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Manuca RD, Covic AM, Brinza C, Floria M, Statescu C, Covic A, Burlacu A. Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:263. [PMID: 38399550 PMCID: PMC10890538 DOI: 10.3390/medicina60020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.
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Affiliation(s)
- Rares-Dumitru Manuca
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Alexandra Maria Covic
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Crischentian Brinza
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Mariana Floria
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Cristian Statescu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Adrian Covic
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Nephrology Clinic, Dialysis, and Renal Transplant Center, “C.I. Parhon” University Hospital, 700503 Iasi, Romania
| | - Alexandru Burlacu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
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Pustjens TFS, Timmermans MJC, Rasoul S, van ‘t Hof AWJ. Multivessel versus Culprit-Only Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Acute Coronary Syndrome. J Clin Med 2022; 11:jcm11206144. [PMID: 36294466 PMCID: PMC9605400 DOI: 10.3390/jcm11206144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/10/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: There is uncertainty whether multivessel (MV-PCI) or culprit-only percutaneous coronary intervention (CO-PCI) should be the treatment of choice in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). Aims: To evaluate clinical characteristics and outcomes in these patients undergoing MV-PCI or CO-PCI at the index procedure. Methods: Data were retrieved from the nationwide Netherlands Heart Registration. All NSTE-ACS patients with MVD undergoing PCI between 1 January 2017 and 1 October 2019 were grouped into a MV-PCI or CO-PCI group. The primary endpoint was all-cause mortality at long-term follow-up (median 756 days (593−996)). Secondary endpoints were reinterventions, urgent CABG, myocardial infarction (MI) < 30 days, target vessel revascularisation (TVR) and mortality at 1 year. Propensity score matching analyses were performed. Results: In total, 10,507 NSTE-ACS patients with MVD were included into the MV-PCI (N = 4235) and CO-PCI group (N = 6272). Analysing crude data, mortality rates at long-term follow-up (10.7% vs. 10.2%; p = 0.383), mortality at 1 year (6.0% vs. 5.6%; p = 0.412) and MI <30 days (0.8% vs. 0.9%; p = 0.513) were similar between both groups. Reinterventions (11.1% vs. 20.0%; p < 0.001), urgent CABG (0.1% vs. 0.4%; p = 0.001) and TVR (5.2% vs. 6.7%; p = 0.003) occurred less often in the MV-PCI group. Survival analysis after multiple imputation and propensity score matching showed similar mortality rates at long-term follow-up (log-rank p = 0.289), but a significant reduction for reinterventions in the MV-PCI group (log-rank p < 0.001). Conclusion: NSTE-ACS patients with MVD undergoing MV-PCI have similar mortality rates at long-term follow-up compared to CO-PCI. However, improved event-free survival in terms of fewer coronary reinterventions was observed.
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Affiliation(s)
- Tobias F. S. Pustjens
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
- Correspondence: ; Tel.: +31-884597777
| | | | - Saman Rasoul
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Arnoud W. J. van ‘t Hof
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
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Almendro-Delia M, Seoane García T, Villar Calle P, García González N, Lorenzo López B, Cortés FJ, García Del Río M, Ruiz García MDP, Hidalgo Urbano RJ, García-Rubira JC. Prevalence and clinical significance of totally occluded infarct-related arteries in patients with non-ST-segment elevation acute coronary syndromes. Int J Cardiol 2020; 324:1-7. [PMID: 32931857 DOI: 10.1016/j.ijcard.2020.09.040] [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: 06/09/2020] [Revised: 08/28/2020] [Accepted: 09/10/2020] [Indexed: 01/28/2023]
Abstract
