Validation of the Coronary Artery Bypass Graft SYNTAX Score (Synergy Between Percutaneous Coronary Intervention With Taxus) as a Prognostic Marker for Patients With Previous Coronary Artery Bypass Graft Surgery After Percutaneous Coronary Intervention

Feasibility of rotational atherectomy in patients with acute coronary syndrome: favorable in-hospital outcomes and clinical importance of complexed coronary atherosclerosis

The feasibility of rotational atherectomy (RA) during percutaneous coronary intervention (PCI) in patients who present with acute coronary syndrome (ACS) remains fully unsettled. We retrospectively evaluated 198 consecutive patients who underwent RA during PCI from 2009 to 2020. All patients underwent intracoronary imaging (intravascular ultrasound 96.5%, optical coherence tomography 9.1%, both 5.6%) during PCI. Patients who underwent RA during PCI were divided into two groups: ACS (n = 49; unstable angina pectoris, n = 27; non-ST-elevation myocardial infarction, n = 18, and ST-elevation myocardial infarction, n = 4) and chronic coronary syndrome (CCS) (n = 149). The RA procedural success rate was comparable between in the ACS and CCS groups (93.9 vs. 89.9%, P = 0.41). No significant differences were observed in procedural complications and in-hospital death between the groups. The incidence of major adverse cardiovascular event (MACE) after 2 years was significantly higher in ACS group compared with CCS group (38.7 vs. 17.4%, log-rank P = 0.002). Multivariable Cox regression analysis identified SYNTAX score or CABG SYNTAX score > 22 (hazard ratio (HR) 2.66, 95% confidence interval (CI) 1.40-5.06, P = 0.002) and mechanical circulatory support during the procedure (HR 2.61, 95% CI 1.21-5.59, P = 0.013) as predictors of MACE at 2 years, but not ACS on index admission (HR 1.58, 95% CI 0.84-2.99, P = 0.151). RA procedure is feasible as a bail-out strategy for ACS lesions. However, more complexed coronary atherosclerosis and mechanical circulatory support during RA procedure, but no ACS lesions were associated with worse mid-term clinical outcomes.

In-hospital predictors for primary prevention of sudden death after acute myocardial infarction with cardiac dysfunction

BACKGROUND

Current guidelines recommend prophylactic defibrillator implantation in patients with acute myocardial infarction (AMI) and left ventricular ejection fraction (LVEF) ≤40 % or LVEF ≤35 % plus heart failure symptoms or inducible ventricular tachyarrhythmias during an electrophysiology study at 40 days after AMI or 90 days after revascularization. In-hospital predictors of sudden cardiac death (SCD) after AMI during the index hospitalization remain unsettled. We sought to examine in-hospital predictors of SCD in patients with AMI and LVEF ≤40 % evaluated during the index hospitalization.

METHODS

We retrospectively evaluated 441 consecutive patients with AMI and LVEF ≤40 % admitted to our hospital between 2001 and 2014 (77 % male gender; median age: 70 years; median hospitalization length: 23 days). The primary endpoint was a composite of SCD or aborted SCD at ≥30 days after AMI onset (composite arrhythmic event). LVEF and QRS duration (QRSd) on electrocardiography were measured at a median of 12 days and 18 days, respectively.

RESULTS

During a median follow-up of 7.6 years, the incidence of composite arrhythmic events was 7.3 % (32 of 441 patients). In multivariable analysis, QRSd ≥100 msec (beta-coefficient = 1.54, p = 0.003), LVEF ≤23 % (beta-coefficient = 1.14, p = 0.007), and onset-reperfusion time > 5.5 h (beta-coefficient = 1.16, p = 0.035) were independent predictors of composite arrhythmic events. The combination of these 3 factors was associated with the highest rate of composite arrhythmic events compared with 0-2 factors (p < 0.001).

CONCLUSIONS

The combination of QRSd ≥100 msec, LVEF ≤23 %, and onset-reperfusion time > 5.5 h during the index hospitalization provides precise risk stratification for SCD in patients early after AMI.

