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Jonjev ŽS, Adam A, Kalinić N, Zdravković R, Mrvić S. Coronary artery bypass grafting versus percutaneous coronary intervention in single-vessel left anterior descending artery disease: mid-term propensity matching study. Indian J Thorac Cardiovasc Surg 2024; 40:311-317. [PMID: 38681724 PMCID: PMC11045704 DOI: 10.1007/s12055-023-01657-7] [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: 07/13/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Coronary artery bypass grafting (CABG) has been considered to be the proven therapeutic choice for coronary artery disease. However, percutaneous coronary intervention (PCI) with drug-eluting stents is increasingly used for extensive coronary artery disease with contradictory results. The aim of this study is to compare immediate- and mid-term results of CABG where skeletonized internal mammary artery (IMA) was used as in situ graft versus PCI with serolimus drug eluted stents (SES) in single-vessel left anterior descending artery (LAD) disease. Methods In 2014-2022, 938 patients treated for isolated LAD revascularization were included in this study. Among them, there were 346 patients with CABG-IMA and 592 patients with SES-PCI. CABG-IMA patients (n = 266) were compared with SES-PCI patients (n = 266) in propensity score-matched method.Primary outcome measures were identified as all-cause mortality at 30 days and 3 years after surgery, while secondary outcome measures were length of hospital stay and the incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE). Results Increased incidence for post procedural MACCE after PCI was recorded (CABG = 1.2% vs. PCI = 5.3%; p < 0.05). There was no difference in immediate-term (30 days: CABG = 1.2% vs. PCI = 1.5%; p = ns) and mid-term (3 years: CABG = 3.7% vs. PCI = 4.5%; p = ns) mortality between the groups. Patient after SES-PCI had shorter length of hospital stay (CABG = 7.7 days vs. PCI = 3.8 days; p < 0.05). Conclusion The results of the study indicated that CABG-IMA performed at the time of myocardial revascularization in single-vessel LAD disease is better than SES-PCI. Our conclusion is independent of traditionally accepted risk factors incorporated in the Logistic EuroSCORE II (European System for Cardiac Operative Risk Evaluation) and SYNTAX score II (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery Score II) and is exclusively method related.
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Affiliation(s)
- Živojin S. Jonjev
- Institute for Cardiovascular Diseases of Vojvodina, Clinic of Cardiovascular Surgery, Sremska Kamenica, Serbia
- University of Banja Luka, Faculty of Medicine, Banja Luka, Republic of Srpska Bosnia and Herzegovina
| | - Adam Adam
- John H. Stroger, Jr., Hospital of Cook County, Chicago, IL USA
| | - Novica Kalinić
- University of Banja Luka, Faculty of Medicine, Banja Luka, Republic of Srpska Bosnia and Herzegovina
| | - Ranko Zdravković
- Institute for Cardiovascular Diseases of Vojvodina, Clinic of Cardiovascular Surgery, Sremska Kamenica, Serbia
| | - Strahinja Mrvić
- Institute for Cardiovascular Diseases of Vojvodina, Clinic of Cardiovascular Surgery, Sremska Kamenica, Serbia
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Sinning JM, Al-Rashid F, Ibrahim K, Aurigemma C, Chieffo A. Defining the optimal revascularization strategy during protected high-risk procedures with Impella. Eur Heart J Suppl 2022; 24:J25-J29. [PMCID: PMC9730788 DOI: 10.1093/eurheartjsupp/suac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Complete revascularization (CR) in patients with multi-vessel disease improves outcomes. The use of percutaneous left-ventricular assist devices, such as the Impella heart pump, is useful to minimize the risk of haemodynamic compromise in complex higher risk and clinically indicated patients. The recently published data from the PROTECT III trial suggest more CR during Impella-protected percutaneous coronary intervention with more extensive lesion preparation and treatment, resulting in the reduced need for repeat revascularization. To achieve CR and improve survival, procedural guidance by intravascular imaging, extensive lesion preparation, debulking with atherectomy devices, advanced chronic total occlusion revascularization techniques, and post-interventional treatment with modern anti-platelet medication are essential.
