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Ezad SM, McEntegart M, Dodd M, Didagelos M, Sidik N, Li Kam Wa M, Morgan HP, Pavlidis A, Weerackody R, Walsh SJ, Spratt JC, Strange J, Ludman P, Chiribiri A, Clayton T, Petrie MC, O'Kane P, Perera D. Impact of Anatomical and Viability-guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy. J Am Coll Cardiol 2024:S0735-1097(24)07132-8. [PMID: 38759904 DOI: 10.1016/j.jacc.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Complete revascularization of coronary disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function. OBJECTIVES To identify the impact of complete revascularization in patients with severe LV dysfunction. METHODS Patients enrolled in the REVIVED-BCIS2 trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo) respectively, where RIcoro=[change in BCIS Jeopardy Score (BCIS-JS)] / [baseline BCIS-JS] and RImyo=[number of revascularized viable segments] / [ number of viable segments supplied by diseased vessels]. The PCI group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure. RESULTS Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX scores were 8 (6 to 10) and 22 (15 to 29) respectively. In those assigned to PCI, median RIcoro and RImyo values were 67% and 85%. Compared to the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those receiving complete anatomical or viability-guided revascularization (HR 0.90, 95% CI 0.62-1.32 and HR 0.95, 95% CI 0.66-1.35 respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome. CONCLUSIONS In patients with severe left ventricular dysfunction, neither complete anatomical nor viability-guided revascularization were associated with improved event-free survival compared to incomplete revascularization or treatment with medical therapy alone.
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Affiliation(s)
- Saad M Ezad
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK; Columbia University Medical Center, New York, USA
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthaios Didagelos
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Novalia Sidik
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Matthew Li Kam Wa
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Holly P Morgan
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | | | | | - Simon J Walsh
- Belfast Health and Social Care NHS Trust, Belfast UK
| | | | - Julian Strange
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Amedeo Chiribiri
- Guy's and St Thomas' NHS Foundation Trust, London, UK; Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Tim Clayton
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark C Petrie
- School of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Peter O'Kane
- University Hospitals Dorset NHS Foundation Trust, Bournemouth
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK.
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2
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Madsen KT, Nørgaard BL, Øvrehus KA, Jensen JM, Parner E, Grove EL, Mortensen MB, Fairbairn TA, Nieman K, Patel MR, Rogers C, Mullen S, Mickley H, Thomsen KK, Bøtker HE, Leipsic J, Sand NPR. Coronary computed tomography angiography derived fractional flow reserve and risk of recurrent angina: A 3-year follow-up study. J Cardiovasc Comput Tomogr 2024; 18:243-250. [PMID: 38246785 DOI: 10.1016/j.jcct.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/03/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The association between coronary computed tomography angiography (CTA) derived fractional flow reserve (FFRCT) and risk of recurrent angina in patients with new onset stable angina pectoris (SAP) and stenosis by CTA is uncertain. METHODS Multicenter 3-year follow-up study of patients presenting with symptoms suggestive of new onset SAP who underwent first-line CTA evaluation and subsequent standard-of-care treatment. All patients had at least one ≥30 % coronary stenosis. A per-patient lowest FFRCT-value ≤0.80 represented an abnormal test result. Patients with FFRCT ≤0.80 who underwent revascularization were categorized according to completeness of revascularization: 1) Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤0.80 revascularized; or 2) incompletely revascularized (IR-FFRCT) ≥1 vessels with FFRCT ≤0.80 non-revascularized. Recurrent angina was evaluated using the Seattle Angina Questionnaire. RESULTS Amongst 769 patients (619 [80 %] stenosis ≥50 %, 510 [66 %] FFRCT ≤0.80), 174 (23 %) reported recurrent angina at follow-up. An FFRCT ≤0.80 vs > 0.80 associated to increased risk of recurrent angina, relative risk (RR): 1.82; 95 % CI: 1.31-2.52, p < 0.001. Risk of recurrent angina in CR-FFRCT (n = 135) was similar to patients with FFRCT >0.80, 13 % vs 15 %, RR: 0.93; 95 % CI: 0.62-1.40, p = 0.72, while IR-FFRCT (n = 90) and non-revascularized patients with FFRCT ≤0.80 (n = 285) had increased risk, 37 % vs 15 % RR: 2.50; 95 % CI: 1.68-3.73, p < 0.001 and 30 % vs 15 %, RR: 2.03; 95 % CI: 1.44-2.87, p < 0.001, respectively. Use of antianginal medication was similar across study groups. CONCLUSION In patients with SAP and coronary stenosis by CTA undergoing standard-of-care guided treatment, FFRCT provides information regarding risk of recurrent angina.
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Affiliation(s)
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik Parner
- Department of Public Health, Section for Biostatistics, Aarhus University, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Timothy A Fairbairn
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, Stanford, CA, USA
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | | | | | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathon Leipsic
- Department of Radiology, Providence Health Care, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Niels Peter Rønnow Sand
- Department of Cardiology, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
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3
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Mangieri A, Gitto M. Editorial: Timing of revascularization in acute coronary syndrome with multivessel disease: Do we need to hurry up?? Cardiovasc Revasc Med 2024; 60:9-10. [PMID: 37989705 DOI: 10.1016/j.carrev.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; and IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | - Mauro Gitto
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; and IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
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Shintomi S, Saito S, Hamasaki A, Ichihara Y, Morita K, Ikeda M, Domoto S, Furuta A, Niinami H. Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization. Heart Vessels 2024; 39:175-184. [PMID: 37747541 PMCID: PMC10784338 DOI: 10.1007/s00380-023-02317-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53-2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68-1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women's Medical University Hospital.
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Affiliation(s)
- Shizuya Shintomi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan.
| | - Satoshi Saito
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Azumi Hamasaki
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Yuki Ichihara
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Kozo Morita
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Masahiro Ikeda
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Satoru Domoto
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Akihisa Furuta
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku, Tokyo, Japan
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Bujak K, Rinaldi R, Vidal-Cales P, Montone RA, Diletti R, Gąsior M, Crea F, Sabaté M, Brugaletta S. Immediate versus staged complete revascularization in acute coronary syndrome: A meta-analysis of randomized controlled trials. Int J Cardiol 2023; 393:131397. [PMID: 37769973 DOI: 10.1016/j.ijcard.2023.131397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Clinical guidelines recommend a complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD). However, its optimal timing is unclear. The aim of this meta-analysis was to compare the clinical outcomes following immediate versus staged CR in ACS. METHODS PubMed and Scopus were searched until March 2023 for randomized controlled trials (RCTs) comparing immediate versus staged CR. The primary endpoint was major adverse cardiovascular event (MACE) at the longest follow-up. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction (MI), any unplanned revascularization, target-vessel revascularization (TVR), and stent thrombosis. Safety outcomes were major bleeding, contrast volume, procedure duration, and length of hospitalization. RESULTS Eight RCTs were included (3559 patients, weighted mean follow-up 12.5 months). There were no differences in the primary endpoint (OR 0.74, 95%CI: 0.54-1.01) and in the secondary endpoints of death, and stent thrombosis between the two CR strategies. Immediate CR was associated with a lower risk of recurrent MI (OR 0.51, 95% CI 0.34-0.76), any unplanned revascularization (OR 0.59, 95%CI: 0.43-0.80), and TVR (OR 0.61, 95% CI 0.45-0.84) compared to staged CR. Immediate CR was also associated with lower total contrast volume and shorter total procedure duration and hospitalization length compared to staged CR without differences in major bleedings. CONCLUSION No difference was found between immediate and staged CR regarding MACE, or deaths rates at one year. Immediate CR may be associated with a lower risk of recurrent MI and unplanned coronary revascularization than staged CR.