Background Seemingly conflicting findings exist regarding the prognostic impact of totally occluded infarct-related arteries (oIRA) in non-ST elevation acute coronary syndromes (NSTE-ACS). Methods Retrospective analysis of prospective multicenter registry data comprising a single-center NSTE-ACS cohort, aimed at assessing the impact of occluded (TIMI flow 0/1) versus patent culprit vessels (pIRA, TIMI flow 2/3) on the composite endpoint of all-cause death and cardiogenic shock events at 30 days. Results Of 568 patients, 183 (32.5%) had oIRA. Male sex, refractory angina, ECG suggestive of multivessel or left main disease, and larger infarct sizes with inferior/posterolateral wall involvement, were identified as highly specific markers of oIRA. Successful culprit-lesion revascularization occurred more frequently in patent than in oIRA (90% vs. 96%; P = 0.013). Conversely, patients with oIRA more frequently achieved successful revascularization of concurrent non-IRAs including chronic total occlusions than did those with pIRA (28% vs. 3%; P = 0.0005). Multivariate analysis revealed neutral effects of oIRA on outcomes and identified incomplete revascularization as a powerful predictor of mortality. Moderation analysis revealed a significant interaction between completeness of revascularization and IRA patency, whereby among the incompletely revascularized patients, those with oIRA enjoyed a significant survival advantage over their counterparts with pIRA (11.8% vs. 28%, adjusted OR 0.34; 95% CI 0.10-0.73; Pinteraction = 0.012). Conclusions Approximately one third of NSTE-ACS patients in this cohort had oIRA. However, compared with pIRA, the occurrence of oIRA did not portend poor outcomes, likely resulting from the higher rate of incomplete revascularization and increased risk of subsequent mortality in patients with pIRA. These exploratory findings warrant further investigation.
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Affiliation(s)
- Manuel Almendro-Delia
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain; Cardiovascular Research and Clinical Trials Unit, Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena. Seville. Spain.
| | - Tania Seoane García
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain; Cardiovascular Research and Clinical Trials Unit, Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena. Seville. Spain
| | - Pablo Villar Calle
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Néstor García González
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Beatriz Lorenzo López
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Francisco Javier Cortés
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Manuel García Del Río
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Rafael J Hidalgo Urbano
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain; Cardiovascular Research and Clinical Trials Unit, Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena. Seville. Spain
| | - Juan C García-Rubira
- Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena, Seville, Spain; Cardiovascular Research and Clinical Trials Unit, Cardiology and Cardiovascular Surgery Division, Hospital Universitario Virgen Macarena. Seville. Spain
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Siebert VR, Borgaonkar S, Jia X, Nguyen HL, Birnbaum Y, Lakkis NM, Alam M. Meta-analysis Comparing Multivessel Versus Culprit Coronary Arterial Revascularization for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol 2019; 124:1501-1511. [PMID: 31575424 DOI: 10.1016/j.amjcard.2019.07.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/19/2022]
Abstract
We present a systematic review and meta-analysis comparing efficacy and safety outcomes between single procedure multivessel revascularization (MVR) and culprit vessel only revascularization in patients presenting with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS is the most common form of acute coronary syndrome (ACS), and multivessel disease is common. There is no consensus on the most efficacious single procedure revascularization strategy for patients undergoing percutaneous coronary intervention not meeting coronary artery bypass grafting criteria. Studies in PubMed and EMBASE databases were systematically reviewed, and 15 studies met criteria for inclusion in the meta-analysis. Baseline characteristics between the groups were similar. A random effects model was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity of studies was assessed using Cochrane's Q and Higgins I2 tests. For short-term outcomes, patients who underwent MVR had higher rates of major adverse cardiac events (OR 1.14; 95% CI 1.01 to 1.29; p = 0.03); and stroke (OR 1.94; 95% CI 1.01 to 3.72; p = 0.05), but lower rates of urgent or emergent coronary artery bypass grafting (OR 0.35; 95% CI 0.29 to 0.43; p <0.00001). In the long-term, MVR patients had less frequent major adverse cardiac events (OR 0.76; 95% CI 0.61-0.93; p = 0.009), all-cause death (OR 0.83; 95% CI 0.71 to 0.97; p = 0.03), and repeat revascularization, (OR 0.62; 95% CI 0.42 to 0.90; p = 0.01). MVR following NSTE-ACS was associated with higher short-term risk, but long-term benefit. In conclusion, these results support the use of single procedure multivessel revascularization for NSTE-ACS patients who are suitable candidates at the time of percutaneous coronary intervention.
