI) with bare metal stents (BMS) for unprotected left main coronary artery disease (ULMCAD).

METHODS AND RESULTS

From March 1991 to August 2001, 151 patients who underwent PCI with BMS for ULMCAD were investigated retrospectively. The patient-oriented major adverse cardiac events (MACE) were defined as the occurrence of all-cause death, any MI, and any coronary revascularisation. The median follow-up duration was 10.5 years. The mean age was 69.9±11.5 years, and 106 patients (70.2%) were male. At 10 years, the incidences of cardiac death (CD), target lesion revascularisation (TLR) and patient-oriented MACE were 11.1%, 25.2% and 81.9%, respectively. In multivariate analysis, the pre-reference diameter of the left main trunk (LMT) was significantly associated with TLR (adjusted hazard ratio [HR] [95% confidence interval (CI)], 0.28 [0.14-0.54], p<0.001) and the SYNTAX score remained an independent predictor of patient-oriented MACE (adjusted HR [95% CI], 1.03 [1.007-1.05], p=0.009).

CONCLUSIONS

The pre-reference diameter of LMT was significantly associated with TLR, and the SYNTAX score significantly predicted the risk of patient-oriented MACE at 10 years. BMS implantation for larger size of ULMCAD with a lower SYNTAX score was feasible for up to 10 years.

Predictors of coronary lesions complexity in patients with stable coronary artery disease

Only a few studies focused on the predictors of the SYNTAX score (SS). We evaluated the independent clinical predictors of SS in 436 consecutive patients with stable angina pectoris who underwent coronary angiography. Estimated glomerular filtration rate (eGFR) was calculated. The mean SS was 25.8 ± 13.7. High-sensitivity C-reactive protein and low-density lipoprotein cholesterol levels gradually rise while high-density lipoprotein cholesterol (HDL-C), triglycerides, and eGFR levels gradually decline from low to high SS tertile. Multivariate logistic regression analysis revealed that diabetes (P = .005), left ventricular ejection fraction ([LVEF]; P < .001), previous statin use (P = .02), HDL-C level (P < .001), and eGFR (P < .001) were independent predictors of SS. In conclusion, the presence of diabetes mellitus, no previous statin use, and lower values of HDL-C, LVEF, and eGFR were independent predictors of coronary heart disease complexity. This study has been accepted to present at the 28th Turkish National Cardiology Congress.

Comparison of long-term outcome after percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease (from the CREDO-Kyoto PCI/CABG Registry Cohort-2)

The long-term outcome of percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) remains to be investigated. We identified 1,005 patients with ULMCAD of 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Cumulative 3-year incidence of a composite of death/myocardial infarction (MI)/stroke was significantly higher in the PCI group than in the CABG group (22.7% vs 14.8%, p = 0.0006, log-rank test). However, the adjusted outcome was not different between the PCI and CABG groups (hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.79 to 2.15, p = 0.30). Stratified analysis using the SYNTAX score demonstrated that risk for a composite of death/MI/stroke was not different between the 2 treatment groups in patients with low (<23) and intermediate (23 to 33) SYNTAX scores (adjusted HR 1.70, 95% CI 0.77 to 3.76, p = 0.19; adjusted HR 0.86, 95% CI 0.37 to 1.99, p = 0.72, respectively), whereas in patients with a high SYNTAX score (≥33), it was significantly higher after PCI than after CABG (adjusted HR 2.61, 95% CI 1.32 to 5.16, p = 0.006). In conclusion, risk of PCI for serious adverse events seemed to be comparable to that after CABG in patients with ULMCAD with a low or intermediate SYNTAX score, whereas PCI compared with CABG was associated with a higher risk for serious adverse events in patients with a high SYNTAX score.