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Cheng AM, Doll JA. When to Consider Coronary Revascularization for Stable Coronary Artery Disease. Med Clin North Am 2024; 108:517-538. [PMID: 38548461 DOI: 10.1016/j.mcna.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Revascularization is an effective adjunct to medical therapy for some patients with chronic coronary disease. Despite numerous randomized trials, there remains significant uncertainty regarding if and how to revascularize many patients. Coronary artery bypass grafting is a class I indication for patients with significant left main stenosis or multivessel disease with ejection fraction ≤ 35%. For other patients, clinicians must carefully consider the potential benefits of symptom improvement and reduction of future myocardial infarction or CV death against the risk and cost of revascularization. Although guidelines provide a framework for these decisions, each individual patient will have distinct coronary anatomy, clinical factors, and preferences.
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Affiliation(s)
- Andrew M Cheng
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Section of Cardiology, VA Puget Sound Health Care System, 1660 South Columbian Way S111-CARDIO, Seattle, WA 98108, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Section of Cardiology, VA Puget Sound Health Care System, 1660 South Columbian Way S111-CARDIO, Seattle, WA 98108, USA.
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2
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Romagnoli E, Burzotta F, Cerracchio E, Russo G, Aurigemma C, Pedicino D, Locorotondo G, Graziani F, Leone AM, D'Amario D, Lombardo A, Malara S, Fulco L, Bianchini F, Sanna T, Trani C. Impact of Impella protected-percutaneous coronary intervention on left ventricle function recovery of patients with extensive coronary disease and poor left ventricular function. Int J Cardiol 2023; 387:131098. [PMID: 37290663 DOI: 10.1016/j.ijcard.2023.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/15/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The use of Impella support is increasingly adopted to "protect" patients with severe coronary artery disease (CAD) and left ventricle (LV) dysfunction undergoing percutaneous coronary intervention (PCI). AIMS To evaluate the impact of Impella-protected (Abiomed, Danvers, Massachusetts, USA) PCIs on myocardial function recovery. METHODS Patients with significant LV dysfunction undergoing multi-vessel PCIs with pre-intervention Impella implantation were evaluated by echocardiography before PCI and at median follow up of 6 months: global and segmental LV contractile function were assessed by LV ejection fraction (LVEF) and wall motion score index (WMSI), respectively. Extent of revascularization was graded using the British Cardiovascular Intervention Society Jeopardy score (BCIS-JS). Study endpoints were LVEF and WMSI improvement, and its correlation with revascularization. RESULTS A total of 48 high surgical risk (mean EuroSCORE II 8) patients with median LVEF value of 30%, extensive wall motion abnormalities (median WMSI 2.16), and severe multi-vessel CAD (mean SYNTAX score 35) were included. PCIs brought a significant reduction of ischemic myocardium burden with BCIS-JS decrease from mean value of 12 to 4 (p < 0.001). At follow-up, WMSI reduced from 2.2 to 2.0 (p = 0.004) and LVEF increased from 30% to 35% (p = 0.016). WMSI improvement was proportional to the baseline impairment (R - 0.50, p < 0.001), and confined to revascularized segments (from 2.1 to 1.9, p < 0.001). CONCLUSIONS In patients with extensive CAD and severe LV dysfunction, multi-vessel Impella-protected PCI was associated to an appreciable contractile recovery, mainly determined by regional wall motion improvement in revascularized segments.
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Affiliation(s)
- Enrico Romagnoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Francesco Burzotta
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Emma Cerracchio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giulio Russo
- Division of Cardiology, Policlinico Tor Vergata, University of Rome, Rome, Italy
| | | | - Daniela Pedicino
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | | | | | | | - Antonella Lombardo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Silvia Malara
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Linda Fulco
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Tommaso Sanna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Carlo Trani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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Burgess SN, Mamas MA. Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 24:100225. [PMID: 38560635 PMCID: PMC10978432 DOI: 10.1016/j.ahjo.2022.100225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 04/04/2024]
Abstract
This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.
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Affiliation(s)
- Sonya N. Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia
- University of Sydney, NSW, Australia
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, UK
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Carande EJ, Protty MB, Verhemel S, Hussein MH, Raman AS, UlHaq Z, Bundhoo S, Cullen J, Ionescu A, Choudhury A, Hussain HI, Hailan A. Predictors of 30‐day and 12‐month mortality in left main stem percutaneous coronary intervention 2016−2020: A study from two UK centers. Catheter Cardiovasc Interv 2022; 100:585-592. [DOI: 10.1002/ccd.30400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/01/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022]
Affiliation(s)
| | - Majd B. Protty
- Systems Immunity University Research Institute Cardiff University Cardiff UK
| | - Sarah Verhemel
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | | | - Ajay S. Raman
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | - Zia UlHaq
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | - Shantu Bundhoo
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | - James Cullen
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | - Adrian Ionescu
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | | | | | - Ahmed Hailan
- Department of Cardiology Morriston Cardiac Centre Swansea UK
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Assessing the Clinical Influence of Chronic Total Occlusions (CTOs) Revascularization and the Impact of Vascularization Completeness on Patients with Left Ventricular (LV) Systolic Dysfunction. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:9128206. [PMID: 35990115 PMCID: PMC9385310 DOI: 10.1155/2022/9128206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022]
Abstract
Objectives This paper intends to assess the clinical influence of chronic total occlusions (CTOs), revascularization, and the impact of vascularization completeness on patients with left ventricular (LV) systolic dysfunction. Background The roles of CTO vascularization in clinical benefits remain conflicting. In addition, data concerning the different results of CTO vascularization and vascularization completeness according to LV systole function were assessed. Methods From an overall 918 consecutive patients with at least one CTO, 281 patients with ejection fraction (EF) ≤40% accepted coronary angiographic analysis between Jan 1, 2012, and Dec 31, 2020, and 29 patients were excluded. Subsequently, 261 patients were grouped into the successful CTO-PCI revascularization group (SCR, n = 135) and the optimal medical therapy group (OMT, n = 126). The prognosis influence of successfully finished CTO-PCI and complete revascularization on survival was evaluated. The primary endpoint was cardiac mortality, and the secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE). Results After a median follow-up time of 38.02 months, the cardiac mortality (p=0.037) and MACCE (p=0.001) were more remarkable in the OMT group than in the SCR group. Moreover, patients with CTO-PCI had survival benefits from complete revascularization for MACCE (p=0.025) and cardiac mortality (p=0.041). Based on multivariable Cox proportional hazards regression analysis, age ≧ 75 years (HR: 3.443, 95% CI 1.719–6.897, p < 0.001) predicted a worse probability of cardiac mortality. Additionally, previous PCI (HR: 1.592, 95% CI 1.034–2.449, p=0.035) and previous MI (HR: 1.971, 95% CI 1.258–3.088, p=0.003) predicted a worse probability of MACCE, and SCR (HR: 0.499, 95% CI 0.320–0.776, p=0.002) was a protection predictor of MACCE. Conclusion In patients with LV systole dysfunction (EF ≤ 40%), successfully finished CTO-PCI is related to long-term survival benefits. The benefits were more remarkable in patients with complete coronary revascularization (CCR).
