Long-term outcomes of complete versus incomplete revascularization for patients with multivessel coronary artery disease and left ventricular systolic dysfunction in drug-eluting stent era

Comparison of patients undergoing protected high risk percutaneous coronary intervention using either intravascular lithotripsy or rotational atherectomy

Background

Treating heavily calcified vessels is a challenging task in patients with an impaired left ventricular ejection fraction. Percutaneous mechanical circulatory support (pMCS) is increasingly used in patients in high-risk percutaneous coronary intervention (HRPCI).

Methods

In this retrospective registry, we investigated 25 patients undergoing a protected HRPCI receiving either intravascular lithotripsy (IVL + pMCS; n = 11) or rotational atherectomy (RA + pMCS; n = 14). The primary endpoint was defined as peri-interventional hemodynamic stability. The secondary endpoint was defined as major adverse cardiac events (MACE).

Results

Patients in the IVL + pMCS group had a significantly higher mean arterial pressure (MAP) at the end of the procedure (p = 0.04). However, the Δ-change in MAP was not significant [-12 mmHg (±20.3) vs. -16.1 mmHg (±23.9), p = 0.709]. The proportion of patients requiring post-interventional catecholamines was significantly lower in the IVL + pMCS group (p = 0.02). The Δ-change in Syntax Score was not significant between groups (IVL + pMCS -22 (±5.8) vs. RA + pMCS -21.2 (±7.6), p = 0.783). MACE did occur less in the group of IVL + pMCS (0% vs. 20%, p = 0.046). Patients with pMCS insertion as a bailout strategy had a higher probability for in-hospital death (p < 0.001) and the occurrence of the slow-reflow phenomenon was associated with long-term mortality (p = 0.021) in the cox regression analysis.

Conclusions

In our cohort patients in the IVL + pMCS group were hemodynamically more stable which led to a lower rate of catecholamine usage. pMCS as a bailout strategy was associated with in-hospital death and the occurrence of the slow reflow phenomenon with all-cause mortality during follow-up.

Myocardial Revascularization in Heart Failure: A State-of-the-Art Review

Patients with heart failure (HF) and underlying coronary artery disease (CAD) have a substantially higher risk of mortality compared with those with HF from other causes. However, identifying individuals with HF for whom revascularization is likely to improve prognosis is a complex clinical decision. Revascularization is likely beneficial for patients with CAD-predominant symptoms, such as those with acute myocardial infarction or stable ischemic heart disease with refractory angina. However, for patients with HF-predominant symptoms, characterized by dyspnea without acute myocardial infarction or refractory angina, the benefits of revascularization are less clear. This state-of-the-art review summarizes the outcomes, clinical trials, and therapeutic approaches for patients with both CAD and HF, and proposes a therapeutic algorithm to guide the diagnosis and comprehensive workup of these complex patients.

Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes

Multivessel coronary artery disease (CAD) is associated with worse outcomes across the spectrum of clinical presentations. The prognostic implications of completeness of revascularization in CAD patients, especially those with chronic coronary syndromes (CCS), remain highly debated. This is largely due to the use of non-standardized definitions for complete revascularization (CR) and incomplete revascularization (ICR) within previously published studies, lack of randomized clinical data, varying revascularization methods and heterogenous study populations. In particular, the utility and effectiveness of PCI-mediated CR for CCS remains unknown. In this review, we discuss the various definitions used for CR vs. ICR, highlight the rationale for pursuing CR and summarise the current literature regarding the effects of PCI-mediated CR on clinical outcomes in patients with CCS.

Effects of coronary revascularization by elective percutaneous coronary intervention on cardiac autonomic modulation assessed by heart rate variability: a single-center prospective cohort study

OBJECTIVE

To study the effects of coronary revascularization using elective percutaneous coronary intervention (PCI) on autonomic modulation assessed by heart rate variability measurement (HRV) in coronary artery disease (CAD) patients.

METHODS

A single-center prospective cohort study included 100 patients were included undergoing elective PCI excluding those with contraindication to contrast or dual antiplatelet therapy, atrial fibrillation or multiple premature beats, receiving anti-arrhythmic drugs and those who underwent previous PCI or coronary artery bypass graft (CABG). Short-term measurement of time domain parameters (mean, SDNN, RMSSD) and frequency domain parameters (LF component, HF component, LF/HF ratio) of HRV was performed at the same time of the day, pre-PCI, 24 hours and 6 months post-PCI by CheckMyheart™ handheld HRV device. 5-min HRV analysis software was used to interpret the data using standard methods of HRV measurement of the Task Force of The European Society of Cardiology (ESC) and The North American Society of Pacing and Electrophysiology. SYNTAX (SX) score was calculated before PCI and residual SYNTAX (rSS) score was calculated after PCI using SYNTAX score calculator software.