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Affiliation(s)
- Kamil Bujak
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Riccardo Rinaldi
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Pablo Vidal-Cales
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rocco Antonio Montone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Tsai TY, Serruys PW. Complete revascularization for acute coronary syndrome, one step at a time. Cardiovasc Res 2023; 119:e152-e154. [PMID: 38007606 DOI: 10.1093/cvr/cvad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 11/27/2023] Open
Affiliation(s)
- Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, University Road, Galway H91 TK33, Ireland
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, University Road, Galway H91 TK33, Ireland
- National Heart and Lung Institute, Imperial College London, London, UK
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Kaya IC, Bulut HI, Candelario K, Ozbayburtlu M, Balkanay OO. Complete surgical revascularization after NSTEMI and unstable angina in patients with multivessel coronary artery disease: Institutional experience. Asian Cardiovasc Thorac Ann 2023; 31:675-681. [PMID: 37671414 DOI: 10.1177/02184923231197872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
INTRODUCTION The feasibility and standardization of coronary artery bypass grafting (CABG) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unstable angina (UA) remain topics of ongoing debate. In this study, feasibility and early-term outcomes of CABG in patients with NSTE-ACS and UA were discussed. METHODS This study enrolled 79 patients who underwent on-pump CABG with complete revascularization between January 2020 and May 2022. the survival rates analyzed using Kaplan Meier test with log rank test. The p value of statistical significance was taken as below 0.05. RESULTS Preoperatively, the patients had a mean age of 60.9 years and a BMI of 28.0. The medical history included hypertension (50.6%), peripheral arterial disease and atrial fibrillation (12.7%), and other comorbidities such as COPD (22.8%) and type 2 diabetes mellitus (44.3%). Intraoperatively, the mean distal anastomosis count was 3.4, with average cardiopulmonary bypass and aortic cross-clamp times of 84.0 and 49.0 min, respectively. Early-term outcomes revealed low rates of mortality (2.5%) and complications such as myocardial infarction (1.3%), acute kidney injury (5.1%) and transient ischemic attack (5.1%). Post-discharge outcomes demonstrated low cardiac and all-cause mortality rates (2.5% and 3.8%, respectively) and a high overall survival rate (93.7%) at 12-month follow-up. CONCLUSION This study demonstrated the feasibility and positive outcomes of complete surgical revascularization in patients with UA and NSTE-ACS. It showed no graft occlusion or stroke, low complication rates and promising survival outcomes. Further research is needed for confirmation and to establish the procedure's efficacy and safety in this patient population.
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Affiliation(s)
- Ibrahim C Kaya
- Department of Cardiovascular Surgery, Eskisehir City Health Practice and Research Centers, Eskisehir, Turkey
| | - Halil I Bulut
- Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Merih Ozbayburtlu
- Department of Cardiovascular Surgery, Eskisehir City Health Practice and Research Centers, Eskisehir, Turkey
| | - Ozan O Balkanay
- Department of Cardiovascular Surgery, Cerrahpasa School of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
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Affiliation(s)
- Daniela Pedicino
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, Rome 00168, Italy
| | - Giovanna Liuzzo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, Rome 00168, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University, School of Medicine, Largo F. Vito 1, Rome 00168, Italy
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Benatti G, Gragnano F, Vignali L, Calabrò P, Gurgoglione FL, Niccoli G. Timing and modality of complete revascularization in patients presenting with ST-segment elevation myocardial infarction and multivessel coronary artery disease. Int J Cardiol 2023; 380:6-11. [PMID: 36907453 DOI: 10.1016/j.ijcard.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
Approximately half of the patients presenting with ST-segment elevation myocardial infarction have also significant atherosclerotic disease affecting coronary segments other than the infarct-related artery. Optimal management of residual lesions in this clinical setting has been a topic of intense research in the last decade. On the one hand, a large body of evidence has consistently shown the benefit of complete revascularization for the reduction of adverse cardiovascular outcomes. On the other hand, some crucial aspects such as the optimal timing or the best strategy of the complete treatment approach remain a matter of controversy. In this review, we aim to provide a thorough critical appraisal of the available literature regarding this topic, by discussing areas of relative certainty, gaps in the knowledge, approach to specific clinical subsets and future research directions.
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Affiliation(s)
- Giorgio Benatti
- Cardiology Unit, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy; Division of Cardiology, Azienda Ospedaliera di Rilievo Nazionale "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Luigi Vignali
- Cardiology Unit, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy; Division of Cardiology, Azienda Ospedaliera di Rilievo Nazionale "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Filippo Luca Gurgoglione
- Cardiology Unit, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
| | - Giampaolo Niccoli
- Cardiology Unit, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy.
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10
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Gragnano F, Montalto C, Oreglia JA, Calabrò P. Physiology-guided revascularization of non-culprit lesions in patients with STEMI: Could vFFR be the way? Int J Cardiol 2023; 378:20-21. [PMID: 36640962 DOI: 10.1016/j.ijcard.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy.
| | - Claudio Montalto
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy
| | - Jacopo A Oreglia
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy.
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy.
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Zimbardo G, Cialdella P, Di Fusco P, Donahue ME, D’Aquino UML, Paolucci L, Sergi SC, Talarico GP, Calò L. Acute coronary syndromes and multivessel coronary artery disease. Eur Heart J Suppl 2023; 25:C74-C78. [PMID: 37125291 PMCID: PMC10132620 DOI: 10.1093/eurheartjsupp/suad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Patients with acute coronary syndromes (ACS) and multivessel coronary artery disease are frequently encountered during clinical practice and those patients are at higher risk of subsequent acute cardiovascular events. In patients presenting with both ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndromes, complete revascularization is associated with decreased risk of major adverse cardiovascular events. Nevertheless, the optimal timing of the intervention and treatment modality are still in discussions. Furthermore, non-culprit lesions assessment based on stenosis severity, either on visual or on functional evaluation, may not provide information about vulnerable plaques prone to thrombosis. Therefore, insights from intracoronary imaging could further identify high-risk plaque and patients at higher risk of future adverse events. This article aims to provide an overview of current guideline recommendations, envisioning future perspectives for the treatment of patients with ACS and multivessel disease.
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Affiliation(s)
| | - Pio Cialdella
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
| | - Paolo Di Fusco
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
| | | | | | - Luca Paolucci
- Clinica Mediterranea, Via Orazio, 2, Napoli 80122, Italy
| | - Sonia Cristina Sergi
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
| | | | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Via Casilina 1049, Rome 00169, Italy
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Kato T, Ueki Y, Minamisawa M, Miura T, Oyama Y, Hashizume N, Yokota D, Taki M, Senda K, Okina Y, Wakabayashi T, Fujimori K, Karube K, Sakai T, Nomi H, Yui H, Kanzaki Y, Machida K, Maruyama S, Nagae A, Saigusa T, Ebisawa S, Okada A, Motoki H, Kuwahara K. Association between complete revascularization of the coronary artery and clinical outcomes in peripheral artery disease: a sub-analysis of the I-PAD Nagano registry. Heart Vessels 2023:10.1007/s00380-023-02251-y. [PMID: 37052610 DOI: 10.1007/s00380-023-02251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 02/16/2023] [Indexed: 04/14/2023]
Abstract
Peripheral artery disease (PAD) is commonly caused by atherosclerosis and has an unfavorable prognosis. Complete revascularization (CR) of the coronary artery reduces the risk of major adverse cardiovascular event (MACE) in patients with coronary artery disease (CAD). However, the impact of CR in patients with PAD has not been established to date. Therefore, we evaluated the impact of CR of CAD on the five-year clinical outcomes in patients with PAD. This study was based on a prospective, multicenter, observational registry in Japan. We enrolled 366 patients with PAD undergoing endovascular treatment. The primary endpoint was MACE, defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke. After excluding ineligible patients, 96 and 68 patients received complete revascularization of the coronary artery (CR group) and incomplete revascularization of the coronary artery (ICR group), respectively. Freedom from MACE in the CR group was significantly higher than in the ICR group at 5 years (66.7% vs 46.0%, p < 0.01). Multivariate analysis revealed that CR emerged as an independent predictor of MACE (Hazard ratio: 0.56, 95% confidential interval: 0.34-0.94, p = 0.03). CR of CAD was significantly associated with improved clinical outcomes in patients with PAD undergoing endovascular treatment.
