Benefit Of Revascularization Research Articles

Incremental long-term prognostic value of stress CMR above traditional risk factors to predict death a large registry with > 200,000 patient-years of follow-up

While the benefit of coronary revascularization in patients with stable coronary artery disease (CAD) is debated, data assessing the potential interest of stress CMR to guide coronary revascularization are limited. To assess the long-term prognostic value of stress CMR in consecutive patients from a large registry. Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (IQR: 5.0–8.0) included all consecutive patients referred for stress CMR. The primary outcome was all-cause death based on the National Death Registry. Among the 31,752 consecutive patients (mean age 63.7 ± 12.1 years and 65.7% males), 2679 (8.4%) died at 206,453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement (LGE) by CMR were associated with death (both P < 0.001). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of death (HR = 1.61; 99.5% CI: 1.41–1.84; HR = 1.62; 99.5% CI: 1.41–1.86, respectively; P < 0.001). The addition of LVEF, LGE and inducible ischemia significantly improved the C statistic to 0.71 (99.5% CI: 0.70–0.72; C statistic improvement for model 1: 0.03; NRI = 0.035). The addition of the presence of LGE and the number of segments of LGE and inducible ischemia significantly improved the C statistic to 0.74 (99.5% CI: 0.73–0.75; C statistic improvement for model 1: 0.06; NRI = 0.061) ( Fig. 1 ). In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors.

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

BackgroundMyocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.MethodsIn this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.ResultsA total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P=0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.ConclusionsAmong patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.)

86 STEMI and multivessel disease: medical therapy amplifies the benefit of complete myocardial revascularization

Abstract Aims Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularization strategies. However, the potential predictors of outcomes on top of different revascularization strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularization strategies and the potential impact of medical therapy. Methods and results Using a propensity score approach, the impact of two treatment strategies was analysed—staged non-culprit revascularization group vs. culprit-lesion-only percutaneous coronary intervention (PCI) group—on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularization. Moreover, models were further adjusted for medication at discharge. Among 1385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21–65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularization group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24–0.82; P = 0.01), lower CVD (HR, 0.34; 95% CI, 0.14–0.82; P = 0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24–0.86; P = 0.02). Use of renin–angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27–0.95; P = 0.03), and both renin–angiotensin inhibitors (HR, 0.52; 95% CI, 0.32–0.86; P = 0.01) and beta blockers (HR, 0.48; 95% CI, 0.29–0.79; P = 0.01) were associated with lower all-cause death. Conclusions In a real-word STEMI population with multivessel disease, staged non-culprit revascularization was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularization and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularization.

Abstract 9515: Heterogeneity of Benefit on Quality of Life With an Invasive versus Conservative Strategy for Chronic Coronary Disease. Results From the ISCHEMIA Trial

Background: The ISCHEMIA trial recently showed that, on average, patients with chronic coronary disease (CCD) and at least moderate ischemia randomized to an invasive strategy (INV) reported less angina and better quality of life (QOL) than those treated conservatively (CON)—an effect sustained through follow-up. To better support shared decision-making for individual patients, we explored the heterogeneity of treatment benefit of the INV vs CON strategy within the ISCHEMIA trial. Methods: Disease-specific QOL was assessed with the Seattle Angina Questionnaire (SAQ; scores range 0-100, higher=less angina/better QOL). An ordinal (proportional odds) model for 1-year SAQ summary score (SAQ SS) produced estimates of the odds of better QOL with randomization to INV vs CON, with potential heterogeneity of treatment benefit explored via interactions between patient factors and treatment. The final model included both significant interactions (accounting for multiple testing) and main effects. Results: Among 4617 patients with CCD from 37 countries randomized to INV vs CON treatment (mean age 64 ± 10 y, 23% women, 40% diabetes), mean SAQ SS was 74.1 ± 18.9 at baseline and 85.7 ± 15.6 at 1 year (p&lt;0.001). Patients with lower baseline SAQ SS (i.e., more angina) and younger patients derived greater symptomatic treatment benefit from INV management (model-based interaction p=0.005 and p=0.004, respectively; Figure). No other patient factor was associated with a differential treatment effect. In the final model, female sex and diabetes were also associated with worse 1-year QOL, independent of treatment. Conclusion: Using data from a large multinational randomized trial, we found that younger patients and those with more angina at baseline derived greater QOL benefit from INV management. As the primary benefit of revascularization in CCD is symptom improvement, this model could be used to better inform individual patient’s decision-making for initial treatment.