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Affiliation(s)
- Jan-Malte Sinning
- Department of Cardiology, St Vinzenz Hospital Cologne , 50733 Cologne , Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen , Essen , Germany
| | - Karim Ibrahim
- Department of Cardiology, Technische Universität Dresden (Campus Chemnitz), Klinikum Chemnitz , Chemnitz , Germany
| | - Cristina Aurigemma
- UOC Interventistica Cardiologica e Diagnostica Invasiva, Fondazione Policlinico Gemelli IRCCS and Università Cattolica del Sacro Cuore , Rome , Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Hospital , Milan , Italy
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3
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Carmona-Segovia ADM, Doncel-Abad MV, Becerra-Muñoz VM, Rodríguez-Capitán J, Sabatel-Pérez F, Flores-López M, Sánchez-Quintero MJ, Medina-Vera D, Molina-Ramos AI, El Bekay R, Morales-Asencio JM, Angullo-Gómez M, García-Rodríguez L, Palma-Martí L, Pavón-Morón FJ, Jiménez-Navarro MF. Prognostic stratification of older patients with multivessel coronary artery disease treated with percutaneous transluminal coronary angioplasty based on clinical and biochemical measures: protocol for a prospective cohort study. BMJ Open 2022; 12:e058042. [PMID: 35228293 PMCID: PMC8886411 DOI: 10.1136/bmjopen-2021-058042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The incidence of acute coronary syndrome is rising in step with the growth of life expectancy. An increase in the age of patients with coronary artery disease has been related to in-hospital mortality, which has seen an upsurge over a short period of time. However, there is no consensus about the percutaneous coronary angioplasty strategy to follow for older patients with multivessel coronary artery disease (MVCAD). Complete revascularisation (CR) or incomplete revascularisation (ICR) strategy depends on prognosis but this has not yet been accurately described because of geriatric conditions and comorbidities. The aim of this study is to evaluate changes of clinical and biochemical parameters in older patients with MVCAD undergoing revascularisation and to establish a prognostic stratification model for CR and ICR. METHODS AND ANALYSIS This observational, longitudinal, prospective study will include 150 patients with MVCAD and subsequent revascularisation who attend the Hospital Universitario Virgen de la Victoria (Málaga, Spain). Because of the dropout rates, 180 patients will be recruited at the beginning. Sociodemographic characteristics, clinical and angiographic parameters, and biochemical variables, such as cardiovascular, metabolic, inflammatory, stress oxidative biomarkers, will be collected in the admission for coronary revascularisation and three follow-ups at 6, 12 and 18 months. Statistical analyses will be conducted with these data using CR and ICR as the primary exposure variable. Relevant explanatory variables will be selected from a predictive model for their inclusion in a prognostic stratification model. The primary outcome measures will be major adverse cardiovascular events. ETHICS AND DISSEMINATION Protocols and patient information have been approved by the regional research ethics committee (CEIm Provincial de Málaga-PEIBA (PI0131/2020). The results will be disseminated in international peer-reviewed journals, presented at conferences in Cardiology and Gerontology, and sent to participants, medical and health service managers, clinicians and other researchers.
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Affiliation(s)
- Ada Del Mar Carmona-Segovia
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - María Victoria Doncel-Abad
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Víctor M Becerra-Muñoz
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jorge Rodríguez-Capitán
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando Sabatel-Pérez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - María Flores-López
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - María José Sánchez-Quintero
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Dina Medina-Vera
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Rajaa El Bekay
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, Spain
- Centro de Investigación en Red de la Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Morales-Asencio
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain
| | - María Angullo-Gómez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Luis García-Rodríguez
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Lucía Palma-Martí
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Unidad de Gestión Clínica de Salud Mental, Hospital Regional Uiversitario de Málaga, Málaga, Spain
| | - Manuel F Jiménez-Navarro
- Hospitales y Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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Lampridis S, George SJ. Non-Autologous Grafts in Coronary Artery Bypass Surgery: A Systematic Review. Ann Thorac Surg 2020; 112:2094-2103. [PMID: 33340520 DOI: 10.1016/j.athoracsur.2020.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/17/2020] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Suitable autologous conduits may be lacking when performing coronary artery bypass grafting (CABG). The aim of this review is to determine the status of non-autologous grafts in CABG. METHODS We conducted a literature search on MEDLINE All, Embase Classic and Embase through Ovid from 1960 to April 2020. RESULTS Of the 1579 records identified, 21 studies were included in the review. The following grafts were assessed for patency: 109 homologous saphenous veins (patency rates ranged from 66.7% at a median follow-up of 8.5 months to 0% at 6-12 and 7-18 months, respectively), 29 expanded polytetrafluoroethylene (ePTFE) grafts (from 80% at a median follow-up of 5 months to 14.3% at 45 months), 12 human umbilical veins (50% at a median follow-up of 6 months), 50 Bioflow bovine internal mammary arteries (from 15.8% to 0% at a mean follow-up of 9.5 and 19 months, respectively), 39 Perma-Flow grafts (80% and 76.9% at 1-3 and 12 months, respectively), 20 No-React bovine internal mammary arteries (57.1% at a median follow-up of 28 months and 23.1% at a mean follow-up of 7 months), 40 autologous venous endothelial cell-seeded ePTFE grafts (94.7% and 81% at a mean follow-up of 27 and 60 months, respectively) and 12 autologous venous endothelial cell-seeded cryopreserved homologous veins (83.3% at a mean follow-up of 8.5 months). CONCLUSIONS The goal of an alternative conduit with patency and attributes that match those of autografts remains elusive. Autologous endothelial cell-seeded synthetic grafts have demonstrated promising results but require further investigation.