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Affiliation(s)
- Tamon Kato
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Yasushi Ueki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Masatoshi Minamisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takashi Miura
- Department of Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | - Yushi Oyama
- Department of Cardiology, Shinonoi General Hospital, Nagano, Japan
| | - Naoto Hashizume
- Department of Cardiology, Nagano Red-Cross Hospital, Nagano, Japan
| | | | - Minami Taki
- Department of Cardiology, Saku General Hospital, Nagano, Japan
| | - Keisuke Senda
- Department of Cardiology, Aizawa Hospital, Nagano, Japan
| | - Yoshiteru Okina
- Department of Cardiology, Joetsu General Hospital, Niigata, Japan
| | | | - Koki Fujimori
- Department of Cardiology, Suwa Red-Cross Hospital, Nagano, Japan
| | - Kenichi Karube
- Department of Cardiology, Okaya City Hospital, Nagano, Japan
| | - Takahiro Sakai
- Department of Cardiology, Ina Central Hospital, Nagano, Japan
| | - Hidetomo Nomi
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hisanori Yui
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yusuke Kanzaki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Keisuke Machida
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Shusaku Maruyama
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ayumu Nagae
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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Saito Y, Kobayashi Y. Complete revascularization in acute myocardial infarction: a clinical review. Cardiovasc Interv Ther 2023; 38:177-186. [PMID: 36609898 PMCID: PMC9823266 DOI: 10.1007/s12928-022-00907-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023]
Abstract
In patients with ST segment elevation and non-ST elevation myocardial infarction (MI), multivessel (MV) coronary artery disease is found in approximately 50%, leading to worse clinical outcomes. Recent data have suggested that complete revascularization with MV percutaneous coronary intervention is associated with a reduced risk of major adverse cardiovascular events as compared to culprit vessel-only revascularization. However, the optimal timing of MV intervention, appropriate non-culprit lesion assessment, and the best revascularization strategy in specific subsets such as cardiogenic shock remain to be established. This review article summarizes current evidence on revascularization strategies in patients with acute MI and MV disease.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan.
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
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14
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Lee JM, Kim HK, Park KH, Choo EH, Kim CJ, Lee SH, Kim MC, Hong YJ, Ahn SG, Doh JH, Lee SY, Park SD, Lee HJ, Kang MG, Koh JS, Cho YK, Nam CW, Koo BK, Lee BK, Yun KH, Hong D, Joh HS, Choi KH, Park TK, Yang JH, Song YB, Choi SH, Gwon HC, Hahn JY. Fractional flow reserve versus angiography-guided strategy in acute myocardial infarction with multivessel disease: a randomized trial. Eur Heart J 2023; 44:473-484. [PMID: 36540034 DOI: 10.1093/eurheartj/ehac763] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/09/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS In patients with acute myocardial infarction (MI) and multivessel coronary artery disease, percutaneous coronary intervention (PCI) of non-infarct-related artery reduces death or MI. However, whether selective PCI guided by fractional flow reserve (FFR) is superior to routine PCI guided by angiography alone is unclear. The current trial sought to compare FFR-guided PCI with angiography-guided PCI for non-infarct-related artery lesions among patients with acute MI and multivessel disease. METHODS AND RESULTS Patients with acute MI and multivessel coronary artery disease who had undergone successful PCI of the infarct-related artery were randomly assigned to either FFR-guided PCI (FFR ≤0.80) or angiography-guided PCI (diameter stenosis of >50%) for non-infarct-related artery lesions. The primary end point was a composite of time to death, MI, or repeat revascularization. A total of 562 patients underwent randomization. Among them, 60.0% underwent immediate PCI for non-infarct-related artery lesions and 40.0% were treated by a staged procedure during the same hospitalization. PCI was performed for non-infarct-related artery in 64.1% in the FFR-guided PCI group and 97.1% in the angiography-guided PCI group, and resulted in significantly fewer stent used in the FFR-guided PCI group (2.2 ± 1.1 vs. 2.5 ± 0.9, P < 0.001). At a median follow-up of 3.5 years (interquartile range: 2.7-4.1 years), the primary end point occurred in 18 patients of 284 patients in the FFR-guided PCI group and in 40 of 278 patients in the angiography-guided PCI group (7.4% vs. 19.7%; hazard ratio, 0.43; 95% confidence interval, 0.25-0.75; P = 0.003). The death occurred in five patients (2.1%) in the FFR-guided PCI group and in 16 patients (8.5%) in the angiography-guided PCI group; MI in seven (2.5%) and 21 (8.9%), respectively; and unplanned revascularization in 10 (4.3%) and 16 (9.0%), respectively. CONCLUSION In patients with acute MI and multivessel coronary artery disease, a strategy of selective PCI using FFR-guided decision-making was superior to a strategy of routine PCI based on angiographic diameter stenosis for treatment of non-infarct-related artery lesions regarding the risk of death, MI, or repeat revascularization.
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Affiliation(s)
- Joo Myung Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Hyun Kuk Kim
- Chosun University Hospital, University of Chosun College of Medicine, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea
| | - Keun Ho Park
- Chosun University Hospital, University of Chosun College of Medicine, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea
| | - Eun Ho Choo
- Seoul St. Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Chan Joon Kim
- Uijeongbu St. Mary's Hospital, The Catholic University of Korea, 271 Cheonbo-ro, Uijeongbu, Gyeonggi-do 11765, Korea
| | - Seung Hun Lee
- Department of Internal Medicine, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
| | - Young Joon Hong
- Department of Internal Medicine, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon-do 26426, Korea
| | - Joon-Hyung Doh
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang, Gyeonggi-do 10380, Korea
| | - Sang Yeub Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, 776 Sunhawn-ro, Cheongju, Chungcheongbuk-do 28644, Korea.,Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 501 Iljik-dong, Gwangmyeong, Gyeonggi-do 14353, Korea
| | - Sang Don Park
- Inha University Hospital, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea
| | - Hyun-Jong Lee
- Department of Internal Medicine, Sejong General Hospital, 20 Gyeyangmunhwa-ro, Gyeyang-gu, Incheon 21080, Korea
| | - Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 501 Jinju-daero, Jinju, Gyeongsangnam-do 52727, Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 501 Jinju-daero, Jinju, Gyeongsangnam-do 52727, Korea
| | - Yun-Kyeong Cho
- Keimyung University Dongsan Medical Center, 1035 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea
| | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, 1035 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea
| | - Bong-Ki Lee
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Baengnyeong-ro 156, Chuncheon, Gangwon-do 24289, Korea
| | - Kyeong Ho Yun
- Department of Internal Medicine, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Jeollabuk-do 54538, Korea
| | - David Hong
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-guw, Seoul 06351, Korea
| | - Hyun Sung Joh
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Ki Hong Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Taek Kyu Park
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Jeong Hoon Yang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Seung-Hyuk Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
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15
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Aquino-Bruno H, García-García JF, Muratalla-González R, Alcántara-Meléndez MA, Morales-Portano JD, Gómez-Álvarez EB, Merino-Rajme JA, Castro-Rubio JA, Plata Corona JC. Complete revascularization with PCI in STEMI patients with multivessel disease, when is the appropriate time? Arch Cardiol Mex 2023; 93:053-061. [PMID: 35614449 PMCID: PMC10161824 DOI: 10.24875/acm.21000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose was to compare the outcomes of patients with ST-elevation myocardial infarction and multivessel coronary artery disease undergoing one-time multivessel revascularization (OTMVR) versus in-hospital staged complete revascularization with percutaneous coronary intervention. Methods This was a single-center, retrospective, observational, and cohort study, including data from January 2013 to April 2019. A total of 634 patients were included in the study. Comparisons were made between patients who underwent in-hospital staged complete revascularization versus OTMVR. The primary endpoint was all-cause in-hospital mortality, secondary endpoints included cardiovascular complications, all-cause new hospitalization, and mortality evaluated at 30 days and 1 year. In addition, we constructed a logistic regression model for determining the risk factors that predicted mortality. Results Of the 634 patients, 328 were treated with staged revascularization and 306 with OTMVR. About 76.7% were men, with a mean age of 63.3 years. Less complex coronary lesions and a higher proportion of the left anterior descending artery as the culprit vessel were found in the OTMVR group. Compared with staged revascularization, the primary and secondary endpoints occurred less frequently with OTMVR strategy. Conclusions OTMVR did not generate more complications and demonstrate better clinical outcomes than in-hospital staged revascularization.