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Xu J, Patel A, Meraj P. Impact of chronic total occlusions on outcomes of patients with acute myocardial infarction undergoing percutaneous coronary intervention: A propensity-score matched analysis using the National Inpatient Sample database. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:14-18. [PMID: 35739013 DOI: 10.1016/j.carrev.2022.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/03/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited data on the impact of chronic total occlusions (CTOs) on the outcomes of patients presenting with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) in the contemporary era. METHODS We queried the National Inpatient Sample between October 2015 and December 2017 using the International Classification of Diseases, Tenth revision codes to identify hospitalized AMI patients undergoing PCI. A 1:1 propensity-score matched analysis was performed to compare in-hospital outcomes of patients with and without CTOs. RESULTS Among 576,760 admissions identified during the study period, 51,225(8.8 %) had CTO and 525,535 (91.1 %) did not. After 1:1 propensity-score matching, each matched group contained 51,210 admissions. In-hospital mortality was significantly higher in the CTO group compared with the non-CTO group (4.7 % vs 3 %, p < 0.0001). In the CTO group, hospital length of stay was longer (median 3 vs 2 days, p = 0.001) and lower percentage of patients were discharged to home (78.8 % vs 81.1 %, p < 0.0001), compared with the non-CTO group. Median cost of hospital stay was also higher in the CTO group compared with the non-CTO group ($20,921 vs $19,856, p < 0.0001). CONCLUSIONS In this propensity-score matched analysis of a large US inpatient database, the presence of CTOs in AMI patients undergoing PCI identified a higher risk cohort with in higher in-hospital mortality, longer hospital length of stay and higher hospitalization cost.
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Affiliation(s)
- James Xu
- Department of Cardiology, North Shore University Hospital, Northwell Health, Hofstra Northwell School of Medicine, Manhasset, NY, United States of America; Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Amitkumar Patel
- Department of Cardiology, North Shore University Hospital, Northwell Health, Hofstra Northwell School of Medicine, Manhasset, NY, United States of America
| | - Perwaiz Meraj
- Department of Cardiology, North Shore University Hospital, Northwell Health, Hofstra Northwell School of Medicine, Manhasset, NY, United States of America.
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Carmona-Segovia ADM, Doncel-Abad MV, Becerra-Muñoz VM, Rodríguez-Capitán J, Sabatel-Pérez F, Flores-López M, Sánchez-Quintero MJ, Medina-Vera D, Molina-Ramos AI, El Bekay R, Morales-Asencio JM, Angullo-Gómez M, García-Rodríguez L, Palma-Martí L, Pavón-Morón FJ, Jiménez-Navarro MF. 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. BMJ Open 2022; 12:e058042. [PMID: 35228293 PMCID: PMC8886411 DOI: 10.1136/bmjopen-2021-058042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Ada Del Mar Carmona-Segovia
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - María Victoria Doncel-Abad
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Víctor M Becerra-Muñoz
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jorge Rodríguez-Capitán
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando Sabatel-Pérez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - María Flores-López
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - María José Sánchez-Quintero
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Dina Medina-Vera
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Rajaa El Bekay
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, Spain
- Centro de Investigación en Red de la Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Morales-Asencio
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain
| | - María Angullo-Gómez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Luis García-Rodríguez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Lucía Palma-Martí
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Manuel F Jiménez-Navarro
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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Muraca I, Carrabba N, Virgili G, Bruscoli F, Migliorini A, Pennesi M, Pontecorboli G, Marchionni N, Valenti R. Chronic total occlusion revascularization: A complex piece to "complete" the puzzle. World J Cardiol 2022; 14:13-28. [PMID: 35126869 PMCID: PMC8788177 DOI: 10.4330/wjc.v14.i1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/15/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of “contemporary” strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a “complex” piece to “complete” the puzzle.
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Affiliation(s)
- Iacopo Muraca
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Nazario Carrabba
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giacomo Virgili
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Filippo Bruscoli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Angela Migliorini
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Matteo Pennesi
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giulia Pontecorboli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Niccolò Marchionni
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Renato Valenti
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
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Goldstein DJ, Soltesz E. High-risk cardiac surgery: Time to explore a new paradigm. JTCVS OPEN 2021; 8:10-15. [PMID: 36004162 PMCID: PMC9390359 DOI: 10.1016/j.xjon.2021.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel J. Goldstein
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Bronx, NY
- Address for reprints: Daniel J. Goldstein, MD, Department of Cardiothoracic Surgery, 3400 Bainbridge Ave, MAP 5 Bronx, NY 10467.
| | - Edward Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Hospital, Cleveland, Ohio
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11
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Torregrossa G, Sá MP, Van den Eynde J, Sicouri S, Wertan MC, Ramlawi B, Sutter FP. Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease. J Card Surg 2021; 37:501-511. [PMID: 34811803 DOI: 10.1111/jocs.16146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD. METHODS AND RESULTS We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202). CONCLUSIONS Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.