Additional survival benefit of bilateral in situ internal thoracic artery grafting with composite radial artery graft in total arterial off-pump coronary artery bypass grafting

OBJECTIVE

This study aimed to elucidate whether the use of bilateral internal thoracic arteries (BITAs) confers additional survival benefits compared with a single internal thoracic artery (SITA) in total arterial grafting with the radial artery.

METHODS

Between 2002 and 2016, 617 patients underwent a bilateral in situ internal thoracic artery grafting with the radial artery as a composite I-graft (BITA-I group) and 516 patients underwent single in situ internal thoracic artery grafting with the radial artery as a composite Y-graft (SITA-Y group). All anastomoses were performed without cardiopulmonary bypass and aortic manipulation. Propensity score matching was performed to adjust covariates and compared the outcomes between the 2 groups. Subanalysis was also performed to evaluate the effects of the BITA-I group on survival according to the covariates using Cox proportional hazards regression analysis.

RESULTS

Propensity score matching yielded 348 well-matched pairs. Early postoperative outcomes were similar in the 2 groups. The BITA-I group showed significantly better survival than the SITA-Y group (79.3% vs 70.2% at 10 years, P = .015). The subanalysis revealed a significantly better survival in the BITA-I group among overall patients (hazard ratio, 0.68; 95% confidence interval, 0.49-0.93). There was a significant positive effect on survival in the BITA-I group among patients without comorbidities or those aged <77 years.

CONCLUSIONS

BITA grafting with the radial artery provides better long-term survival than SITA grafting with the radial artery, which is enhanced among patients aged <77 years with minimum comorbidities.

Three-dimensional assessment of coronary high-intensity plaques with T1-weighted cardiovascular magnetic resonance imaging to predict periprocedural myocardial injury after elective percutaneous coronary intervention

BACKGROUND

Periprocedural myocardial injury (pMI) is a common complication of elective percutaneous coronary intervention (PCI) that reduces some of the beneficial effects of coronary revascularization and impacts the risk of cardiovascular events. We developed a 3-dimensional volumetric cardiovascular magnetic resonance (CMR) method to evaluate coronary high intensity plaques and investigated their association with pMI after elective PCI.

METHODS

Between October 2012 and October 2016, 141 patients with stable coronary artery disease underwent T1-weighted CMR imaging before PCI. A conventional 2-dimensional CMR plaque-to-myocardial signal intensity ratio (2D-PMR) and the newly developed 3-dimensional integral of PMR (3Di-PMR) were measured. 3Di-PMR was determined as the sum of PMRs above a threshold of > 1.0 for voxels in a target plaque. pMI was defined as high-sensitivity cardiac troponin T > 0.07 ng/mL.

RESULTS

pMI following PCI was observed in 46 patients (33%). 3Di-PMR was significantly higher in patients with pMI than those without pMI. The optimal 3Di-PMR cutoff value for predicting pMI was 51 PMR*mm3 and the area under the receiver operating characteristic curve (0.753) was significantly greater than that for 2D-PMR (0.683, P = 0.015). 3Di-PMR was positively correlated with lipid volume (r = 0.449, P < 0.001) based on intravascular ultrasound. Stepwise multivariable analysis showed that 3Di-PMR ≥ 51 PMR*mm3 and the presence of a side branch at the PCI target lesion site were significant predictors of pMI (odds ratio [OR], 11.9; 95% confidence interval [CI], 4.6-30.4, P < 0.001; and OR, 4.14; 95% CI, 1.6-11.1, P = 0.005, respectively).

CONCLUSIONS

3Di-PMR coronary assessment facilitates risk stratification for pMI after elective PCI.

TRIAL REGISTRATION

retrospectively registered.

Impact of residual coronary atherosclerosis on transfemoral transcatheter aortic valve replacement

OBJECTIVES

This study reports on the clinical effects of complete vs incompletely revascularized coronary artery disease on transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a high prevalence of active coronary artery disease (CAD) in patients undergoing TAVR but preemptive revascularization remains controversial.