TCT-113 Ten-Year Survival Benefit and Appropriateness of Surgical or Percutaneous Revascularization Based on Individual Predicted All-Cause Mortality in Patients With Complex Coronary Artery Disease

TCT-113 Ten-Year Survival Benefit and Appropriateness of Surgical or Percutaneous Revascularization Based on Individual Predicted All-Cause Mortality in Patients With Complex Coronary Artery Disease

Long-Term Prognostic Value of Stress Cardiovascular Magnetic Resonance-Related Coronary Revascularization to Predict Death: A Large Registry With >200 000 Patient-Years of Follow-Up.

Although the benefit of coronary revascularization in patients with stable coronary disease is debated, data assessing the potential interest of stress cardiovascular magnetic resonance (CMR) to guide coronary revascularization are limited. We aimed to assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry. Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range, 5.0-8.0) included all consecutive patients referred for stress CMR. CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the National Death Registry. Among the 31 762 consecutive patients (mean age 63.7±12.1 years and 65.7% males), 2679 (8.4%) died at 206 453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement by CMR were associated with death (both P<0.001). In multivariable Cox regression, inducible ischemia and late gadolinium enhancement were independent predictors of death (hazard ratio, 1.61 [99.5% CI, 1.41-1.84]; hazard ratio, 1.62 [99.5% CI, 1.41-1.86], respectively; P<0.001). In the overall population, CMR-related coronary revascularization was an independent predictor of greater survival (hazard ratio, 0.58 [99.5% CI, 0.46-0.74]; P<0.001). In 1680, 1:1 matched patients using a limited number of variables (840 revascularized, 840 nonrevascularized), CMR-related revascularization was associated with a lower incidence of death in patients with severe inducible ischemia (≥6 segments, P<0.001) but showed no benefit in patients with mild or moderate ischemia (<6 segments, P=0.109). Using multivariable analysis in the propensity-matched population, CMR-related revascularization remained an independent predictor of a lower incidence of all-cause mortality (hazard ratio, 0.66 [99.5% CI, 0.54-0.80], P<0.001). In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

Deteriorating cardiac function in patients with chronic total occlusion after successful percutaneous coronary intervention: A case series

Background: Current trials show conflicting results about the effect of successful Percutaneous Coronary Intervention (PCI) on cardiac function in patients with chronic total occlusion (CTO). Various factors contribute to a lack of functional changes after CTO revascularization. Case summary: Here, we present three patients who underwent PCI to treat CTO of the single main branch, all of whom demonstrated a decline in cardiac function detected by Cardiovascular Magnetic Resonance (CMR). Case 1 is a patient with a history of smoking, and transmural myocardial necrosis in the territory of the CTO at baseline. Case 2 exhibites hyperglycemia and persistent ischemia in a non-CTO-supplied territory. Case 3 has a long history of alcohol abuse, likely causing adverse ventricle remodeling after PCI. Discussion: The deterioration observed in these cases does not appear to be associated with the PCI itself. It should be considered that postoperative risk factors attenuate the true benefits of CTO revascularization. This case series also highlights the prudent selection of patients eligible for revascularization by comprehensive assessments and recommends continuous strict management during follow-up to improve the long-term prognosis of patients and the application value of CTO revascularization. Keywords: chronic total occlusion; percutaneous coronary intervention; cardiac function; adverse ventricle remodeling; cardiovascular magnetic resonance imaging

Myocardial work and left ventricular contractile reserve during stress echocardiography: An angiographic validation.