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Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - MaryAnn C Wertan
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Francis P Sutter
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA
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12
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Takahashi K, Serruys PW, Gao C, Ono M, Wang R, Thuijs DJFM, Mack MJ, Curzen N, Mohr FW, Davierwala P, Milojevic M, Wykrzykowska JJ, de Winter RJ, Sharif F, Onuma Y, Head SJ, Kappetein AP, Morice MC, Holmes DR. Ten-Year All-Cause Death According to Completeness of Revascularization in Patients With Three-Vessel Disease or Left Main Coronary Artery Disease: Insights From the SYNTAX Extended Survival Study. Circulation 2021; 144:96-109. [PMID: 34011163 DOI: 10.1161/circulationaha.120.046289] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ten-year all-cause death according to incomplete (IR) versus complete revascularization (CR) has not been fully investigated in patients with 3-vessel disease and left main coronary artery disease undergoing percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). METHODS The SYNTAX Extended Survival study (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]) evaluated vital status up to 10 years in patients who were originally enrolled in the SYNTAX trial. In the present substudy, outcomes of the CABG CR group were compared with the CABG IR, PCI CR, and PCI IR groups. In addition, in the PCI cohort, the residual SYNTAX score (rSS) was used to quantify the extent of IR and to assess its association with fatal late outcome. The rSS of 0 suggests CR, whereas a rSS>0 identifies the degree of IR. RESULTS IR was more frequently observed in patients with PCI versus CABG (56.6% versus 36.8%) and more common in those with 3-vessel disease than left main coronary artery disease in both the PCI arm (58.5% versus 53.8%) and the CABG arm (42.8% versus 27.5%). Patients undergoing PCI with CR had no significant difference in 10-year all-cause death compared with those undergoing CABG (22.2% for PCI with CR versus 24.3% for CABG with IR versus 23.8% for CABG with CR). In contrast, those with PCI and IR had a significantly higher risk of all-cause death at 10 years compared with CABG and CR (33.5% versus 23.7%; adjusted hazard ratio, 1.48 [95% CI, 1.15-1.91]). When patients with PCI were stratified according to the rSS, those with a rSS≤8 had no significant difference in all-cause death at 10 years as the other terciles (22.2% for rSS=0 versus 23.9% for rSS>0-4 versus 28.9% for rSS>4-8), whereas a rSS>8 had a significantly higher risk of 10-year all-cause death than those undergoing PCI with CR (50.1% versus 22.2%; adjusted hazard ratio, 3.40 [95% CI, 2.13-5.43]). CONCLUSIONS IR is common after PCI, and the degree of incompleteness was associated with 10-year mortality. If it is unlikely that complete (or nearly complete; rSS<8) revascularization can be achieved with PCI in patients with 3-vessel disease, CABG should be considered. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00114972. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03417050.
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Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (P.W.S., Y.O.)
| | - Chao Gao
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands (C.G., R.W.)
| | - Masafumi Ono
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Rutao Wang
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands (C.G., R.W.)
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White Health, Dallas, TX (M.J.M.)
| | - Nick Curzen
- Department of Cardiology, University Hospital Southampton NHS FT, UK (N.C.)
| | | | - Piroze Davierwala
- University Department of Cardiac Surgery, Heart Centre Leipzig, Germany (F.-W.M., P.D.).,Now with Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Ontario, Canada (P.D.)
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.).,Department of Cardiothoracic Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia (M.M.)
| | - Joanna J Wykrzykowska
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.).,Department of Cardiology, University Medical Centre Groningen, University of Groningen, The Netherlands (J.J.W.)
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Faisal Sharif
- CURAM, Cardiovascular Research and Innovation Centre (CVRI), BioInnovate Ireland, Department of Cardiology, Galway University Hospital and National University of Ireland, Ireland (F.S.)
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (P.W.S., Y.O.)
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Marie-Claude Morice
- Département of Cardiologie, Hôpital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.)
| | - David R Holmes
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN (D.R.H.)
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13
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Prediction of 5-Year Mortality in Patients with Chronic Coronary Syndrome Treated with Elective Percutaneous Coronary Intervention: Role of the ACEF Score. J Cardiovasc Transl Res 2021; 14:1125-1130. [PMID: 33754275 DOI: 10.1007/s12265-021-10122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
We evaluated the predictive power of age, creatinine, and ejection fraction (ACEF) score on mortality at 5-year follow-up in a population of 471 patients with chronic coronary syndrome (CCS) treated with percutaneous coronary intervention (PCI). Patients in the ACEF-High tertile showed the highest incidence of death at 5 years (15.7% vs. 2.6% in ACEF-Low and 4.3% in ACEF-Mid; log rank p<0.001). The ACEF score could significantly discriminate between patients who died and those who were still alive at 5 years (AUC 0.741, 95% CI 0.654-0.828), and an ACEF score >1.32 was identified as the optimal cutoff point to predict 5-year mortality (sensitivity 74%, specificity 68%). An ACEF score >1.32 was an independent predictor of 5-year mortality (HR 5.77, 95% CI 2.70-12.31; p<0.001). Our study shows that the ACEF score can predict mortality at 5-year follow-up in patients with CCS treated with PCI.
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14
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Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate. J Interv Cardiol 2020; 2020:4587414. [PMID: 32607081 PMCID: PMC7313166 DOI: 10.1155/2020/4587414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/06/2020] [Accepted: 05/27/2020] [Indexed: 11/22/2022] Open
Abstract
Background The outcomes of patients with concomitant left main coronary artery (LMCA) and right coronary artery (RCA) diseases are reportedly worse than those with only LMCA disease. To date, only few studies have investigated the clinical impact of percutaneous coronary intervention (PCI) on RCA stenosis during the same hospitalization, in which LMCA disease was treated. This study was aimed at comparing the outcomes between patients with and without right coronary artery intervention during the same hospital course for LMCA intervention. Methods and Results From a total of 776 patients who were undergoing PCI to treat LMCA disease, 235 patients with concomitant RCA significant stenosis (more than 70% stenosis) were enrolled. The patients were divided into two groups: 174 patients received concomitant PCI for RCA stenosis during the same hospitalization, in which LMCA disease was treated, and 61 patients did not receive PCI for RCA stenosis. Patients without intervention to the right coronary artery had higher 30-day cardiovascular mortality rates and 3-year RCA revascularization rates compared to those with right coronary artery intervention. Patients without RCA intervention at the same hospitalization did not increase the 30-day total death, 3-year myocardial infarction rate, 3-year cardiovascular death, and 3-year total death. Conclusions In patients with LM disease and concomitant above or equal to 70% RCA stenosis, PCI for RCA lesion during the same hospitalization is recommended to reduce the 30-day cardiovascular death and 3-year RCA revascularization rate.