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Affiliation(s)
| | - Sarah J George
- Bristol Medical School, University of Bristol, United Kingdom
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5
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Chieffo A, Burzotta F, Pappalardo F, Briguori C, Garbo R, Masiero G, Nicolini E, Ribichini F, Trani C, Álvarez BC, Leor OR, Moreno R, Santos R, Fiarresga A, Silveira JB, de Prado AP, Musumeci G, Esposito G, Tarantini G. Clinical expert consensus document on the use of percutaneous left ventricular assist support devices during complex high-risk indicated PCI: Italian Society of Interventional Cardiology Working Group Endorsed by Spanish and Portuguese Interventional Cardiology Societies. Int J Cardiol 2019; 293:84-90. [PMID: 31174920 DOI: 10.1016/j.ijcard.2019.05.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/18/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022]
Abstract
Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Vita Salute University, Milan, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | | | - Giulia Masiero
- Cardiovascular Department, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Elisa Nicolini
- Unità di Emodinamica, Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Carlo Trani
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Raúl Moreno
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
| | | | - António Fiarresga
- Centro Hospitalar Lisboa Central, Hospital de Santa Marta, Lisboa, Portugal
| | - João Brum Silveira
- Centro Hospitalar e Universitário do Porto, Hospital de Santo António, Porto, Portugal
| | | | - Giuseppe Musumeci
- Cardiovascular Department, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Divisions of Cardiology and Cardiothoracic Surgery, Federico II University, Naples, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Italy..
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Kranjec I, Zavrl Džananovič D, Mrak M, Bunc M. Robustness of Percutaneously Completed Coronary Revascularization in Stable Coronary Artery Disease: Obstructive Versus Occlusive Lesions. Angiology 2018; 70:78-86. [PMID: 29631418 DOI: 10.1177/0003319718767737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our study sought to assess long-term outcomes of percutaneously completed coronary revascularization (CCR) in patients with obstructive coronary artery disease (CAD) comprising chronic total occlusions (CTOs). Between 2010 and 2014, percutaneous coronary interventions (PCIs) of the CTOs were attempted in 213 patients: the CCR was achieved in 125 patients (group 1), while the PCI failed in 88 patients (group 2). They were matched against 252 patients (group 3) with the CCR obtained by the non-CTO PCIs. In the 5-year follow-up, more adverse cardiovascular (CV) events occurred in group 2 (29.5% vs 4.8% in group 1 vs 3.5% in group 3, P = .0001), mainly due to recurrent severe symptoms and additional revascularization of the CTOs; CV mortality did not seem to be significantly affected. Survival curves for the successful CTO and non-CTO PCIs appeared indistinguishable. Stent thromboses were infrequent in the CCR groups. In conclusion, long-term outcomes of the patients with the obstructive CAD containing the CTOs showed a favorable outcome if the CCR had been achieved percutaneously.
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Affiliation(s)
- Igor Kranjec
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | | | - Miha Mrak
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Matjaz Bunc
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
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Aurigemma C, Burzotta F, Russo G, Previ L, Trani C. Definitions and clinical impact of revascularization completeness. Minerva Cardioangiol 2018; 66:594-599. [PMID: 29546745 DOI: 10.23736/s0026-4725.18.04654-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The completeness of revascularization in patients with multivessel coronary artery disease (CAD) remains an unanswered question. Despite 20 years of investigation there are still major doubts in this topic, reaching as far as to the lack of a standardized definition. The employment of different definition and the multiplicity of confounding variables that in general favor patients who receive a complete revascularization (CR) are the reason of difficult comparisons between studies. The complexity of coronary anatomy diseases and the clinical features play important role in the revascularization strategy. However, the clinical impact of CR is different in particular clinical subsets, such as diabetes, ST-segment elevation myocardial infarction, cardiogenic shock, ischemic heart failure. The CR is a desirable objective, but it is not mandatory and sometimes a reasonable incomplete revascularization (IR) offers comparable results. Clinical variables, including patient's age, life expectancy, the severity of symptoms at presentation, comorbidities (particularly diabetes mellitus), left ventricular function and myocardial viability, as well as coronary anatomy should be considered in the decision making whether to attempt CR or to follow a reasonable IR strategy, for both percutaneous coronary intervention and coronary artery bypass graft surgery, in patients with multivessel CAD.
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Affiliation(s)
- Cristina Aurigemma
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy -
| | - Francesco Burzotta
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulio Russo
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Leonardo Previ
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Trani
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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8
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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] [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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10
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Goel PK, Jatain S, Khanna R, Pandey CM. Left main PCI: An observational analysis from large single-centre experience. Indian Heart J 2016; 68:36-42. [PMID: 26896264 PMCID: PMC4759493 DOI: 10.1016/j.ihj.2015.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 06/08/2015] [Accepted: 07/07/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data. OBJECTIVES To study long-term outcome after uLMPCI and identify predictors of adverse outcome. METHODS Case details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained. RESULTS Mean follow-up duration was 669.8±404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p=0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p=0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p=0.001]. Syntax score >32 was the only independent predictor of adverse outcome. CONCLUSION uLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.