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Affiliation(s)
- Heberto Aquino-Bruno
- Department of Cardiology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Juan F García-García
- Department of Cardiology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | | | | | - Enrique B Gómez-Álvarez
- Department of Cardiology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - José A Merino-Rajme
- Department of Cardiology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - José A Castro-Rubio
- Departament of Internal Medicine, Hospital Regional de Alta Especialidad, ISSSTE, Puebla, Mexico
| | - Juan C Plata Corona
- Department of Cardiology, Hospital General de Puebla, Puebla, Mexico, Mexico
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16
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Kurup R, Wijeysundera HC, Bagur R, Ybarra LF. Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes. Cardiovasc Revasc Med 2023; 47:86-92. [PMID: 36266152 DOI: 10.1016/j.carrev.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Rahul Kurup
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Rodrigo Bagur
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luiz F Ybarra
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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17
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Rumiz E, Vilar JV, Cubillos A, Valero E, Berenguer A, Fácila L, Vidal V, Fernandez C, Llopis G, Paya R, Nuñez J. Long-term recurrent events in ST-elevation myocardial infarction and multivessel disease. The impact of different revascularization strategies. Rev Port Cardiol 2023; 42:445-451. [PMID: 36706913 DOI: 10.1016/j.repc.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/22/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION The benefit of complete revascularization (CR) on long-term total event reduction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), still remains unclear. We assessed the efficacy of three different revascularization strategies on long-term total recurrent events. METHODS We retrospectively analyzed 414 consecutive patients admitted with STEMI and MVD who were categorized according to the revascularization strategy used: culprit-vessel-only percutaneous coronary intervention (PCI) (n=163); in-hospital CR (n=136); and delayed CR (n=115). The combined endpoint assessed was all-cause mortality, the total number of myocardial infarctions, ischemia-driven revascularizations or strokes. Negative binomial regression was used to assess the association between the revascularization strategy and total events; risk estimates were expressed as an incidence rates ratio (IRR). RESULTS At a median follow-up of four years (1.2-6), rates of the combined endpoint per 10 patient-years were 18, 0.8, and 0.6 in culprit-vessel-only PCI, in-hospital CR, and delayed CR strategies, respectively (p<0.001). After multivariable adjustment and when compared with culprit-vessel-only PCI, both in-hospital and delayed CR strategies were significantly associated with a reduction in the combined endpoint (IRR=0.40: 95% confidence interval (CI), 0.25-0.64; p<0.001; and IRR 0.40: 95% CI, 0.24-0.62; p<0.001, respectively). No differences were observed across in-hospital and delayed CR strategies. CONCLUSIONS Complete revascularization of non-culprit lesions in patients with STEMI and MVD reduces the risk of total recurrent events during long-term follow-up. No differences between in-hospital and delayed CR strategies were found.
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Affiliation(s)
- Eva Rumiz
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain; Universitat Jaume I, Spain.
| | - Juan Vicente Vilar
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain
| | - Andrés Cubillos
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Ernesto Valero
- Cardiology Department, Hospital Quiron Salud Valencia, Valencia, Spain; Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain
| | - Alberto Berenguer
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Lorenzo Fácila
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Verónica Vidal
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Carmen Fernandez
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Guillem Llopis
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Rafael Paya
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Julio Nuñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Spain
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Archilletti F, Ricci F, Pelliccia F, Dangas G, Giuliani L, Radico F, Perfetti M, Rossi S, Gallina S, Maddestra N, Khanji MY, Zimarino M. Coronary angiography- or fractional flow reserve-guided complete revascularization in multivessel disease STEMI: A Bayesian hierarchical network meta-analysis. Int J Cardiol 2023; 370:122-128. [PMID: 36328114 DOI: 10.1016/j.ijcard.2022.10.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/28/2022] [Accepted: 10/28/2022] [Indexed: 11/05/2022]
Abstract
AIMS To identify the best strategy to achieve complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD). METHODS AND RESULTS We systematically reviewed the literature for randomized controlled trials (RCTs) comparing IRA-only PCI and CR guided by angiography or fractional flow reserve (FFR) in MVD-STEMI. Both frequentist (classical) and Bayesian network meta-analysis were performed, including a comparative hierarchy estimation of the probability to reduce the primary composite endpoint of all-cause death and new myocardial infarction (MI). We identified 11 RCTs, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the primary endpoint (OR: 0.73; 95%CI0.55-0.97). We observed non-significant difference between angiography and FFR guidance in reducing the primary endpoint (OR: 0.73, 95% CI 0.35-1.57). The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of all-cause death or new MI (SUCRA92%). CONCLUSIONS In patients with MVD-STEMI, CR is associated with a reduction in all-cause mortality and new MI compared with IRA-only PCI. Angio-guided CR is associated with the lowest risk of all-cause death or new MI, therefore the role of FFR-guidance in this setting is questionable. CONDENSED ABSTRACT Both frequentist and Bayesian network meta-analysis were performed to compare infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) and complete revascularization (CR) guided by angiography or fractional flow reserve (FFR) in multivessel disease (MVD) and acute ST-elevation myocardial infarction (STEMI). Eleven randomized controlled trials were identified, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the incidence of the composite endpoint of all-cause death and new myocardial infarction without significant difference in angio-guided and FFR-guided CR. The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of the composite endpoint and, therefore the role of FFR-guidance in this setting is questionable.
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Affiliation(s)
- Federico Archilletti
- Institute of Cardiology, "G. d'Annunzio" University, 66100 Chieti, Italy; William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy; Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden; Casa di Cura Villa Serena, 65013 Città San'Angelo, Pescara, Italy
| | | | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Livio Giuliani
- Cath Lab, Ospedale SS. Annunziata, ASL 2 Abruzzo, 66100 Chieti, Italy
| | - Francesco Radico
- Institute of Cardiology, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Matteo Perfetti
- Cath Lab, Ospedale SS. Annunziata, ASL 2 Abruzzo, 66100 Chieti, Italy
| | - Serena Rossi
- Cath Lab, Ospedale SS. Annunziata, ASL 2 Abruzzo, 66100 Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100 Chieti, Italy
| | - Nicola Maddestra
- Cath Lab, Ospedale SS. Annunziata, ASL 2 Abruzzo, 66100 Chieti, Italy
| | - Mohammed Y Khanji
- Newham University Hospital, Barts Health NHS Trust, Glen Road, London E3 8SL, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK; William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Marco Zimarino
- Institute of Cardiology, "G. d'Annunzio" University, 66100 Chieti, Italy; Cath Lab, Ospedale SS. Annunziata, ASL 2 Abruzzo, 66100 Chieti, Italy
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Hwang D, Park J, Yang HM, Yang S, Kang J, Han JK, Park KW, Kang HJ, Koo BK, Kim HS. Angiographic complete revascularization versus incomplete revascularization in patients with diabetes mellitus. Cardiovasc Diabetol 2022; 21:56. [PMID: 35439958 PMCID: PMC9019985 DOI: 10.1186/s12933-022-01488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Considering the nature of diabetes mellitus (DM) in coronary artery disease, it is unclear whether complete revascularization is beneficial or not in patients with DM. We investigated the clinical impact of angiographic complete revascularization in patients with DM. Methods A total of 5516 consecutive patients (2003 patients with DM) who underwent coronary stenting with 2nd generation drug-eluting stent were analyzed. Angiographic complete revascularization was defined as a residual SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score of 0. The patient-oriented composite outcome (POCO, including all-cause death, any myocardial infarction, and any revascularization) and target lesion failure (TLF) at three years were analyzed. Results Complete revascularization was associated with a reduced risk of POCO in DM population [adjusted hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.52–0.93, p = 0.016], but not in non-DM population (adjusted HR 0.90, 95% CI 0.69–1.17, p = 0.423). The risk of TLF was comparable between the complete and incomplete revascularization groups in both DM (adjusted HR 0.75, 95% CI 0.49–1.16, p = 0.195) and non-DM populations (adjusted HR 1.11, 95% CI 0.75–1.63, p = 0.611). The independent predictors of POCO were incomplete revascularization, multivessel disease, left main disease and low ejection fraction in the DM population, and old age, peripheral vessel disease, and low ejection fraction in the non-DM population. Conclusions The clinical benefit of angiographic complete revascularization is more prominent in patients with DM than those without DM after three years of follow-up. Relieving residual disease might be more critical in the DM population than the non-DM population. Trial registration The Grand Drug-Eluting Stent registry NCT03507205. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01488-7.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea.