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15
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Kim YH, Her AY, Jeong MH, Kim BK, Hong SJ, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Culprit-only versus multivessel or complete versus incomplete revascularization in patients with non-ST-segment elevation myocardial infarction and multivessel disease who underwent successful percutaneous coronary intervention using newer-generation drug-eluting stents. Atherosclerosis 2020; 301:54-64. [PMID: 32330691 DOI: 10.1016/j.atherosclerosis.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS The long-term comparative results between culprit-only percutaneous coronary intervention (C-PCI) and multivessel PCI (M-PCI) or those between complete revascularization (CR) and incomplete revascularization (IR) in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) after successful newer-generation drug-eluting stent (DES) implantation are limited. Therefore, we compared the 2-year clinical outcomes in such patients. METHODS A total of 4588 patients with NSTEMI and MVD (C-PCI, n = 2055; M-PCI, n = 2533; CR, n = 2029; IR, n = 504) were evaluated. The primary outcome was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction MI, and any repeat coronary revascularization. The secondary outcome was stent thrombosis (ST). RESULTS The cumulative incidences of the primary and secondary outcomes were similar in the three comparison groups (C-PCI vs. M-PCI, CR vs. IR, or CR vs. C-PCI). However, the cumulative incidence of non-target vessel revascularization (non-TVR) was higher in the C-PCI group than in the M-PCI group (adjusted hazard ratio [aHR]: 2.011; 95% confidence interval [CI]: 1.942-3.985; p = 0.012), higher in the IR group than in the CR group (aHR: 2.051; 95% CI: 1.216-4.183; p = 0.043), and higher in the C-PCI group than in the CR group (aHR: 2.099; 95% CI: 1.237-3.564; p = 0.006). CONCLUSIONS Regarding the higher cumulative incidence of non-TVR, M-PCI and CR were preferred compared to C-PCI or IR in patients with NSTEMI and MVD. However, further randomized studies are required to confirm these findings.
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Affiliation(s)
- Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Seunghwan Kim
- Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
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16
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De Gregorio MG, Marcucci R, Migliorini A, Gori AM, Giusti B, Vergara R, Paniccia R, Carrabba N, Marchionni N, Valenti R. Clinical Implications of "Tailored" Antiplatelet Therapy in Patients With Chronic Total Occlusion. J Am Heart Assoc 2020; 9:e014676. [PMID: 32067582 PMCID: PMC7070214 DOI: 10.1161/jaha.119.014676] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Clopidogrel nonresponsiveness is a prognostic marker after percutaneous coronary intervention. Prasugrel and ticagrelor provide a better platelet inhibition and represent the first‐line antiplatelet treatment in acute coronary syndrome. We sought to assess the prognostic impact of high platelet reactivity (HPR) and the potential clinical benefit of a “tailored” escalated or changed antiplatelet therapy in patients with chronic total occlusion. Methods and Results From Florence CTO‐PCI (chronic total occlusion‐percutaneous coronary intervention) registry, platelet function assessed by light transmission aggregometry, was available for 1101 patients. HPR was defined by adenosine diphosphate test ≥70% and optimal platelet reactivity by adenosine diphosphate test <70%. The endpoint of the study was long‐term cardiac survival. Patients were stratified according to light transmission aggregometry results: optimal platelet reactivity (82%) and HPR (18%). Means for the adenosine diphosphate test were 44±16% versus 77±6%, respectively. Three‐year survival was significantly higher in the optimal platelet reactivity group compared with HPR patients (95.3±0.8% versus 86.2±2.8%; P<0.001). With the availability of new P2Y12 inhibitors, a deeper platelet inhibition (46±17%) and similar survival to the optimal platelet reactivity group were achieved in patients with HPR on clopidogrel therapy after escalation. Conversely, HPR on clopidogrel therapy “not switched” was associated with cardiac mortality (hazard ratio 2.37; P=0.003) after multivariable adjustment. Conclusions HPR on treatment could be a modifiable prognostic marker by new antiaggregants providing a deeper platelet inhibition associated with clinical outcome improvement in complex chronic total occlusion patients. A “tailored” antiplatelet therapy, also driven by the entity of platelet inhibition, could be useful in these high risk setting patients.