METHODS

Patients were categorized into three cohorts: complete revascularization (CR), incomplete revascularization of a major epicardial artery (IR Major), and incomplete revascularization of a minor epicardial artery only (IR Minor). When feasible, SYNTAX scoring was performed for exploratory analysis. Analyses were performed using Cox proportional hazard models and Kaplan-Meier method.

RESULTS

A total of 323 patients with active CAD were included. Adjusted outcomes showed that patients with IR Major had increased incidence of acute myocardial infarction (AMI) or revascularization compared with those in the CR cohort (HR 3.72, P = 0.048). No difference was noted in all-cause mortality or all-cause readmission rates. Exploratory secondary analysis with residual SYNTAX scores showed a significant interaction between disease burden and AMI/revascularization, as well as all-cause readmission. All-cause mortality remained unaffected based on residual SYNTAX scores.

CONCLUSIONS

This is a retrospective single-center study reporting on pre-TAVR revascularization outcomes in patients with active CAD. In this analysis, we found that patients undergoing TAVR benefited from achieving complete revascularization to abate future incidence of AMI/revascularization. Despite this finding, all-cause mortality remained unaffected. Future efforts should focus on the role of functional assessment of the coronaries, as well as the long-term effects of complete revascularization in a larger patient cohort.

Comparison of Long-Term Mortality in Patients With Previous Coronary Artery Bypass Grafting Who Underwent Percutaneous Coronary Intervention With Versus Without Optimal Medical Therapy

Although current guidelines have highlighted the importance of evidence-based optimal medical therapy (OMT) in patients with previous coronary artery bypass grafting (CABG), the effect of OMT on post-CABG patients requiring secondary coronary revascularization on prognosis remains unknown. We sought to examine the impact of OMT on post-CABG patients who underwent percutaneous coronary intervention (PCI) as secondary revascularization. A total of 632 consecutive post-CABG patients who underwent PCI between 2001 and 2013 at our hospital (84% men, median age 71 years) were divided into 2 groups: patients who were discharged with OMT and patients who were discharged without OMT (non-OMT). OMT was defined as the combination of an antiplatelet agent, statin, β blocker, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Despite having a higher prevalence of clinical comorbidities, patients with OMT (n = 163) had a lower prevalence of all-cause death than those without OMT (n = 469) during a median follow-up of 95 months (OMT group 21.5%, non-OMT group 34.1%, p = 0.002). Both groups had similar procedural success rates. In a propensity-matched cohort (n = 146 each), OMT was associated with lower rates of all-cause death and cardiac death than non-OMT 8 years after PCI. In multivariable analysis, OMT was an independent predictor of all-cause death (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.34 to 0.72, p <0.001). In conclusion, OMT plays a protective role and reduces all-cause death in post-CABG patients requiring subsequent PCI. Outside of the domain of coronary revascularization, OMT could be considered an essential treatment in this patient population.

Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery and the SYNTAX score: A systematic review and meta-analysis

The SYNTAX [Synergy Between percutaneous coronary intervention (PCI) With Taxus and coronary artery bypass surgery (CABG)] score is a decision-making tool in interventional cardiology. However, several facts still remain to be addressed: What about PCI or CABG with a low versus a high score respectively? And what about PCI with a low score versus CABG with a high score? Electronic databases were carefully searched for relevant publications. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated and the analysis was carried out by RevMan 5.3. Eleven studies with a total number of 11,037 patients were included. In terms of clinical outcomes, this analysis showed PCI to have significantly favored patients with a low versus a high SYNTAX score. In patients who were re-vascularized by CABG, mortality and major adverse cardiac events were significantly lower with a low SYNTAX score. However, when PCI with a low SYNTAX score was compared with CABG with a high SYNTAX score, no significant difference in mortality and combined death/stroke/myocardial infarction were observed. In conclusion, the SYNTAX score might be considered useful in interventional cardiology. Nevertheless, the fact that it has limitations when compared to newer tools should also not be ignored.