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Zientara A, Mirsadraee S, Quarto C. Routine postoperative coronary computed tomography after coronary artery bypass grafting: the new standard of care? Eur J Cardiothorac Surg 2021; 61:467-468. [PMID: 34694359 DOI: 10.1093/ejcts/ezab446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alicja Zientara
- Department of Cardiac Surgery, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Saeed Mirsadraee
- Department of Radiology, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Cesare Quarto
- Department of Cardiac Surgery, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
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22
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Mahmoudi M, Curzen N. Treatment of non-culprit lesions in STEMI: An incomplete journey. Cardiovasc Revasc Med 2021; 39:114-116. [PMID: 34531150 DOI: 10.1016/j.carrev.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/05/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
Approximately 50% of patients presenting with an acute ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). A number of randomized studies (Table 1) have all shown that complete revascularization (CR), either at the time of primary percutaneous coronary revascularization (PPCI) or within 45 days of the index admission, is safe and reduces the risk of repeat coronary revascularization and myocardial infarction (MI), particularly in the non-infarct related artery (NIRA). Despite consistently showing clinical benefit for CR, the results from the trials show variations in what drives this effect. Specifically, no study to date has provided a mechanistic insight as to how complete revascularization of chronic bystander disease may lead to the observed clinical benefit. Indeed, the randomized studies, through the variable nature of their results (reduction in MI versus revascularization etc.), have suggested the possibility that there are differing mechanisms for the observed benefit. In this review, we summarize the evidence base, highlight the limitations, and make the case that we need to understand the mechanism(s) underpinning the advantage of revascularization of NIRA in order to establish which patients are most likely to benefit. Without this insight, the current "one size fits all" approach may lead us in the wrong direction.
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Affiliation(s)
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, UK
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23
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Sivapathan S, Jeyaprakash P, Zaman SJ, Burgess SN. Management of Multivessel Disease and Physiology Testing in ST Elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:333-343. [PMID: 34053620 DOI: 10.1016/j.iccl.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
For decades, advances in ST elevation myocardial infarction (STEMI) care have been driven by timely reperfusion of the occluded culprit vessel. More recently, however, the focus has shifted to revascularization of nonculprit vessels in STEMI patients. Five landmark randomized trials, all published in the past 7 years, have highlighted the importance of complete revascularization in STEMI treatment. This review focuses on evidence-based management of STEMI in the setting of multivessel disease, highlighting contemporary data that investigate the impact of complete revascularization.
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Affiliation(s)
- Shanthosh Sivapathan
- Department of Cardiology, University of Sydney and Nepean Hospital, Derby Street, Kingswood, New South Wales 2747, Australia. https://twitter.com/drsonyaburgess
| | - Prajith Jeyaprakash
- Department of Cardiology, University of Sydney and Nepean Hospital, Derby Street, Kingswood, New South Wales 2747, Australia
| | - Sarah J Zaman
- Department of Cardiology, University of Sydney, Monash University and Westmead Hospital, Corner of Darcy Road, Westmead 2145, Australia
| | - Sonya N Burgess
- University of New South Wales, University of Sydney, and Department of Cardiology, Nepean Hospital, Derby Street, Sydney, New South Wales 2747, Australia.
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24
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Pavasini R, Biscaglia S, Barbato E, Tebaldi M, Dudek D, Escaned J, Casella G, Santarelli A, Guiducci V, Gutierrez-Ibanes E, Di Pasquale G, Politi L, Saglietto A, D'Ascenzo F, Campo G. Complete revascularization reduces cardiovascular death in patients with ST-segment elevation myocardial infarction and multivessel disease: systematic review and meta-analysis of randomized clinical trials. Eur Heart J 2021; 41:4103-4110. [PMID: 31891653 DOI: 10.1093/eurheartj/ehz896] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/18/2019] [Accepted: 11/29/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS The aim of this work was to investigate the prognostic impact of revascularization of non-culprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease by performing a meta-analysis of available randomized clinical trials (RCTs). METHODS AND RESULTS Data from six RCTs comparing complete vs. culprit-only revascularization in STEMI patients with multivessel disease were analysed with random effect generic inverse variance method meta-analysis. The endpoints were expressed as hazard ratio (HR) with 95% confidence interval (CI). The primary outcome was cardiovascular death. Main secondary outcomes of interest were all-cause death, myocardial infarction (MI), and repeated coronary revascularization. Overall, 6528 patients were included (3139 complete group, 3389 culprit-only group). After a follow-up ranging between 1 and 3 years (median 2 years), cardiovascular death was significantly reduced in the group receiving complete revascularization (HR 0.62, 95% CI 0.39-0.97, I2 = 29%). The number needed to treat to prevent one cardiovascular death was 70 (95% CI 36-150). The secondary endpoints MI and revascularization were also significantly reduced (HR 0.68, 95% CI 0.55-0.84, I2 = 0% and HR 0.29, 95% CI 0.22-0.38, I2 = 36%, respectively). Needed to treats were 45 (95% CI 37-55) for MI and 8 (95% CI 5-13) for revascularization. All-cause death (HR 0.81, 95% CI 0.56-1.16, I2 = 27%) was not affected by the revascularization strategy. CONCLUSION In a selected study population of STEMI patients with multivessel disease, a complete revascularization strategy is associated with a reduction in cardiovascular death. This reduction is concomitant with that of MI and the need of repeated revascularization.
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Affiliation(s)
- Rita Pavasini
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, Ferrara 44124, Italy
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, Ferrara 44124, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Via Pansini, Naples 80131, Italy
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, Ferrara 44124, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, ul. Sw Anny 12, Krakow 31-008, Poland.,Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, Cotignola 48033, Italy
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martin Lagos s/n, Madrid 28040, Spain
| | - Gianni Casella
- U.O.C. Cardiologia, Ospedale Maggiore, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Andrea Santarelli
- Cardiovascular Department, Infermi Hospital, Viale Luigi Settembrini 2, Rimini 47923, Italy
| | - Vincenzo Guiducci
- Interventional Cardiology Unit, S. Maria Nuova Hospital, Viale Risorgimento 80, Reggio Emilia 42123, Italy
| | - Enrique Gutierrez-Ibanes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Calle del Dr Esquerdo 46, Madrid 28007, Spain.,Universidad Carlos III, Calle Madrid 126 Madrid 28903 Spain
| | | | - Luigi Politi
- Cardiologia Interventistica, ASST Rhodense, Corso Europa 250, Rho 20024, Italy
| | - Andrea Saglietto
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, Turin 10126, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, Turin 10126, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, Ferrara 44124, Italy.,Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, Cotignola 48033, Italy
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25
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Tiemuerniyazi X, Yan H, Song Y, Nan Y, Xu F, Feng W. Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2021; 32:188-195. [PMID: 33221913 PMCID: PMC8906773 DOI: 10.1093/icvts/ivaa252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/23/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events. METHODS A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes. RESULTS The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013). CONCLUSIONS When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.