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Affiliation(s)
- Maria Grazia De Gregorio
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy.,Experimental and Clinical Medicine Department University of Florence Italy
| | - Rossella Marcucci
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy.,Experimental and Clinical Medicine Department University of Florence Italy
| | - Angela Migliorini
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy
| | - Anna Maria Gori
- Experimental and Clinical Medicine Department University of Florence Italy
| | - Betti Giusti
- Experimental and Clinical Medicine Department University of Florence Italy
| | - Ruben Vergara
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy
| | - Rita Paniccia
- Experimental and Clinical Medicine Department University of Florence Italy
| | - Nazario Carrabba
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy
| | - Niccolò Marchionni
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy.,Experimental and Clinical Medicine Department University of Florence Italy
| | - Renato Valenti
- Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy
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17
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Towards a Saphenous Vein Graft Moratorium. Cardiol Rev 2020; 28:236-239. [DOI: 10.1097/crd.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Hannan EL, Zhong Y, Berger PB, Jacobs AK, Walford G, Ling FSK, Venditti FJ, King SB. Association of Coronary Vessel Characteristics With Outcome in Patients With Percutaneous Coronary Interventions With Incomplete Revascularization. JAMA Cardiol 2019; 3:123-130. [PMID: 29282471 DOI: 10.1001/jamacardio.2017.4787] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Many studies have compared outcomes for incomplete revascularization (IR) among patients undergoing percutaneous coronary interventions (PCI), but little is known about whether outcomes are related to the nature of the IR. Objective To determine whether some coronary vessel characteristics are associated with worse outcomes in patients with PCI with IR. Design, Setting, and Participants New York's PCI registry was used to examine mortality (median follow-up, 3.4 years) as a function of the number of vessels that were incompletely revascularized, the stenosis in those vessels, and whether the proximal left anterior descending artery was incompletely revascularized after controlling for other factors associated with mortality for patients with and without ST-elevation myocardial infarction (STEMI). This was a multicenter study (all nonfederal PCI hospitals in New York State) that included 41 639 New York residents with multivessel coronary artery disease undergoing PCI in New York State between January 1, 2010, and December 31, 2012. Exposures Percutaneous coronary interventions, with complete and incomplete revascularization. Main Outcomes and Measures Medium-term mortality. Results For patients with STEMI, the mean age was 62.8 years; 26.2% were women, 11.9% were Hispanic, and 81.5% were white. For other patients, the mean age was 66.6 years, 29.1% were women, 11.3% were Hispanic, and 79.1% were white. Incomplete revascularization was very common (78% among patients with STEMI and 71% among other patients). Patients with IR in a vessel with at least 90% stenosis were at higher risk than other patients with IR. This was not significant among patients with STEMI (17.18% vs 12.86%; adjusted hazard ratio [AHR], 1.16; 95% CI, 0.99-1.37) and significant among patients without STEMI (17.71% vs 12.96%; AHR, 1.15; 95% CI, 1.07-1.24). Similarly, patients with IR in 2 or more vessels had higher mortality than patients with completely revascularization and higher mortality than other patients with IR among patients with STEMI (20.37% vs 14.39%; AHR, 1.35; 95% CI, 1.15-1.59) and among patients without STEMI (20.10% vs 12.86%; AHR, 1.17; 95% CI, 1.09-1.59). Patients with proximal left anterior descending artery vessel IR had higher mortality than other patients with IR (20.09% vs 14.67%; AHR, 1.31; 95% CI, 1.04-1.64 for patients with STEMI and 20.78% vs 15.62%; AHR, 1.11; 95% CI, 1.01-1.23 for patients without STEMI). More than 20% of all PCI patients had IR of 2 or more vessels and more than 30% had IR with more than 90% stenosis. Conclusions and Relevance Patients with IR are at higher risk of mortality if they have IR with at least 90% stenosis, IR in 2 or more vessels, or proximal left anterior descending IR.
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Affiliation(s)
- Edward L Hannan
- University at Albany, State University of New York, Rensselaer
| | - Ye Zhong
- University at Albany, State University of New York, Rensselaer
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19
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Valenti R, Migliorini A, De Gregorio MG, Martone R, Berteotti M, Bernardini A, Carrabba N, Vergara R, Marchionni N, Antoniucci D. Impact of complete percutaneous revascularization in elderly patients with chronic total occlusion. Catheter Cardiovasc Interv 2019; 95:145-153. [PMID: 31430034 DOI: 10.1002/ccd.28452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/10/2019] [Accepted: 08/01/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The aim of the study was to assess the prognostic impact of successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and completeness of revascularization in the elderly. BACKGROUND Successful CTO-PCI is associated with clinical benefit. Notwithstanding elderly patients are currently underrepresented in CTO-PCI randomized controlled trials and registries. METHODS From the Florence CTO-PCI registry 1,405 patients underwent CTO-PCI between 2004 and 2015; out of these, 460 consecutive patients were ≥75 years. End point of the study was long-term cardiac survival. The prognostic impact of successful CTO-PCI and complete revascularization on survival was assessed by Kaplan-Meier estimation and by Cox multivariable regression analysis. RESULTS Patients were stratified according to success (72%) or failure of CTO-PCI. Completeness of revascularization was achieved in 57% of patients. Five-year cardiac survival was significantly higher in the successful CTO-PCI group (84 ± 3% vs. 72 ± 6%; p = .006) and it was further improved if complete coronary revascularization was achieved (90 ± 3% vs. 68 ± 5%; p < .001). At multivariable analysis, increasing age (hazard ratio [HR] 1.08; p = .001), diabetes (HR 1.55; p = .033), chronic kidney disease (HR 1.96, p = .002), left ventricular ejection fraction <0.40 (HR 2.10; p < .001), and completeness of revascularization (HR 0.58; p < .005) resulted independently associated with long-term cardiac survival. CONCLUSIONS In the elderly successful CTO-PCI is associated with a long-term survival benefit. The results of this study suggest that, even in the elderly, a CTO-PCI attempt should be considered to achieve complete coronary revascularization.
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Affiliation(s)
- Renato Valenti
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angela Migliorini
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Maria Grazia De Gregorio
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Raffaele Martone
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Martina Berteotti
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Bernardini
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Nazario Carrabba
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Ruben Vergara
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Niccolò Marchionni
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - David Antoniucci
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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20
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Chen S, Karmpaliotis D, Redfors B, Shlofmitz E, Ben-Yehuda O, Crowley A, Mehdipoor G, Puskas JD, Kandzari DE, Banning AP, Morice MC, Taggart DP, Sabik JF, Serruys PW, Kappetein AP, Stone GW. Does an occluded RCA affect prognosis in patients undergoing PCI or CABG for left main coronary artery disease? Analysis from the EXCEL trial. EUROINTERVENTION 2019; 15:e531-e538. [PMID: 31186220 DOI: 10.4244/eij-d-19-00263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The impact of an occluded right coronary artery (RCA) in patients with left main coronary artery disease (LMCAD) undergoing revascularisation is unknown. We compared outcomes for patients with LMCAD randomised to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to the presence of an occluded RCA in the EXCEL trial. METHODS AND RESULTS The EXCEL trial randomised 1,905 patients with LMCAD and SYNTAX scores ≤32 to PCI with everolimus-eluting stents versus CABG. Patients were categorised according to whether they had an occluded RCA at baseline, and their outcomes were examined using multivariable Cox proportional hazards regression. The primary endpoint was a composite of death, stroke, or myocardial infarction at three years. Among 1,753 patients with a dominant RCA by core laboratory analysis, the RCA was occluded in 130 (7.4%) at baseline. PCI was attempted in 34 of 65 patients with an occluded RCA (52.3%) and was successful in 27 (79.4% of those attempted; 41.5% of all RCAs recanalised). The RCA was bypassed in 42 of 65 patients with an occluded RCA (64.6%; p=0.0008 versus PCI). The three-year absolute and relative rates of the primary endpoint were similar between PCI and CABG, in patients with or without an occluded RCA (pinteraction=0.92). CONCLUSIONS In the EXCEL trial, the presence of an occluded RCA at baseline did not confer a worse three-year prognosis in patients undergoing revascularisation for LMCAD and did not affect the relative outcomes of PCI versus CABG in this high-risk patient cohort.