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Affiliation(s)
- Pravin K Goel
- Professor & Head of Cardiology, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Suman Jatain
- Senior Resident, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Roopali Khanna
- Assistant Professor Cardiology, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - C M Pandey
- Professor & Head of Biostatistics & Health Informatics, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Zhang Q, Long Wang X, Lei Liao M, Hu J, Kun Yang Z, Hua Ding F, Sheng Zhang J, Du R, Qi Zhu T, Feng Shen W, Yan Zhang R. Periprocedural use of tirofiban in elective percutaneous coronary intervention for long coronary lesions in stable patients with overlapping drug-eluting stents-the PETITION study: A prospective, randomized, multicenter study. Catheter Cardiovasc Interv 2015; 85 Suppl 1:762-9. [PMID: 25630513 DOI: 10.1002/ccd.25864] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/07/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Qi Zhang
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Xiao Long Wang
- Department of Cardiology; Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Shanghai 201203 China
| | - Min Lei Liao
- Department of Cardiology; Wusong Hospital; Shanghai 200940 China
| | - Jian Hu
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Zhen Kun Yang
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Feng Hua Ding
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Jian Sheng Zhang
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Run Du
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Tian Qi Zhu
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Wei Feng Shen
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
| | - Rui Yan Zhang
- Department of Cardiology; Ruijin Hospital, Shanghai Jiaotong University School of Medicine; Shanghai 200025 China
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Completeness of coronary revascularization and survival: Impact of age and off-pump surgery. J Thorac Cardiovasc Surg 2014; 148:1307-1315.e1. [DOI: 10.1016/j.jtcvs.2013.12.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/11/2013] [Accepted: 12/30/2013] [Indexed: 01/26/2023]
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Zimarino M, D'Andreamatteo M, Waksman R, Epstein SE, De Caterina R. The dynamics of the coronary collateral circulation. Nat Rev Cardiol 2014; 11:191-7. [DOI: 10.1038/nrcardio.2013.207] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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14
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Yi G, Youn YN, Joo HC, Hong S, Yoo KJ. Association of incomplete revascularization with long-term survival after off-pump coronary artery bypass grafting. J Surg Res 2013; 185:166-73. [DOI: 10.1016/j.jss.2013.05.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/23/2013] [Accepted: 05/09/2013] [Indexed: 11/15/2022]
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15
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Zimarino M, Curzen N, Cicchitti V, De Caterina R. The adequacy of myocardial revascularization in patients with multivessel coronary artery disease. Int J Cardiol 2013; 168:1748-57. [DOI: 10.1016/j.ijcard.2013.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 04/04/2013] [Accepted: 05/03/2013] [Indexed: 02/04/2023]
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16
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Late Thrombosis After Double Versus Single Drug-Eluting Stent in the Treatment of Coronary Bifurcations. JACC Cardiovasc Interv 2013; 6:687-95. [DOI: 10.1016/j.jcin.2013.03.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/06/2013] [Accepted: 03/15/2013] [Indexed: 12/19/2022]
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Wittwer T, Sabashnikov A, Rahmanian PB, Choi YH, Zeriouh M, Mehler TO, Wahlers T. Less invasive coronary artery revascularization with a minimized extracorporeal circulation system: preliminary results of a comparative study with off-pump-procedures. J Cardiothorac Surg 2013; 8:75. [PMID: 23577663 PMCID: PMC3639032 DOI: 10.1186/1749-8090-8-75] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/11/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Coronary-artery-bypass-grafting (CABG) with conventional extracorporeal circulation (CECC) is associated with adverse effects such as systemic inflammatory response leading to a decrease in systemic vascular resistance and hemodynamic instability. Modern "less invasive" procedures have been established recently which potentially avoid negative side effects of CECC. The aim of this study was to compare perioperative outcome following coronary revascularization using either a minimized extracorporeal circuit (Mini-HLM) or off-pump technique (OPCAB). METHODS In this prospective ethics-approved trial, 120 patients referred for CABG were randomly assigned either to off-pump coronary artery bypass (OPCAB) or to a Mini-HLM procedure. Patient demographics, preoperative characteristics and extensive postoperative outcome were analyzed for both groups. Hemodynamic data were measured at seven time points perioperatively. RESULTS Operation-time was longer in the Mini-HLM group (178,3 ± 32,9 min) compared to OPCAB (133,2 ± 32,7 min, p < 0,001) with higher graft numbers in Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p < 0.001). There were no significant differences in perioperative hemodynamic criteria, catecholaminergic support, hospital (p = 0,534) and intensive care unit stay (p = 0,880), ventilation time (p = 0,113), blood loss (p = 0,570), transfusion requirements, postoperative atrial fibrillation rate (p = 0,706) and neurocognitive disturbance (p = 0,297). No deaths and no myocardial infarctions were observed. CONCLUSIONS Coronary revascularisation with Mini-HLM represents a suitable and "less invasive" procedure which achieves all benefits of OPCAB but may allow for less demanding revascularisation than OPCAB in special patients with complex coronary anatomy and can therefore be used both on a routine basis and in all "conversion" cases of OPCAB.