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Affiliation(s)
- Xieraili Tiemuerniyazi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Yan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangwu Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yifeng Nan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Xu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Feng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Corresponding author. Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, 100037 Beijing, China. Tel: +86-10-88396771; fax: +86-10-88322355; e-mail: (W. Feng)
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26
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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27
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Bajraktari G, Bytyçi I, Henein MY, Alfonso F, Ahmed A, Jashari H, Bhatt DL. Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial infarction after the COMPLETE trial: A meta-analysis of randomized controlled trials. Int J Cardiol Heart Vasc 2020; 29:100549. [PMID: 32577495 PMCID: PMC7301199 DOI: 10.1016/j.ijcha.2020.100549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesions had a reduced risk of major adverse cardiac events (MACE), but not of cardiovascular or total mortality. The aim of this meta-analysis was to assess the efficacy of complete revascularization on cardiovascular or total mortality reduction using available randomized controlled trials (RCTs) including the COMPLETE trial, in hemodynamically stable STEMI patients with MVD. METHODS PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n = 3420) vs. only culprit lesion (n = 3613) PCI for a median 27.7 months follow-up. Random effect risk ratios were used to estimate for efficacy and safety outcomes. RESULTS Complete revascularization reduced the risk of MACE (10.4% vs.16.6%; RR = 0.59, 95% CI: 0.47 to 0.74, p < 0.0001), CV mortality (2.87% vs. 3.72%; RR = 0.73, 95% CI: 0.56 to 0.95, p = 0.02), reinfarction (5.1% vs. 7.1%; RR = 0.67, 95% CI: 0.52 to 0.86, p = 0.002), urgent revascularization (7.92% vs.17.4%; RR = 0.47, 95% CI: 0.30 to 0.73, p < 0.001), and CV hospitalization (8.68% vs.11.4%; RR = 0.65, 95% CI: 0.44to 0.96, p = 0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy. CONCLUSION The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
- University of Prishtina, Prishtina, Kosovo
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, Madrid, Spain
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC, USA
| | - Haki Jashari
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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Salih M, Ibrahim AM, Al-Akchar M, Bhattarai M, Koester C, Ayan M, Hafiz AM. Complete Versus Culprit-Only Revascularization in Patients Presenting With ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Randomized Control Trials. Cardiovasc Revasc Med 2020; 21:1482-8. [PMID: 32571757 DOI: 10.1016/j.carrev.2020.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred treatment option. For patients with multivessel disease, the benefit of revascularization of the non-culprit artery is not well known. This meta-analysis aims to assess the efficacy and safety of complete versus culprit vessel only revascularization. METHODS Randomized control trials (RCT) that compared head-to-head complete versus culprit-vessel only revascularization in STEMI patients and reported main outcomes of interest such as mortality, myocardial infarction, and revascularization, were included in this meta-analysis. RESULTS We found ten RCTs satisfying our inclusion criteria. Data was extracted and used to estimate the risk ratio (RR) and 95% confidence interval (CI) for dichotomous variables. Our study included 7030 patients (3426 complete revascularization, and 3604 culprit-only revascularization). Complete revascularization (CR) (both immediate and staged) significantly reduced the risk of MACE compared with culprit only (CO) revascularization (10.7% vs 20.1%, RR 0.53; 95% CI 0.43 to 0.64; P < 0.0001), reinfarction (5.0% vs 6.9%, RR 0.69; 95 CI 0.51 to 0.93; P < 0.01), and revascularization (4.2% vs 12.7%, RR 0.37; 95 CI 0.26 to 0.54; P < 0.0001). Our analysis did not find any significant difference in all-cause mortality between CR and CO (4.6% vs 5.0%, RR 0.89; 95 CI 0.72 to 0.1.10; P = 0.27). CONCLUSION In conclusion, complete revascularization was associated with a significant reduction in major adverse cardiovascular events, revascularization and reinfarction.
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Tuttle MK, Pinto DS. Culprit-Only or Complete Revascularization for ST-Elevation Myocardial Infarction in Patients with and Without Shock. Interv Cardiol Clin 2019; 8:225-34. [PMID: 30832944 DOI: 10.1016/j.iccl.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
ST-elevation myocardial infarction (STEMI) patients with multivessel disease and without shock are a common clinical entity, but the best approach to nonculprit vessel lesions remains controversial. In contrast, STEMI patients with shock do not appear to benefit from primary multivessel percutaneous coronary interventions (PCIs) during the index procedure. The optimal treatment strategy in a given STEMI patient involves an individualized approach, incorporating clinical, hemodynamic, and angiographic/imaging parameters. Patients with STEMI and cardiogenic shock may benefit from therapies other than PCI, such as mechanical cardiovascular support.
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Endo H, Dohi T, Miyauchi K, Takahashi D, Funamizu T, Shitara J, Wada H, Doi S, Kato Y, Okai I, Iwata H, Okazaki S, Isoda K, Daida H. Clinical impact of complex percutaneous coronary intervention in patients with coronary artery disease. Cardiovasc Interv Ther 2020; 35:234-41. [PMID: 31350706 DOI: 10.1007/s12928-019-00608-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Abstract
For the revascularization of patients with clinical and anatomical complexities, several technical skills are often required. However, the prognostic effect of complex percutaneous coronary intervention (C-PCI) on the clinical outcomes is not well known. The aim of this study was to investigate the relationship between the C-PCI and mid-term clinical outcomes. We assessed 1062 patients who underwent PCI with newer-generation drug-eluting stent and stratified the patients according to whether they had complex PCI (C-PCI, n = 358) or non-complex PCI (non-C-PCI, n = 704). C-PCI was defined as a procedure with at least 1 of the following features: 3 vessels treated, ≥ 3 stents per vessel implanted, ≥ 3 lesions treated, use of a 2-stent technique, the total stent length per vessel > 60 mm, chronic total occlusion, unprotected left main coronary artery stenting, and rotational atherectomy use. All-cause death and major adverse cardiac and cerebrovascular events (MACCE; cardiovascular death, non-fatal myocardial infarction, and non-fatal ischemic stroke) were evaluated. The median follow-up period was 1.9 (0.8-3.0) years. The baseline SYNTAX score was significantly higher in the C-PCI group than in the non-C-PCI group [20 (14-27) vs. 10 (6-17), p < 0.001]. Kaplan-Meier analysis showed that the cumulative incidences of all-cause death (log-rank p = 0.12) and MACCE (log-rank p = 0.64) did not differ between the two groups. On multivariable Cox analysis, C-PCI did not adversely affect the clinical outcomes. Despite a high rate of anatomically complex coronary lesions, the patients who underwent C-PCI had comparable "hard" clinical outcomes with those of non-C-PCI.
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Xu H, Zhang X, Li J, Liu H, Hu X, Yang J. Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a meta-analysis of randomized trials. BMC Cardiovasc Disord 2019; 19:91. [PMID: 31010423 PMCID: PMC6477715 DOI: 10.1186/s12872-019-1073-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022] Open
Abstract
Background The best strategy for the treatment of the non-infarct artery in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) is not yet defined. Methods We searched the literature for randomized controlled trials (RCTs) that compared complete revascularization (CR) with infarct-related coronary artery (IRA) only revascularization in hemodynamically stable patients with STEMI. Random effect risk ratios (RRs) were calculated for clinical outcomes. Results Nine RCTs with 2989 patients were included. No significant difference in all-cause mortality emerged between CR and IRA-only groups (relative risk [RR] = 0.74; 95% confidence interval [CI]: 0.52 to 1.04; p = 0.08). Compared with IRA-only, CR was associated with significantly lower rates of major adverse cardiac events (MACE) (RR = 0.53; 95% CI: 0.41 to 0.68; p < 0.001), cardiac death (RR = 0.48; 95% CI: 0.29 to 0.79; p = 0.004) and repeat revascularization (RR = 0.38; 95% CI: 0.30 to 0.47; p < 0.001). In subgroups analysis, immediate complete revascularization (ICR) reduced the risk of all-cause mortality (RR = 0.62; 95% CI: 0.39 to 0.97; p = 0.04), whereas staged complete revascularization (SCR) did not show any significant benefit in all-cause mortality (RR = 0.92; 95% CI: 0.46 to 1.86; p = 0.82). Stroke, contrast-induced nephropathy and major bleeding were not different between CR and IRA-only. Conclusions For patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization did not decrease the risk of all-cause mortality in current evidence from randomized trials. When feasible, immediate complete revascularization might be considered in patients with STEMI and multivessel disease. Electronic supplementary material The online version of this article (10.1186/s12872-019-1073-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haiyan Xu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Xiwen Zhang
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Jiangjin Li
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Hailang Liu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Xiao Hu
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China
| | - Jing Yang
- Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China.