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Affiliation(s)
- Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
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21
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Saito Y, Kobayashi Y. Percutaneous coronary intervention strategies in patients with acute myocardial infarction and multivessel disease: Completeness, timing, lesion assessment, and patient status. J Cardiol 2019; 74:95-101. [DOI: 10.1016/j.jjcc.2019.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/23/2019] [Indexed: 02/07/2023]
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22
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Becher T, Eder F, Baumann S, Loßnitzer D, Pollmann B, Behnes M, Borggrefe M, Akin I. Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function. Medicine (Baltimore) 2018; 97:e12665. [PMID: 30412063 PMCID: PMC6221604 DOI: 10.1097/md.0000000000012665] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04-0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.
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Affiliation(s)
- Tobias Becher
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Frederik Eder
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
| | - Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Dirk Loßnitzer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Berit Pollmann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
| | - Michael Behnes
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
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23
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Riley RF, McCabe JM, Kalra S, Lazkani M, Pershad A, Doshi D, Kirtane AJ, Nicholson W, Kearney K, Demartini T, Aaron Grantham J, Moses J, Lombardi W, Karmpaliotis D. Impella‐assisted chronic total occlusion percutaneous coronary interventions: A multicenter retrospective analysis. Catheter Cardiovasc Interv 2018; 92:1261-1267. [DOI: 10.1002/ccd.27679] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/15/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Robert F. Riley
- The Christ Hospital Heart and Vascular Center and The Lindner Research CenterCincinnati Ohio
| | | | | | | | | | | | | | | | | | | | - J. Aaron Grantham
- University of MissouriKansas City Missouri
- Mid America Heart InstituteKansas City Missouri
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24
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Leviner DB, Torregrossa G, Puskas JD. Incomplete revascularization: what the surgeon needs to know. Ann Cardiothorac Surg 2018; 7:463-469. [PMID: 30094210 DOI: 10.21037/acs.2018.06.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For many years, the concept of "complete revascularization" (CR) was considered an absolute truth in coronary surgery with improved long-term survival and a lower rate of reintervention. This was derived from early publications which showed a survival benefit for patients undergoing coronary artery bypass grafting (CABG) who received CR. Many advances in the field of coronary revascularization have been made in the years that passed since those publications, including more frequent use of percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). This has led some to question the importance of CR and raise the option of "reasonable incomplete revascularization" (IR) for selected patients. The definition of CR is variable in the literature with the two most common definitions being an anatomical (revascularization of all coronary segments with stenosis and larger than a predefined size) and a functional definition (where revascularization is considered complete if all ischemic and viable territories are reperfused). No randomized control trials have been conducted to compare complete versus IR, and a significant proportion of data is based on post hoc analysis of data from randomized control trials and registries. Multiple studies have proven that CR is achieved more frequently with CABG then with PCI. A review of the available data from the past three to four decades shows a trend toward improved results with CR, regardless of the reperfusion strategy chosen. This should impact the heart team discussion when choosing a revascularization strategy and impact the surgical decision making while preforming CABG. IR can be part of a hybrid revascularization strategy or be reserved for rare cases where the cost of achieving CR much outweighs the benefit.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gianluca Torregrossa
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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25
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Rahman H, Khan SU, Lone AN, Kaluski E. Revascularization strategies in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:647-654. [PMID: 29909948 DOI: 10.1016/j.carrev.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/24/2018] [Accepted: 06/06/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal revascularization strategy in patients with multi-vessel disease (MVD) presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remains unclear. OBJECTIVE To investigate the comparative differences between culprit-only revascularization (COR) versus instant multi-vessel revascularization (IMVR) in AMI and CS. METHODS 13 studies were selected using MEDLINE, EMBASE and the CENTRAL (Inception - 31 November2017). Outcomes were assessed at short-term (in-hospital or ≤30 days duration) and long-term duration (≥6 months). Estimates were reported as random effects relative risk (RR) with 95% confidence interval (CI). RESULTS In analysis of 7311 patients, COR significantly reduced the relative risk of short-term all-cause mortality (RR: 0.87; 95% CI, 0.77-0.97; p = 0.01, I2 = 50%) and renal failure (RR: 0.75; 95% CI, 0.61-0.94; p = 0.01, I2 = 7%) compared with IMVR. There were no significant differences between both the strategies in terms of reinfarction (RR: 1.25; 95% CI, 0.59-2.63; p = 0.56, I2 = 0%), major bleeding (RR: 0.88; 95% CI, 0.75-1.04; p = 0.14, I2 = 0%) and stroke (RR: 0.77; 95% CI, 0.50-1.17; p = 0.22, I2 = 0%) at short term duration. Similarly, no significant differences were observed between both groups regarding all-cause mortality (RR; 1.01; 95% CI, 0.85-1.20; p = 0.93, I2 = 61%) and reinfarction (RR: 0.71; 95% CI, 0.34-1.47; p = 0.35, I2 = 26%) at long term duration. CONCLUSION In MVD patients presenting with AMI and CS, IMVR was comparable to COR in terms of all-cause mortality at long term follow up duration. These results are predominantly derived from observational data and more randomized controlled trials are required to validate this impression.