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Affiliation(s)
- Thorsten Wittwer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Thorsten O Mehler
- Department of Anesthesiology, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
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Incomplete revascularization in the drug eluting stent era permits meaningful long-term (12-78 months) outcomes in patients ≥ 75 years with acute coronary syndrome. J Geriatr Cardiol 2013; 9:336-43. [PMID: 23341837 PMCID: PMC3545249 DOI: 10.3724/sp.j.1263.2012.05021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 07/11/2012] [Accepted: 09/24/2012] [Indexed: 11/25/2022] Open
Abstract
Objective To compare long-term prognosis between complete revascularization (CR) and incomplete revascularization (IR) in elderly patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Methods We prospectively enrolled patients ≥ 75 years with ACS and multi-lesion disease between January 2005 and December 2010 at our center (Institute of Geriatric Cardiology, Chinese PLA General Hospital). Baseline clinical characteristics, PCI parameters and long-term (12 to 78 months) outcomes including main adverse cardiac and cerebral events (MACCE) were compared between CR and IR groups. We used the Kaplan-Meier curve to describe the survival rates, and variables reported to be associated with prognosis were included in Cox regression. Results Of the 502 patients, 230 patients obtained CR, and the other 272 patients underwent IR. Higher SYNTAX score was an independent predictor of IR [Odds ratio (OR): 1.141, 95% confidence interval (95% CI): 1.066–1.221, P = 0.000]. A total of 429 patients (85.5%) were followed with a duration ranging from 12 months to 78 months. There were no significant differences in cumulative survival rates and event free survival rates between the two groups, even for patients with multi-vessel disease. Older age (OR: 1.079, 95% CI: 1.007–1.157, P = 0.032), prior myocardial infarction (OR: 1.440, 95% CI: 1.268–2.723, P = 0.001) and hypertension (OR: 1. 653, 95% CI: 1.010-2.734, P = 0.050) were significant independent predictors of long-term MACCE. Conclusions Given that both clinical and coronary lesion characteristics are much more complex in patients ≥75 years with ACS and multi-lesion disease, IR may be an option allowing low risk hospital results and meaningful long-term (12 to 78 months) outcomes.
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The prognosis of periprocedural myocardial infarction after percutaneous coronary interventions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:32-6. [DOI: 10.1016/j.carrev.2012.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/16/2012] [Accepted: 10/16/2012] [Indexed: 12/24/2022]
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Vieira RD, Hueb W, Gersh BJ, Lima EG, Pereira AC, Rezende PC, Garzillo CL, Hueb AC, Favarato D, Soares PR, Ramires JAF, Kalil Filho R. Effect of complete revascularization on 10-year survival of patients with stable multivessel coronary artery disease: MASS II trial. Circulation 2012; 126:S158-63. [PMID: 22965977 DOI: 10.1161/circulationaha.111.084236] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The importance of complete revascularization remains unclear and contradictory. This current investigation compares the effect of complete revascularization on 10-year survival of patients with stable multivessel coronary artery disease (CAD) who were randomly assigned to percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). METHODS AND RESULTS This is a post hoc analysis of the Second Medicine, Angioplasty, or Surgery Study (MASS II), which is a randomized trial comparing treatments in patients with stable multivessel CAD, and preserved systolic ventricular function. We analyzed patients who underwent surgery (CABG) or stent angioplasty (PCI). The survival free of overall mortality of patients who underwent complete (CR) or incomplete revascularization (IR) was compared. Of the 408 patients randomly assigned to mechanical revascularization, 390 patients (95.6%) underwent the assigned treatment; complete revascularization was achieved in 224 patients (57.4%), 63.8% of those in the CABG group and 36.2% in the PCI group (P=0.001). The IR group had more prior myocardial infarction than the CR group (56.2% × 39.2%, P=0.01). During a 10-year follow-up, the survival free of cardiovascular mortality was significantly different among patients in the 2 groups (CR, 90.6% versus IR, 84.4%; P=0.04). This was mainly driven by an increased cardiovascular specific mortality in individuals with incomplete revascularization submitted to PCI (P=0.05). CONCLUSIONS Our study suggests that in 10-year follow-up, CR compared with IR was associated with reduced cardiovascular mortality, especially due to a higher increase in cardiovascular-specific mortality in individuals submitted to PCI. CLINICAL TRIAL REGISTRATION INFORMATION URL: http://www.controlled-trials.com. REGISTRATION NUMBER ISRCTN66068876.
