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da Silveira Maia A, Dos Santos MA. 2023 ACC/AHA Chronic Coronary Disease Guideline - An opportunity to reestablish coronary artery bypass recommendations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00172-6. [PMID: 38631937 DOI: 10.1016/j.carrev.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/19/2024]
Abstract
Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.
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Belyayev L, Stock EM, Hattler B, Bakaeen FG, Kinlay S, Quin JA, Haime M, Biswas K, Zenati MA. Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial. Am J Cardiol 2024; 217:127-135. [PMID: 38266796 DOI: 10.1016/j.amjcard.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.
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Affiliation(s)
- Leonid Belyayev
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Eileen M Stock
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Division of Cardiology, Eastern Colorado Veterans Affairs Healthcare System and University of Colorado, Aurora, Colorado
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott Kinlay
- Divisions of Cardiology, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Jacqueline A Quin
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Miguel Haime
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Marco A Zenati
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
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Ogunsakin A, Abbott JD. REGROUPing on the Importance of Complete Revascularization in Patients Referred for Coronary Artery Bypass Grafting. Am J Cardiol 2024; 217:156-157. [PMID: 38401655 DOI: 10.1016/j.amjcard.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/12/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Adebola Ogunsakin
- Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Lifespan Cardiovascular Institute, Providence, Rhode Island.
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Ali ZA, Garcia JJ, Karimi Galougahi K, Horst J, Gallo A, Shin D, Ben-Yehuda O, Chen S, Redfors B, Kappetein AP, Sabik JF, Serruys PW, Stone GW. Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial. Circ Cardiovasc Interv 2024; 17:e013192. [PMID: 38502720 DOI: 10.1161/circinterventions.123.013192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 01/02/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). METHODS Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS). RESULTS The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; P=0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; P=0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; P=0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; P<0.001). The risk was the highest for residual ostial/proximal LCX lesions. CONCLUSIONS Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.
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Affiliation(s)
- Ziad A Ali
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
- St Francis Hospital and Heart Center, Roslyn, NY (Z.A.A., K.K.G., D.S.)
| | - Javier Jas Garcia
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | | | - Jennifer Horst
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Anthony Gallo
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Doosup Shin
- St Francis Hospital and Heart Center, Roslyn, NY (Z.A.A., K.K.G., D.S.)
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Shmuel Chen
- Weill-Cornell Medical Center/New York-Presbyterian Hospital, NY (S.C.)
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | | | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
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Cilia L, Megaly M, Davies R, Tehrani BN, Batchelor WB, Truesdell AG. A non-interventional cardiologist's guide to coronary chronic total occlusions. Front Cardiovasc Med 2024; 11:1350549. [PMID: 38380179 PMCID: PMC10876789 DOI: 10.3389/fcvm.2024.1350549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications, and post-procedure management and follow-up unique to patients undergoing this highly specialized intervention. Distinct from other existing topical reviews, the current manuscript focuses on key knowledge relevant to non-interventional cardiologists.
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Affiliation(s)
- Lindsey Cilia
- Virginia Heart, Falls Church, VA, United States
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Michael Megaly
- Willis Knighton Medical Center, Shreveport, LA, United States
| | | | - Behnam N. Tehrani
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Virginia Heart, Falls Church, VA, United States
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
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Stone GW, Ali ZA, Hochman JS, Maron DJ. REPLY: Interpreting the Impact of Complete Revascularization in the ISCHEMIA Trial. J Am Coll Cardiol 2024; 83:e39-e40. [PMID: 38267120 DOI: 10.1016/j.jacc.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Ziad A Ali
- St Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | | | - David J Maron
- Stanford School of Medicine, Stanford, California, USA
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Guyton RA, Halkos ME. Benefit of Complete Anatomic Revascularization in ISCHEMIA: Reprise of a Familiar Theme. J Am Coll Cardiol 2024; 83:e37. [PMID: 38267119 DOI: 10.1016/j.jacc.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Robert A Guyton
- Carlyle Fraser Heart Center and the Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Michael E Halkos
- Carlyle Fraser Heart Center and the Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Dimitriadis K, Pyrpyris N, Tsioufis K. Functional vs Anatomical Complete Revascularization: Is There an "ISCHEMIA" of FFR? J Am Coll Cardiol 2024; 83:e35. [PMID: 38267118 DOI: 10.1016/j.jacc.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/13/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Dayan V, Sadaba R, Myers P, Sabik J, Bakeen F. And Yet it Moves: E Pur Si Muove. J Am Coll Cardiol 2024; 83:e33. [PMID: 38267117 DOI: 10.1016/j.jacc.2023.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Victor Dayan
- Centro Cardiovascular Universitario, Facultad de Medicina, Universidad de la Republica, Montevideo, Uruguay.
| | - Rafael Sadaba
- Hospital Universitario de Navarra, Universidad Pública de Navarra, Pamplona, Spain
| | - Patrick Myers
- Division of Cardiac Surgery, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Joe Sabik
- University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Faisal Bakeen
- Department of Thoracic and Cardiovascular Surgery, Center for Coronary Revascularization, Cleveland Clinic, Cleveland, Ohio, USA
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Kaul S, Mancini GBJ, Weintraub WS, De Caterina R. Drawing Conclusions From Exploratory Analyses: A Slippery Slope. J Am Coll Cardiol 2024; 83:e31. [PMID: 38267116 DOI: 10.1016/j.jacc.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - G B John Mancini
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - William S Weintraub
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raffaele De Caterina
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Bateman TM. In 2023 PET myocardial perfusion imaging is preferred to invasive coronary angiography for the initial work-up of a symptomatic patient with a high coronary artery calcium score. J Nucl Cardiol 2023; 30:2273-2278. [PMID: 37948013 DOI: 10.1007/s12350-023-03386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Timothy M Bateman
- Cardiovascular Radiologic Imaging, Saint-Lukes Health System, University of Missouri-Kansas City, Kansas City, MO, 64111, USA.
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Isath A, Panza JA. The Evolving Paradigm of Revascularization in Ischemic Cardiomyopathy: from Recovery of Systolic Function to Protection Against Future Ischemic Events. Curr Cardiol Rep 2023; 25:1513-1521. [PMID: 37874470 DOI: 10.1007/s11886-023-01977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW We aim to reevaluate how the assessment of myocardial viability can guide optimal treatment strategies for patients with ischemic cardiomyopathy (ICM) based on a more contemporary understanding of the mechanism of benefit of revascularization. RECENT FINDINGS The assessment of viability in left ventricular (LV) segments with diminished contraction has been proposed as key to predict the benefit of revascularization and, therefore, as a requisite for the selection of patients to undergo this form of treatment. However, data from prospective trials have diverged from earlier retrospective studies. Traditional binary viability assessment may oversimplify ICM's complexity and the nuances of revascularization benefits. A conceptual shift from the traditional paradigm centered on the assessment of viability as a dichotomous variable to a more comprehensive approach encompassing a thorough understanding of ICM's complex pathophysiology and the salutary effect of revascularization in the prevention of myocardial infarction and ventricular arrhythmias is required.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, USA
| | - Julio A Panza
- Department of Cardiology, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, USA.
- Department of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY, USA.
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Leopold JA. Complete Coronary Revascularization: A New Strategy to Improve Clinical Outcomes for Stable Coronary Artery Disease? J Am Coll Cardiol 2023; 82:1189-1191. [PMID: 37704308 DOI: 10.1016/j.jacc.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Jane A Leopold
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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