RESULTS

The mean age of the studied population was 56.89±10.75 years with 85% males. HRV time and frequency domain parameters showed a statistically significant improvement at different time intervals (before PCI, 24 hours and 6 months after PCI) (p-value <0.001). HRV time and frequency domain measures showed a statistically significant difference between time and frequency domain HRV parameters 24 hours and 6 months after PCI in patients who had complete revascularization (CR) with those who had incomplete revascularization (IR). (p-value <0.001).

CONCLUSION

Autonomic modulation in CAD patients was improved by coronary revascularization using PCI assessed by serial HRV measurement. Patients with CR had better autonomic modulation than those with IR assessed by HRV 24 and 6 months after PCI.

Validating the Performance of 5 Risk Scores for Major Adverse Cardiac Events in Patients Who Achieved Complete Revascularization After Percutaneous Coronary Intervention

BACKGROUND

Risk scores, like the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (SS), clinical SS, logistic SS (core model and extended model [LSS_extended]), Age, Creatinine, and Ejection Fraction (ACEF) score, and modified ACEF score, are predictive for major adverse cardiac events (MACE; including all-cause mortality, myocardial infarction [MI], and revascularization) in patients who have undergone percutaneous coronary intervention (PCI). However, few studies have validated the performance of these scores in complete revascularization (CR) patients. We aimed to compare the performance of previous risk scores in patients who achieved CR after PCI.

METHODS

All patients (N = 10,724) who underwent PCI at Fuwai Hospital in 2013 were screened, and those who achieved CR after PCI were enrolled. Risk scores were calculated by experienced cardiologists blinded to the clinical outcomes. Discrimination of risk scores was assessed according to the area under the receiver operating characteristic curve (AUC).

RESULTS

Fifty-one percent (5375/10,724) of patients who underwent PCI achieved CR. At a mean follow-up of 2.4 years, the mortality, MI, revascularization, and MACE rates were 1.2%, 1.0%, 6.3%, and 7.7%, respectively. SS was not predictive for mortality (AUC, 0.51; 95% confidence interval [CI], 0.44-0.59). All scores involving clinical variables, especially modified ACEF score (AUC, 0.73; 95% CI, 0.66-0.79), could predict mortality. LSS_extended was the most accurate for MI (AUC, 0.68; 95% CI, 0.61-0.75). SS and LSS_extended were predictive for revascularization, with marginally significant AUCs (SS, 0.54; LSS_extended, 0.55). No score was particularly accurate for predicting MACE, with AUCs ranging from 0.51 (ACEF score) to 0.58 (LSS_extended).

CONCLUSIONS

In CR patients, risk scores involving clinical variables might help to predict mortality; however, no risk scores showed helpful discrimination for MACE.

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug-Eluting Stent Era

BACKGROUND

There are limited data regarding the prognostic impact of angiographic complete revascularization (CR) in patients with chronic kidney disease (CKD). We sought to investigate the differential prognostic impact of angiographic CR over incomplete revascularization (IR), according to the presence of CKD in the drug-eluting stent era.

METHODS AND RESULTS

Between 2003 and 2011 at Samsung Medical Center, consecutive patients with multivessel disease were stratified by the presence of CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m²) and classified according to angiographic CR (residual SYNTAX score=0) or IR. Clinical outcomes were compared between angiographic CR and IR, stratified by the presence of CKD. Primary outcome was patient-oriented composite outcomes (POCO, a composite of all-cause death, myocardial infarction, any revascularization) at 3 years. Inverse probability weighting was performed between the CR and IR groups. A total of 3224 patients were eligible for analysis: 2295 without CKD; 929 with CKD. Among non-CKD patients, angiographic CR showed a significantly lower risk of POCO than IR (17.2% versus 21.7%, adjusted hazard ratio 0.76, 95% confidence interval, 0.62-0.95, P=0.014), mainly driven by a significantly lower risk of any revascularization. Among CKD patients, however, angiographic CR was associated with a significantly higher risk of POCO than IR (37.7% versus 28.4%, adjusted hazard ratio 1.42, 95% confidence interval, 1.08%-1.85%, P=0.011), mainly driven by a significantly higher risk of nonfatal target vessel myocardial infarction.

CONCLUSIONS

Angiographic CR was associated with reduced risk of POCO than IR in patients without CKD; however, it was associated with a significantly higher risk of POCO and nonfatal myocardial infarction in CKD patients.

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis.

Methods and Results

A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR.

Conclusion

CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.

To achieve, or not to achieve complete revascularization

Prior to minimally invasive valve surgery, a strategy of complete revascularization did not impact overall survival. Angiographically guided revascularization may have resulted in unnecessary procedures. A larger sample size and greater atherosclerotic burden may be needed to observe an impact with complete revascularization.