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Complete Versus Incomplete Revascularization With Coronary Artery Bypass Graft or Percutaneous Intervention in Stable Coronary Artery Disease. Circ Cardiovasc Interv 2012; 5:597-604. [DOI: 10.1161/circinterventions.111.965509] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Zimarino M, Cicchitti V, Genovesi E, Rotondo D, De Caterina R. Isolated troponin increase after percutaneous coronary interventions: Does it have prognostic relevance? Atherosclerosis 2012; 221:297-302. [DOI: 10.1016/j.atherosclerosis.2011.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 10/06/2011] [Accepted: 10/10/2011] [Indexed: 10/16/2022]
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Guerra M, Mota JC. Impact of incomplete surgical revascularization on survival. Interact Cardiovasc Thorac Surg 2011; 14:176-82. [PMID: 22159258 DOI: 10.1093/icvts/ivr080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.
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Affiliation(s)
- Miguel Guerra
- Department of Thoracic Surgery, Centro Hospitalar de Vila Nova de Gaia, Portugal.
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Galassi AR, Marzá F, Azzarelli S, Tomasello SD. Role of Stress Myocardial Scintigraphy in the Evaluation of Incompletely Revascularized Post-PCI Patients. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2011; 2011:180936. [PMID: 21941646 PMCID: PMC3177365 DOI: 10.1155/2011/180936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 03/21/2011] [Accepted: 06/14/2011] [Indexed: 11/17/2022]
Abstract
Percutaneous coronary intervention (PCI) is actually the most used method of revascularization. Although complete revascularization remains a desirable goal, it may not be possible or not easy to plan in many patients. Thus, incomplete revascularization might be a preferred treatment strategy in selected patient categories. Stress myocardial scintigraphy, because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram, is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization.
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Affiliation(s)
- Alfredo R. Galassi
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Francesco Marzá
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Salvatore Azzarelli
- Division of Cardiology, Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy
| | - Salvatore D. Tomasello
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
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Gowdak LHW, Schettert IT, Rochitte CE, Lisboa LAF, Dallan LAO, César LAM, de Oliveira SA, Krieger JE. Early increase in myocardial perfusion after stem cell therapy in patients undergoing incomplete coronary artery bypass surgery. J Cardiovasc Transl Res 2011; 4:106-13. [PMID: 21061106 DOI: 10.1007/s12265-010-9234-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 10/22/2010] [Indexed: 11/29/2022]
Abstract
Incomplete revascularization is associated with worse long-term outcomes. Autologous bone marrow cells (BMC) have recently been tested in patients with severe coronary artery disease. We tested the hypothesis that intramyocardial injection of autologous BMC increases myocardial perfusion in patients undergoing incomplete coronary artery bypass grafting (CABG). Twenty-one patients (19 men), 59 ± 7 years old, with limiting angina and multivessel coronary artery disease (CAD), not amenable to complete CABG were enrolled. BMC were obtained prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5 mL containing 2.1 ± 1.3 × 108 BMC (CD34+ = 0.8 ± 0.3%) were injected in the ischemic non-revascularized myocardium. Myocardial perfusion was assessed by magnetic resonance imaging (MRI) at baseline and 1 month after surgery. The increase in myocardial perfusion was compared between patients with <50% (group A, n = 11) with that of patients with >50% (group B, n = 10) of target vessels (stenosis ≥ 70%) successfully bypassed. Injected myocardial segments included the inferior (n = 12), anterior (n = 7), and lateral (n = 2) walls. The number of treated vessels (2.3 ± 0.8) was significantly smaller than the number of target vessels (4.2 ± 1.0; P < 0.0001). One month after surgery, cardiac MRI showed a similar reduction (%) in the ischemic score of patients in group A (72.5 ± 3.2), compared to patients in group B (78.1 ± 3.2; P = .80). Intramyocardial injection of autologous BMC may help increase myocardial perfusion in patients undergoing incomplete CABG, even in those with fewer target vessels successfully treated. This strategy may be an adjunctive therapy for patients suffering from a more advanced (diffuse) CAD not amenable for complete direct revascularization.
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Affiliation(s)
- Luís Henrique Wolff Gowdak
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, 05403-000 São Paulo, SP, Brazil.
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Zimarino M, Ruggieri B, De Caterina R. Patient management and care after primary percutaneous coronary intervention: reinforcing a continuum of care after primary percutaneous coronary intervention. Am Heart J 2010; 160:S42-7. [PMID: 21147292 DOI: 10.1016/j.ahj.2010.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Primary percutaneous coronary interventions (PPCIs) improve outcomes in patients with ST-elevation myocardial infarction and facilitate the hospitalization course. In most cases, the patient can be discharged within 3 to 5 days after the PPCI, provided that careful triage is applied. Bleeding--often associated with excessive antithrombotic drug dosing--is a major concern. Transfusion has been documented to be a strong and independent predictor of mortality; for this reason, recent guidelines recommend that bleeding be managed using a conservative strategy that limits transfusions and the discontinuation of antithrombotic drugs to major bleeding events and only when local hemostatic interventions are not effective. Primary percutaneous coronary intervention is often performed without previous assessment of renal function, and the amount of contrast medium should be kept to a minimum, because contrast-induced nephropathy occurs frequently and is associated with higher early and late mortality. The risk of major arrhythmias should also be addressed correctly. The prognostic implication of ventricular arrhythmias is extremely dependent on the timing of presentation: midterm mortality is much higher among subjects experiencing a new arrhythmic event after PPCI compared with patients with existing arrhythmias at PPCI or those without arrhythmias. The Zwolle risk score is useful for identifying subjects who may be safely discharged early. Secondary prevention starts at the end of PPCI. Hospital discharge and the planning of follow-up visits are critical for therapeutic recommendations. After an ST-elevation myocardial infarction, patients are at increased risk of recurrences, even when the PPCI is timely; a rehabilitation program and all measures that increase adherence to medications should be implemented, starting at discharge.