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Hirai T, Kitahara H, Balkhy HH, Blair JEA. Advanced Hybrid Complete Revascularization with TECAB and Impella-Assisted PCI of CTO. Cardiovasc Revasc Med 2019; 20:51-54. [PMID: 30930011 DOI: 10.1016/j.carrev.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/14/2019] [Accepted: 03/14/2019] [Indexed: 11/25/2022]
Abstract
An 80-year-old man was referred for multi-vessel coronary artery disease with baseline SYNTAX score of 45 after evaluation for persistent stable angina. He underwent complete hybrid revascularization combining total endoscopic coronary artery bypass utilizing bilateral internal mammary arteries (IMA) with sequential LIMA to left anterior descending artery and diagonal arteries, and RIMA to obtuse marginal after Impella-assisted chronic total occlusion percutaneous coronary intervention of the right coronary artery. This represents a successful case of advanced hybrid coronary revascularization.
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Affiliation(s)
- Taishi Hirai
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL, United States of America
| | - Hiroto Kitahara
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, United States of America
| | - Husam H Balkhy
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, United States of America
| | - John E A Blair
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL, United States of America.
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Wang LJ, Han S, Zhang XH, Jin YZ. Fractional flow reserve-guided complete revascularization versus culprit-only revascularization in acute ST-segment elevation myocardial infarction and multi-vessel disease patients: a meta-analysis and systematic review. BMC Cardiovasc Disord 2019; 19:49. [PMID: 30823897 PMCID: PMC6397458 DOI: 10.1186/s12872-019-1022-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 30–50% patients with acute ST-segment elevation myocardial infarction (STMEI) were found to have non-infarct-related coronary artery (IRA) disease, which was significantly associated with worse prognosis. However, challenges still remain for these patients: which non-infarct-related lesion should be treated and when should the procedure be performed? The present study aims to investigate Fractional flow reserve (FFR)-guided complete revascularization (CR) in comparison to culprit-only revascularization (COR) in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD). Methods Three appropriate randomized controlled trials (RCTs) were selected from the PubMed/Medline, EMBASE, and the Cochrane library /CENTRAL databases. 1631 patients (688 patients underwent FFR-guided CR and 943 patients underwent COR) following-up 12–44 months was evaluated. Results FFR-guided CR significantly reduced major adverse cardiac event (MACE) (OR 0.47, 95% CI: 0.35–0.62, P < 0.00001) and ischemia-driven repeat revascularization (OR 0.36, 0.26–0.51, P < 0.00001), as compared to COR. However, there is no difference in all-cause mortality (OR 1.24, 0.65–2.35, P = 0.51). Conclusions In patients with STEMI and MVD, FFR-guided CR is better than COR in terms of MACE and ischemia-driven repeat revascularization, while there are almost similar in all-cause mortality. Trial registration All analyses were based on previous published studies, thus no ethical approval and patient consent are required COMPARE-ACUTE trial number NCT01399736; DANAMI-3–PRIMULTI trial number NCT01960933. Electronic supplementary material The online version of this article (10.1186/s12872-019-1022-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Li-Jie Wang
- Department of Cardiology, the fourth Affiliated Hospital of China Medical University, Shenyang, 110032, Liaoning, China
| | - Shuo Han
- Department of Cardiology, the fourth Affiliated Hospital of China Medical University, Shenyang, 110032, Liaoning, China
| | - Xiao-Hong Zhang
- Department of Cardiology, the fourth Affiliated Hospital of China Medical University, Shenyang, 110032, Liaoning, China
| | - Yuan-Zhe Jin
- Department of Cardiology, the fourth Affiliated Hospital of China Medical University, Shenyang, 110032, Liaoning, China.
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Lee Y, Ohno T, Uemura Y, Osanai A, Miura S, Taketani T, Fukuda S, Ono M, Takamoto S. Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction. Circ J 2018; 83:122-129. [PMID: 30369591 DOI: 10.1253/circj.cj-18-0653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear. Methods and Results: We evaluated a consecutive series of 111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG: 63 underwent CR and 48 underwent incomplete revascularization (IR). At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and major adverse cardiac and cerebrovascular events (MACCE) were significantly greater in the IR group. After adjusting for propensity score, no significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75-2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68-3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08-3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34-11.44; P=0.013). CONCLUSIONS Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.
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Affiliation(s)
- Yangsin Lee
- Department of Cardiac Surgery, The University of Tokyo Hospital.,Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukari Uemura
- Biostatistics Division, Clinical Research Support Center, The University of Tokyo Hospital
| | - Akira Osanai
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Sumio Miura
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | | | - Sachito Fukuda
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital
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Hsieh MJ, Chen CC, Lee CH, Wang CY, Chang SH, Chen DY, Yang CH, Tsai ML, Yeh JK, Ho MY, Hsieh IC. Complete and in complete revascularization in non-ST segment myocardial infarction with multivessel disease: long-term outcomes of first- and second-generation drug-eluting stents. Heart Vessels 2018; 34:251-258. [PMID: 30159655 DOI: 10.1007/s00380-018-1252-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/24/2018] [Indexed: 12/17/2022]
Abstract
The therapeutic effects of reperfusion strategies with complete revascularization (CR) or incomplete revascularization (IR) in non-ST segment myocardial infarction (NSTEMI) patients with multivessel disease (MVD) are controversial. In such patients, whether utilization of different generations of drug-eluting stents (DES) for IR or CR affect long-term major adverse cardiovascular events (MACE) is unknown. This study included 702 NSTEMI patients with MVD who received first-generation (1G) or second-generation (2G) DES. In multivariable analysis, chronic kidney disease, chronic total, 1G DES and IR were independent predictors of long-term MACE. In patients receiving 1G DES, no significant differences of MACE were observed between the IR and CR groups (39.1% vs. 36.2%, p = 0.854). However, in patients receiving 2G DES, significantly fewer MACE were observed in the CR group than in the IR group (3.7% vs. 10.2%, p = 0.002). Compared with patients receiving 1G DES for IR, those receiving 2G DES for IR and CR exhibited significantly lower risk of MACE (59% and 83% lower, respectively). CR could not provide clinical benefits over IR in NSTEMI patients with MVD receiving 1G DES. However, in patients receiving 2G DES, compared with IR, CR was associated with a lower risk of long-term MACE, which was mainly caused by low rates of non-TLR and any revascularization.
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Affiliation(s)
- Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Cheng-Hung Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chao-Yung Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chia-Hung Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Ming-Lung Tsai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Jih-Kai Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Ming-Yun Ho
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan.
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Auchoybur ML, Chen X. Complete revascularization reduces adverse outcomes in patients with multivessel coronary artery disease. World J Meta-Anal 2017; 5:167-176. [DOI: 10.13105/wjma.v5.i6.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/13/2017] [Accepted: 10/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the influence of complete and incomplete revascularization (ICR) in patients with multivessel coronary artery disease undergoing coronary artery bypass or percutaneous coronary intervention.
METHODS We searched PubMed using the keywords “complete revascularization”, “incomplete revascularization”, “coronary artery bypass”, and “percutaneous coronary intervention”. We selected randomized controlled studies (RCT) and observational studies only for review. The main outcomes of interest were mortality, myocardial infarction (MI) and repeat revascularization. We identified further studies by hand searching relevant publications and included those that met with the inclusion criteria in our final analysis and performed a systematic review.
RESULTS Ten studies were identified, including 13327 patients of whom, 8053 received complete revascularization and 5274 received ICR. Relative to ICR, CR was associated with lower mortality (RR: 0.755, 95%CI: 0.66 to 0.864, P = 0.765, I2 = 0.0%), lower rates of MI (RR: 0.759, 95%CI: 0.615 to 0.937, P = 0.091, I2 = 45.1%), lower rates of MACCE (RR: 0.731, 95%CI: 0.668 to 0.8, P = 0.453, I2 = 0.0%) and reduced rates of repeat coronary revascularization (RR: 0.691, 95%CI: 0.541 to 0.883, P = 0.0, I2 = 88.3%).
CONCLUSION CR is associated with lower rates of adverse outcomes. CR can be used as a standard in the choice of any particular revascularization strategy.