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Affiliation(s)
| | - Sanket Borgaonkar
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Xiaoming Jia
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hong Loan Nguyen
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Nasser M Lakkis
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
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Doğan C, Bayram Z, Çap M, Özkalaycı F, Unkun T, Erdoğan E, Uslu A, Acar RD, Guvendi B, Akbal ÖY, Karagöz A, Hakgor A, Karaduman A, Uysal S, Aykan A, Kaymaz C, Özdemir N. Comparison of 30-Day MACE between Immediate versus Staged Complete Revascularization in Acute Myocardial Infarction with Multivessel Disease, and the Effect of Coronary Lesion Complexity. ACTA ACUST UNITED AC 2019; 55:medicina55020051. [PMID: 30781429 PMCID: PMC6410006 DOI: 10.3390/medicina55020051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/12/2022]
Abstract
Background and objective: In patients with acute myocardial infarction and multivessel disease, the timing of intervention to non-culprit lesions is still a matter of debate, especially in patients without shock. This study aimed to compare the effect of multivessel intervention, performed at index percutaneous coronary intervention (PCI) (MVI-I) or index hospitalization (MVI-S), on the 30-day results of acute myocardial infarction (AMI), and to investigate the effect of coronary lesion complexity assessed by the Syntax (Sx) score on the timing of multivessel intervention. Materials and methods: We enrolled 180 patients with MVI-I, and 425 patients with MVI-S. The major adverse cardiovascular events (MACE) for this study were identified as mortality, nonfatal myocardial infarction, nonfatal stroke, acute heart failure, ischemia driven revascularization, major bleeding, and acute renal failure developed within 30 days. Results: The unadjusted MACE rates at 30 days were 11.2% and 5% among those who underwent MVI-I and MVI-S, respectively (OR 3.02; 95% confidence interval (CI) 1.51–6.02; p = 0.002). Associations were statistically significant after adjusting for covariates in the penalized multivariable model (adjusted OR 2.06; 95%CI 1.02–4.18; p = 0.043), propensity score adjusted multivariable model (adjusted OR 2.46; 95%CI 1.19–5.07; p = 0.015), and IPW (adjusted OR 2.11; 95%CI 1.28–3.47; p = 0.041). We found that the Syntax score of lesions did not affect the results. Conclusion: MVI-S was associated with a lower incidence of major adverse cardiovascular events within 30 days after discharge.
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Affiliation(s)
- Cem Doğan
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Zübeyde Bayram
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Murat Çap
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Flora Özkalaycı
- Department of Cardiology, Hisar Intercontinental Hospital, 34844 Istanbul, Turkey.
| | - Tuba Unkun
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Emrah Erdoğan
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Abdulkadir Uslu
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Rezzan Deniz Acar
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Busra Guvendi
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Özgur Yaşar Akbal
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Ali Karagöz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Aykun Hakgor
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Ahmet Karaduman
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Samet Uysal
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Ahmet Aykan
- Department of Cardiology, Kahraman Maraş Sütçü İmam University, 46000 Kahraman Maraş, Turkey.
| | - Cihangir Kaymaz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
| | - Nihal Özdemir
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, 34844 Istanbul, Turkey.
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Desperak P, Hawranek M, Gąsior P, Desperak A, Lekston A, Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes. Cardiol J 2017; 26:157-168. [PMID: 28980282 DOI: 10.5603/cj.a2017.0110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/10/2017] [Accepted: 09/10/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography. METHODS 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. RESULTS After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20-0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31-0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19-0.69; p = 0.0020). CONCLUSIONS In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis.
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Affiliation(s)
- Piotr Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Michał Hawranek
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Paweł Gąsior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, Katowice, Poland
| | - Aneta Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Andrzej Lekston
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
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