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Affiliation(s)
- Marco Zimarino
- Institute of Cardiology and Center of Excellence on Aging, G. d'Annunzio University, Chieti, Italy.
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Biondi-Zoccai G, Lotrionte M, Sheiban I. Management of multivessel coronary disease after ST-elevation myocardial infarction treated by primary coronary angioplasty. Am Heart J 2010; 160:S28-35. [PMID: 21147289 DOI: 10.1016/j.ahj.2010.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Primary percutaneous coronary intervention of the infarct-related artery is now considered the gold standard for patients with acute ST-elevation myocardial infarction. However, a sizable portion of patients with ST-elevation myocardial infarction have concomitant multivessel disease, which raises important therapeutic and prognostic issues. Indeed, it is still unclear whether percutaneous coronary intervention of the culprit vessel alone is superior, equivalent, or inferior in terms of risk-benefit balance in comparison to a strategy of complete revascularization, with percutaneous coronary intervention of nonculprit vessels as well. The present systematic review provides an updated prospective on the rationale, background, and outcomes of culprit-only versus multivessel percutaneous revascularization in subjects undergoing primary percutaneous coronary intervention. Our findings clearly demonstrate that multivessel coronary disease significantly and adversely impacts on patient prognosis, yet a culprit-only revascularization strategy should be sought after in most cases, unless patient instability or symptoms/signs of residual myocardial ischemia support nonculprit vessel intervention.
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Zimarino M, Barnabei L, De Caterina R. ‘Missing’ coronary arteries at urgent coronary angiography for ST-elevation myocardial infarction. J Cardiovasc Med (Hagerstown) 2010; 11:754-7. [DOI: 10.2459/jcm.0b013e328332e9a5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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GALASSI ALFREDOR, WERNER GERALDS, TOMASELLO SALVATORED, AZZARELLI SALVATORE, CAPODANNO DAVIDE, BARRANO GIOMBATTISTA, MARZA' FRANCESCO, COSTANZO LUCA, CAMPISANO MARIABARBARA, TAMBURINO CORRADO. Prognostic Value of Exercise Myocardial Scintigraphy in Patients with Coronary Chronic Total Occlusions. J Interv Cardiol 2010; 23:139-48. [DOI: 10.1111/j.1540-8183.2010.00527.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Reber D, Brouwer R, Buchwald D, Fritz M, Germing A, Lindstaedt M, Klak K, Laczkovics A. Beating-Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off-Pump Grafting. Artif Organs 2010; 34:179-84. [DOI: 10.1111/j.1525-1594.2009.00836.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Aziz A, Lee AM, Pasque MK, Lawton JS, Moazami N, Damiano RJ, Moon MR. Evaluation of revascularization subtypes in octogenarians undergoing coronary artery bypass grafting. Circulation 2009; 120:S65-9. [PMID: 19752388 DOI: 10.1161/circulationaha.108.844316] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data suggest that octogenarians' long-term survival after complete coronary artery bypass graft revascularization is superior to incomplete revascularization. Discriminating between variable definitions of "complete" complicates interpretation of survival data. We aimed to clarify octogenarian long-term survival rates by stratifying revascularization subtypes. METHODS AND RESULTS From 1986 to 2007, 580 patients 80 to 94 years of age underwent coronary artery bypass graft. Functional complete revascularization was defined as at least 1 graft to all diseased coronary vessels with >50% stenosis. Traditional complete revascularization was defined as 1 graft to each major arterial system with at least 50% stenosis. Incomplete revascularization was defined as leaving diseased, ungrafted regions. Revascularization was functional in 279 (48%), traditional in 181 (31%), and incomplete in 120 (21%). Long-term survival was evaluated by Kaplan-Meier analysis. Of 537 operative survivors, there were 402 late deaths. Cumulative long-term survival totaled 2890 patient-years. Late survival (Kaplan-Meier) was similar between functional (mean, 6.8 years) and traditional (6.7 years) groups (P=0.51), but diminished with incomplete (4.2 years) revascularization (P=0.007). Survival by group at 5 years was: 59+/-3% functional, 57+/-4% traditional, and 45+/-5% incomplete. Survival at 8 years was: 40+/-3% functional, 37+/-4% traditional, and 26+/-5% incomplete. To minimize selection bias in patients with limited life expectancy, Kaplan-Meier analysis was repeated including only patients with survival >12 months. Survival was again impaired with incomplete revascularization (P=0.04), and there was no difference between functional and traditional complete revascularization (P=0.73). CONCLUSIONS Bypassing all diseased arterial vessels after revascularization does not afford significant long-term survival advantage compared to a traditional approach. Incomplete revascularization, related to more extensive disease, is associated with an 18% decline in survival. These data suggest that it is important to avoid incomplete revascularization in octogenarians, but the supplementary endeavor required to perform functional complete revascularization does not improve survival.
