Impact of the Presence and Extent of Incomplete Angiographic Revascularization After Percutaneous Coronary Intervention in Acute Coronary Syndromes

Background—

The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown.

Methods and Results—

We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter ≥2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was 75%, 55%, 37%, 25%, and 17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18–1.89; P =0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28–1.96; P <0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90–2.27; P =0.13). By multivariable analysis, ICR (≥50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12–1.64; P =0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions.

Conclusions—

Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00093158.

Myocardial revascularization without extracorporeal circulation in patients at high operative risk

It is considered that over 25% of surgical patients with coronary artery disease are treated without extracorporeal circulation, i.e. off-pump coronary artery bypass. The aim of the study was to evaluate results of surgical myocardium revascularization in patients at high operative risk. During the period 2005-2008, 148 patients were operated without the use of extracorporeal ciruculation. According to the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) stratification, 28 patients (19%) were designated as the high risk patients. The average age of these high risk patients was 72 years (55-86). The group consisted of 23 men (82.1%) and 5 women (17.8%). The postoperative mortality in the whole group of patients was 0.68% (1/148), whereas it was 0% in the high risk group. The average number of coronary anastomoses was 2.4. Eight patients (28.6%) had some sort of postoperative complications. Our results demonstrate safety and efficacy of surgical revascularization without cardiopulmonary bypass in patients at high operative risk.