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Affiliation(s)
- Hammad Rahman
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA.
| | - Safi U Khan
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | - Ahmad N Lone
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | - Edo Kaluski
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA; Rutgers New Jersey Medical School, Newark, NJ, USA; The Geisinger Commonwealth Medical College, Scranton, PA, USA
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26
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Goel PK, Khanna R, Pandey CM, Ashfaq F. Long-term outcomes post chronic total occlusion intervention-implications of completeness of revascularization. J Interv Cardiol 2018; 31:293-301. [PMID: 29314289 DOI: 10.1111/joic.12480] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/24/2017] [Accepted: 10/29/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Long term clinical outcomes post chronic total occlusion (CTO) intervention may depend not only on CTO success/failure alone but also on Completeness of revascularization. OBJECTIVES To determine long term outcomes post CTO intervention and relate them to both success versus failure and Complete Revascularization (CR) versus Incomplete Revascularization (IR). METHODS Consecutive patients taken up for CTO intervention with at-least one CTO vessel between Jan 2006 to Dec 2015 were included. Clinical, procedural and follow up details were recorded in a pre-specified custom made software. Primary endpoint of the study was survival free of major adverse event individual, death, myocardial infarction (MI), repeat revascularisation (percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) and recurrent or continued angina. Each individual adverse event was considered as a secondary end point. RESULTS A total of 632 patients were enrolled in study with follow up data available in 549 (86%) constituting the study group with 490 (89.3%) success and 59 (11.7%) failure. Complete revascularization (CR) was obtained in 410 (74.7%). Follow up was median 2.9 years with inter-quartile range 1.1-4.8 years. Kaplan Meier survival analysis showed a better EFS with both CTO success versus failure (P = 0.03)and CR versus IR (P = 0.017). Individual adverse outcomes however were not significantly different in CTO success versus failure group but significantly better when analyzed with respect to CR versus IR including death (P = 0.049) and recurrent angina (P = 0.024). Repeat intervention and MI were not different by either analysis. CONCLUSIONS Successful CTO PCI results in a better long term event free survival but the difference between the groups is more if analyzed with respect to completeness of revascularization rather than CTO success/failure alone.
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Affiliation(s)
- Pravin K Goel
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Roopali Khanna
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - C M Pandey
- Department of Biostatistics and Health Informatic, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Fauzia Ashfaq
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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27
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Mamas MA, Rao SV. Editorial: Navigating the rough seas of anemia; caught between the devil and the deep blue sea. J Interv Cardiol 2017; 30:500-501. [PMID: 28971537 DOI: 10.1111/joic.12411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina
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28
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Kinnaird T, Anderson R, Ossei-Gerning N, Cockburn J, Sirker A, Ludman P, de Belder M, Johnson TW, Copt S, Zaman A, Mamas MA. Coronary Perforation Complicating Percutaneous Coronary Intervention in Patients With a History of Coronary Artery Bypass Surgery. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005581. [DOI: 10.1161/circinterventions.117.005581] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/07/2017] [Indexed: 11/16/2022]
Abstract
Background—
The evidence base for coronary perforation (CP) occurring during percutaneous coronary intervention in patients with a history of coronary artery bypass surgery (PCI-CABG) is limited and the long-term effects unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during PCI-CABG were defined.
Methods and Results—
Data were analyzed on all PCI-CABG procedures performed in England and Wales between 2005 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. During the study period, 309 CPs were recorded during 59 644 PCI-CABG procedures with the incidence rising from 0.32% in 2005 to 0.68% in 2013 (
P
<0.001 for trend). Independent associates of perforation in native vessels included age, chronic occlusive disease intervention, rotational atherectomy use, number of stents, hypertension, and female sex. In graft PCI, predictors of perforation were history of stroke, New York Heart Association class, and number of stents used. In-hospital clinical complications including Q-wave myocardial infarction (2.9% versus 0.2%;
P
<0.001), major bleeding (14.0% versus 0.9%;
P
<0.001), blood transfusion (3.7% versus 0.2%;
P
<0.001), and death (10.0% versus 1.1%;
P
<0.001) were more frequent in patients with CP. A continued excess mortality occurred after perforation, with an odds ratio for 12-month mortality of 1.35 for perforation survivors compared with matched nonperforation survivors without a CP (
P
<0.0001).
Conclusions—
CP is an infrequent event during PCI-CABG but is closely associated with adverse clinical outcomes. A legacy effect of perforation on 12-month mortality was observed.
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Affiliation(s)
- Tim Kinnaird
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Richard Anderson
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Nick Ossei-Gerning
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - James Cockburn
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Alex Sirker
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Peter Ludman
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Mark de Belder
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Thomas W. Johnson
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Samuel Copt
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Azfar Zaman
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Mamas A. Mamas
- From the Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K., R.A., N.O.-G.); Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (J.C.); Department of Cardiology, University College Hospital, London, United Kingdom (A.S.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
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Patel S, Bailey SR. Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged. Curr Cardiol Rep 2017; 19:93. [PMID: 28840487 DOI: 10.1007/s11886-017-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. RECENT FINDINGS STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.
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Affiliation(s)
- Shalin Patel
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA
| | - Steven R Bailey
- From the Janey Briscoe Center of Excellence for Cardiovascular Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78232, USA.