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Affiliation(s)
- Abdulhameed Aziz
- Washington University School of Medicine, St. Louis, MO 63110-1013, USA
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Biondi Zoccai G, Moretti C, Abbate A, Lipinski MJ, De Luca G, Agostoni P, Meliga E, Goudreau E, Vetrovec GW, Trevi GP, Sheiban I. Percutaneous coronary stenting in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis. EUROINTERVENTION 2007; 3:409-415. [PMID: 19737725 DOI: 10.4244/eijv3i3a72] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
AIMS There is uncertainty on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with left ventricular dysfunction (LVD). We thus performed a systematic review of studies reporting on PCI in LVD. METHODS AND RESULTS Pertinent studies were searched in PubMed, and included if reporting on >/=30 patients, with ejection fraction < 50%, and prevalently (>60%) treated with stents. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) at the longest follow-up. Outcomes were pooled with random-effect methods (95% confidence intervals). We retrieved 11 studies including 1,284 patients with ejection fraction <50% (specifically <40% in 1,033 and <30% in 211). All studies but one reported on bare-metal stenting only. In-hospital MACE occurred in 5% (3-6), with death in 2% (1-3), myocardial infarction in 3% (2-4), and repeat revascularisation in 1% (0-2). After a median of 18 months, MACE occurred in 33% (30-36), with death in 11% (9-13), myocardial infarction in 7% (6-9), and repeat revascularisation in 15% (13-18). Meta-regression suggested the beneficial impact of drug-eluting stents on MACE (p=0.030). CONCLUSIONS Currently available data support the adoption of percutaneous revascularisation in carefully selected patients with LVD. While event attrition remains substantial at long-term follow-up, drug-eluting stents hold the promise of significantly improving event-free and overall survival.
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Zingone B. Stenting the coronaries and bypassing the evidence in patients with multivessel coronary artery disease: time to set the record straight. J Cardiovasc Med (Hagerstown) 2007; 8:362-70. [PMID: 17443104 DOI: 10.2459/jcm.0b013e32807fb088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bartolo Zingone
- Cardiovascular Department, Division of Cardiac Surgery, Ospedali Riuniti di Trieste, Trieste, Italy.
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Kalarus Z, Lenarczyk R, Kowalczyk J, Kowalski O, Gasior M, Was T, Zebik T, Krupa H, Chodór P, Poloński L, Zembala M. Importance of complete revascularization in patients with acute myocardial infarction treated with percutaneous coronary intervention. Am Heart J 2007; 153:304-12. [PMID: 17239694 DOI: 10.1016/j.ahj.2006.10.033] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 10/28/2006] [Indexed: 01/01/2023]
Abstract
BACKGROUND The role of incomplete revascularization (ICR) in patients with acute myocardial infarction (AMI) is controversial. We evaluated the impact of ICR on short- and long-term outcome in patients with AMI and multivessel disease (MVD) treated with percutaneous coronary interventions (PCI) during index hospital stay. METHODS Single-center observational study covered 798 patients with MVD selected from 1486 consecutive patients with AMI treated with PCI. At discharge, 605 (75.8%) of the patients still had at least 1 diseased artery (ICR group); in 193, complete revascularization (CR) has been achieved (CR group). Any-cause mortality rate and major adverse cardiac events (MACE) during hospitalization, within a follow-up period of 30 days and 29.7 months, were compared between both groups in the whole population and within the high-risk subgroups. Propensity model to predict the probability of CR according to 16 variables was used. RESULTS Mortality and MACE rates were significantly higher in ICR group than among completely revascularized subjects during short- and long-term observation (remote mortality 18.5% vs 7.2%, MACE 53.1% vs 24.3%, both P < .001). Higher mortality rate was also observed within the subgroups with diabetes (25.2% vs 4.8%), renal dysfunction (44.1% vs 13.8%), and lowered ejection fraction (26.5% vs 10.5%, all P < .05). Propensity-adjusted multivariate analysis showed that ICR was a significant and strong predictor of remote death (propensity-adjusted hazard ratio 2.01, 95% CI 1.71-2.31, P = .02) and MACE (hazard ratio 2.08, 95% CI 1.90-2.26, P < .001). CONCLUSIONS Incomplete revascularization is a strong and independent risk factor of death and MACE in patients with AMI treated with PCI.
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Affiliation(s)
- Zbigniew Kalarus
- First Department of Cardiology, Silesian Medical School, Silesian Center for Heart Disease, Zabrze, Poland.
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