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Affiliation(s)
- Merveesh L Auchoybur
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
| | - Xin Chen
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Vaidya SR, Devarapally SR, Arora S. Infarct related artery only versus complete revascularization in ST-segment elevation myocardial infarction and multi vessel disease: a meta-analysis. Cardiovasc Diagn Ther 2017; 7:16-26. [PMID: 28164009 DOI: 10.21037/cdt.2016.08.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The 2015 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) focused update on primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) only gives a class II b (weak) indication for non-infarct artery intervention at the time of primary PCI. Recent randomized controlled trials, however, suggest strong evidence supporting complete revascularization. METHODS A systematic search was conducted in PUBMED, MEDLINE, EMBASE and Cochrane central register for randomized controlled trials comparing complete versus infarct artery (IRA) only revascularization in patients with STEMI. A meta-analysis was performed using the data extracted from each study. Summary risk ratios (RR) and 95% confidence intervals (CI) were calculated for five outcomes. RESULTS Six trials fulfilled the inclusion criteria yielding 1,792 patients. Follow up ranged from 6 months to 2.5 years. The incidence of major adverse cardiac events (MACE) was significantly lower in the complete revascularization group compared to the IRA only revascularization (13.8% vs. 25.1%, RR =0.51; 95% CI: 0.41-0.64, P<0.00001). It was attributed to significantly lower repeat revascularization rate in the complete revascularization group (8.2% vs. 18.9%, RR =0.41; 95% CI: 0.31-0.54, P<0.00001). This meta-analysis also showed a significant reduction in cardiovascular mortality (2.0% vs. 4.6%, RR =0.42; 95% CI: 0.24-0.74; P=0.003), non-fatal myocardial infarction (4.37% vs. 5.76%, RR =0.64; 95% CI: 0.34-1.20; P=0.16) and all-cause mortality rates [(4.6% vs. 6%), RR =0.75; 95% CI: 0.49-1.14, P=0.17] in the complete revascularization group, compared to the IRA revascularization group. CONCLUSIONS In patients who present with STEMI, complete revascularization is associated with lower rates of MACE and cardiovascular deaths as compared to revascularization of the IRA alone. Even though the outcomes of all-cause mortality and nonfatal re-infarction rates were lower in the complete revascularization group, they were not significant.
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Affiliation(s)
| | - Santhosh R Devarapally
- Division of Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC, USA;; Division of Cardiology, New York Methodist Hospital, Weill Cornell Medical College, NY, USA
| | - Sameer Arora
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, USA;; Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA
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Mashayekhi K, Büttner HJ. [Chronic coronary occlusions : When and how should revascularization be performed?]. Herz 2016; 41:585-90. [PMID: 27484494 DOI: 10.1007/s00059-016-4464-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic occlusion of coronary arteries also known as chronic total occlusions (CTO) are found in approximately 20 % of patients undergoing percutaneous coronary interventions (PCI) and in approximately 50 % of patients after coronary artery bypass grafts (CABG). As a result of technical advancements in retrograde recanalization techniques specialized centers can now achieve success rates of over 85 %, regardless of the CTO anatomy. Given the complexity of retrograde CTO techniques, a consensus paper issued by the Euro CTO Club requires interventional cardiologists to have sufficient experience in antegrade approaches (>300 antegrade CTO cases and >50 per year) with an additional training program (25 retrograde cases each as first and second operating surgeon) before becoming a qualified independent retrograde surgeon. The increased investment in time and technical resources can only be justified if the patient has a clear clinical benefit. This technical advancement and the progressively clearer evidence that complete revascularization can be achieved in patients with multivessel coronary artery disease have attracted growing interest in recent years from interventional cardiologists in the recanalization of CTO.
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Spadaccio C, Nappi F, Nenna A, Beattie G, Chello M, Sutherland FWH. Is it time to change how we think about incomplete coronary revascularization? Int J Cardiol 2016; 224:295-298. [PMID: 27665400 DOI: 10.1016/j.ijcard.2016.09.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/04/2016] [Accepted: 09/15/2016] [Indexed: 01/17/2023]
Abstract
The optimal degree of revascularization for patients with chronic multivessel coronary artery disease remains an unsolved issue. Intuitively, complete revascularization decreases cardiovascular events and improves outcomes compared to incomplete procedures, but in recent years the concept of incomplete revascularization moved from a sub-optimal or a defective treatment towards the most appropriate revascularization technique in some categories of patients. A reasonable level of incomplete anatomic revascularization has been shown to be safe and achievable with both percutaneous (PCI) and surgical procedures (CABG), despite with different long-term outcomes. What are the mechanisms underlying the clinical benefits of an incomplete revascularization and what are the factors explaining the discrepancy in the long-term clinical outcomes between the two modes of revascularization PCI and CABG? The biological consequences of coronary reperfusion might provide valuable hints in this context and at the same time cast new light on the way we think about incomplete revascularization.
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Affiliation(s)
- Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK.
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Gwyn Beattie
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Fraser W H Sutherland
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, UK
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Di Pasquale G, Filippini E, Pavesi PC, Tortorici G, Casella G, Sangiorgio P. Complete versus culprit-only revascularization in ST-elevation myocardial infarction and multivessel disease. Intern Emerg Med 2016; 11:499-506. [PMID: 26951188 DOI: 10.1007/s11739-016-1419-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/18/2016] [Indexed: 02/04/2023]
Abstract
In 30-60 % of patients presenting with ST-segment elevation myocardial infarction (STEMI), significant stenoses are present in one or more non-infarct-related arteries (IRA). This correlates with an increased risk of major adverse cardiac events (MACE). Current guidelines, do not recommend revascularization of non-culprit lesions unless complicated by cardiogenic shock or persistent ischemia after primary percutaneous coronary intervention (PCI). Prior observational and small randomized controlled trials (RCTs) have demonstrated conflicting results regarding the optimal revascularization strategy in STEMI patients with multivessel disease. Recently, randomized studies (PRAMI, CvLPRIT, and DANAMI 3-PRIMULTI) provide encouraging data that suggest potential benefit with complete revascularization in STEMI patients with obstructive non-culprit lesions. Differently, in the PRAGUE-13 trial there were no differences in MACE between complete revascularization and culprit-only PCI. Several meta-analyses were recently published including randomized and non-randomized clinical trials, showing different results depending on the included trials. In conclusion, the current available evidence from the randomized clinical trials, with a total sample size of only 2000 patients, is not robust enough to firmly recommend complete revascularization in STEMI patients. This uncertainty lends support to the continuation of the COMPLETE trial. This ongoing trial is anticipated to enroll 3900 patients with STEMI from across the world, and will be powered for the hard outcomes of death and myocardial infarction. Until the results of the COMPLETE trial are reported, physicians need to individualize care regarding the opportunity and the timing of the non-IRA PCI.
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Affiliation(s)
- Giuseppe Di Pasquale
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy.
| | - Elisa Filippini
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pier Camillo Pavesi
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianfranco Tortorici
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Gianni Casella
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Pietro Sangiorgio
- Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
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Sardar P, Chatterjee S, Giri J, Alfonso F, Helmy T, Ledley GS, Magalhaes MA, Mukherjee D, Waksman R. Intervention strategies for multi-vessel disease in patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Int J Cardiol 2015; 179:225-7. [PMID: 25464453 DOI: 10.1016/j.ijcard.2014.11.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/05/2014] [Indexed: 11/24/2022]
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Papakonstantinou NA, Baikoussis NG, Apostolakis E. Coronary endarterectomy: new flavors from old recipes. J Cardiol 2014; 63:397-401. [PMID: 24674746 DOI: 10.1016/j.jjcc.2014.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/30/2014] [Accepted: 02/03/2014] [Indexed: 11/22/2022]
Abstract
Coronary endarterectomy is an old surgical procedure against coronary artery disease first described by Baily et al. in 1957. Despite its first adverse results, several current publications have shown that coronary endarterectomy with on-pump or off-pump coronary artery bypass grafting can be safely performed with acceptable mortality, morbidity, and angiographic patency rates. Coronary endarterectomy can assure complete revascularization supplying the myocardium with satisfactory blood flow in cases of a diffusely diseased left anterior descending artery or diffuse calcification, thus preventing residual ischemia. Hence, it is important to evaluate current results, rethink this old recipe, and redefine its indications.
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