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30
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Zhou LJ, Chen XY, Liu SP, Zhang LL, Xu YN, Mu PW, Geng DF, Tan Z. Downregulation of Cavin-1 Expression via Increasing Caveolin-1 Degradation Prompts the Proliferation and Migration of Vascular Smooth Muscle Cells in Balloon Injury-Induced Neointimal Hyperplasia. J Am Heart Assoc 2017; 6:e005754. [PMID: 28751541 PMCID: PMC5586430 DOI: 10.1161/jaha.117.005754] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Percutaneous coronary intervention has been widely used in the treatment of ischemic heart disease, but vascular restenosis is a main limitation of percutaneous coronary intervention. Our previous work reported that caveolin-1 had a key functional role in intimal hyperplasia, whereas whether Cavin-1 (another important caveolae-related protein) was involved is still unknown. Therefore, we will investigate the effect of Cavin-1 on neointimal formation. METHODS AND RESULTS Balloon injury markedly reduced Cavin-1 protein and enhanced ubiquitin protein expression accompanied with neointimal hyperplasia in injured carotid arteries, whereas Cavin-1 mRNA had no change. In cultured vascular smooth muscle cells (VSMCs), Cavin-1 was downregulated after inhibition of protein synthesis by cycloheximide, which was distinctly prevented by pretreatment with proteasome inhibitor MG132 but not by lysosomal inhibitor chloroquine, suggesting that proteasomal degradation resulted in Cavin-1 downregulation. Knockdown of Cavin-1 by local injection of Cavin-1 short hairpin RNA (shRNA) into balloon-injured carotid arteries in vivo promoted neointimal formation. In addition, inhibition or overexpression of Cavin-1 in cultured VSMCs in vitro prompted or suppressed VSMC proliferation and migration via increasing or decreasing extracellular signal-regulated kinase phosphorylation and matrix-degrading metalloproteinases-9 activity, respectively. However, under basic conditions, the effect of Cavin-1 on VSMC migration was stronger than on proliferation. Moreover, our results indicated that Cavin-1 regulated caveolin-1 expression via lysosomal degradation pathway. CONCLUSIONS Our study revealed the role and the mechanisms of Cavin-1 downregulation in neointimal formation by promoting VSMC proliferation, migration, and synchronously enhancing caveolin-1 lysosomal degradation. Cavin-1 may be a potential therapeutic target for the treatment of postinjury vascular remodeling.
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MESH Headings
- Angioplasty, Balloon/adverse effects
- Animals
- Carotid Artery Injuries/etiology
- Carotid Artery Injuries/genetics
- Carotid Artery Injuries/metabolism
- Carotid Artery Injuries/pathology
- Carotid Artery, External/metabolism
- Carotid Artery, External/pathology
- Caveolin 1/metabolism
- Cell Movement
- Cell Proliferation
- Cells, Cultured
- Disease Models, Animal
- Extracellular Signal-Regulated MAP Kinases/metabolism
- Lysosomes/metabolism
- Matrix Metalloproteinase 9/metabolism
- Membrane Proteins/genetics
- Membrane Proteins/metabolism
- Muscle, Smooth, Vascular/injuries
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Neointima
- Proteasome Endopeptidase Complex/metabolism
- Proteolysis
- RNA Interference
- RNA, Small Interfering/administration & dosage
- RNA-Binding Proteins/genetics
- RNA-Binding Proteins/metabolism
- Rats, Sprague-Dawley
- Signal Transduction
- Time Factors
- Transfection
- Vascular Remodeling
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Affiliation(s)
- Li-Jun Zhou
- Department of Physiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Xue-Ying Chen
- Department of Physiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Shui-Ping Liu
- Department of Forensic Pathology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Lin-Lin Zhang
- Department of Physiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ya-Nan Xu
- Department of Physiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Pan-Wei Mu
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Deng-Feng Geng
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Tan
- Department of Physiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
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31
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Rao SV. Complete Coronary Revascularization: The End Justifies the Means, as Long as Something Justifies the End. JACC Cardiovasc Interv 2017; 10:1425-1427. [PMID: 28728655 DOI: 10.1016/j.jcin.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina.
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32
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Ando T, Takagi H, Grines CL. Complete versus incomplete revascularization with drug-eluting stents for multi-vessel disease in stable, unstable angina or non-ST-segment elevation myocardial infarction: A meta-analysis. J Interv Cardiol 2017; 30:309-317. [DOI: 10.1111/joic.12390] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/26/2017] [Accepted: 04/28/2017] [Indexed: 01/17/2023] Open
Affiliation(s)
- Tomo Ando
- Harper Hospital/Detroit Medical Center, Division of Cardiology; Wayne State University; Detroit Michigan
| | - Hisato Takagi
- Department of Cardiovascular Surgery; Shizuoka Medical Center; Shizuoka Japan
| | - Cindy L. Grines
- Harper Hospital/Detroit Medical Center, Division of Cardiology; Wayne State University; Detroit Michigan
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33
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Hannan EL, Zhong Y, Jacobs AK, Ling FSK, Berger PB, Walford G, Venditti FJ, King SB. Incomplete revascularization for percutaneous coronary interventions: Variation among operators, and association with operator and hospital characteristics. Am Heart J 2017; 186:118-126. [PMID: 28454825 DOI: 10.1016/j.ahj.2017.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/21/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many studies have compared outcomes for incomplete revascularization (IR) among patients undergoing percutaneous coronary interventions (PCIs), but little is known about the correlates of IR, the extent to which complete revascularization (CR) was attempted unsuccessfully, and the variation across operators in the use of IR. METHODS New York's PCI registry was used to examine medium-term mortality for IR, the variables associated with the use of IR, and the variation across operators in the utilization of IR after controlling for patient factors. RESULTS Incomplete revascularization occurred for 63% of all patients and was significantly associated with higher 3-year mortality (adjusted hazard ratio1.35, 95% CI 1.23-1.48) than for CR. A total of 96% of all attempted CRs were successful. Operators with 15 or fewer years in practice (the lowest half) used IR significantly more (65% vs 61%, adjusted odds ratio [AOR] 1.17, 95% CI 1.00-1.37) than other operators, and operators with annual volumes of 171 or lower (the lowest 3 quartiles) used IR more than other operators (68% vs 60%, AOR 1.35, 95% CI 1.14-1.59). Also, hospitals with annual volumes of 645 and lower (the lowest 50% of hospitals) used IR more (67% vs 62%, AOR 1.46, 95% CI 1.07-1.99) than other hospitals. CONCLUSIONS Percutaneous coronary intervention patients without myocardial infarction who undergo IR continue to have higher medium-term (3-year) risk-adjusted mortality rates. There is a large amount of variability among operators in the frequency with which IR occurs. Operators who have been in practice longer, and higher-volume operators and hospitals have lower rates of IR. Failed attempts at CR occur very infrequently.
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Affiliation(s)
- Edward L Hannan
- State University of New York, University at Albany, Albany, NY.
| | - Ye Zhong
- State University of New York, University at Albany, Albany, NY
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