This study sought to determine the contractile reserve (CR) response to exercise stress echocardiography (ESE) quantified by the novel parameter, non-invasive myocardial work (MW), in subjects with angiographically proven coronary artery disease (CAD). CR was measured by the relative change in ejection fraction (EF), global longitudinal strain (GLS) and MW indices from rest to peak exercise in 304 patients referred for clinically indicated ESE. Positive ESE patients proceeded to coronary angiography and further risk stratified based on either percutaneous or surgical intervention. CRGLS and global work index (CRGWI ) significantly decreased with exercise induced ischemia and angiographically proven significant CAD (CRGLS -1.6±3.5%; CRGWI -8.6±511mm Hg% decrement, p<0.001) compared to non-ischemic patients (CRGLS 1.4±2.2%; CRGWI 398±404mm Hg% improvement). Global constructive work (CRGCW ) was significantly higher (p<0.0001) in non-ischemic (818±457mm Hg%) and blunted in ischemic patients (208±550mm Hg%). CRGCW (AUC .81; 95%CI:.75-.86) demonstrated the most association for inducible ischemia followed by CRGLS (AUC .75; 95%CI:.69-.80), CRGWI (AUC .73, 95%CI:.67-.79) and CREF (AUC .71; 95%CI:.65-.77, p<0.001). Subgroup analysis showed patients requiring surgical revascularization demonstrated a significantly lower CRGWE (-11.5±7.6%, p<0.05) as a result of reduced CRGCW (281±573mm Hg%, p<0.05) and increased global wasted work (CRGWW , 289±151mm Hg%, p=0.09). Multivessel disease requiring surgical revascularization have the greatest reduction in CR. MW may potentially improve detection of ischemia and further risk stratification during ESE to maximize the benefits of revascularization.

Reintervention and Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection With a Zone 3 Entry Tear

Treatment of acute type B aortic dissections (TBADs) using thoracic endovascular aortic repair (TEVAR) is influenced by the location and extent of the pathology, the presence of high-risk features, and complication status. The technical aspects of TEVAR for TBAD (specifically the location of the proximal seal zone [PSZ], the need to cover the left subclavian artery [LSA], distal seal zone [DSZ; length of aortic coverage]), the benefits of LSA revascularization, and prophylactic lumbar spinal drainage are still debated.

Angiography Is an Important Adjunct to WIfI Clinical Staging

The SVS Threatened Limb Classification System (“WIfI”) is used to predict risk of limb loss and potentially predict benefit of revascularization in the setting of chronic limb-threatening ischemia (CLTI). We sought to analyze angiographic findings by WIfI classification in patients with CLTI.

STEMI and Multivessel Disease: Medical Therapy Amplifies the Benefit of Complete Myocardial Revascularisation

Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularisation strategies. However, the potential predictors of outcomes on top of different revascularisation strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularisation strategies and the potential impact of medical therapy. Using a propensity score approach, the impact of two treatment strategies was analysed -staged non-culprit revascularisation group vs culprit-lesion-only percutaneous coronary intervention (PCI) group -- on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularisation. Moreover, models were further adjusted for medication at discharge. Among 1,385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21-65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularisation group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24-0.82; p=0.01), lower CVD (HR, 0.34; 95% CI, 0.14-0.82; p=0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24-0.86; p=0.02). Use of renin-angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27-0.95; p=0.03), and both renin-angiotensin inhibitors (HR, 0.52; 95% CI, 0.32-0.86; p=0.01) and beta blockers (HR, 0.48; 95% CI, 0.29-0.79; p=0.01) were associated with lower all-cause death. In a real-word STEMI population with multivessel disease, staged non-culprit revascularisation was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularisation and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularisation.

Survival benefit of coronary revascularization after myocardial perfusion SPECT: The role of ischemia

BackgroundSurvival benefit of revascularization over medical therapy (MT) in patients with stable ischemic heart disease (SIHD) is uncertain. We evaluated the prognostic effects of revascularization in patients with SIHD undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). MethodsOf 47,894 patients, 7973 had ischemia ≥ 5% of the left ventricle. Of these, 1837 underwent early revascularization (≤ 60 days after SPECT-MPI). The rest were MT subgroup. Follow-up period was 4.04 ± 1.86 years. Statin therapy intensity and adherence were assessed. Outcomes were all-cause mortality, death + non-fatal myocardial infarction (MI), and MACE [major adverse cardiac event = death + MI + late revascularization (> 60 days after SPECT-MPI)]. ResultsAmong patients with moderate-severe ischemia (≥ 10%), death rate was lower in early revascularization compared to MT subgroup (1.42%/year vs 3.12%/year, adjusted hazard ratio (HR) 0.67 (95% CI 0.50-0.90, P = .008). Death + MI and MACE rates were also lower, adjusted HR 0.69 (0.55-0.88, P = .003) and 0.80 (0.69-0.92, P = .003). Revascularization was beneficial in optimal statin therapy subgroup (death rate 1.04%/year vs 2.36%/year, adjusted HR 0.51 (0.30-0.86, P = .012). In mild ischemia (5%-9%), revascularization did not improve survival or MI-free survival, and was associated with higher MACE rate (8.86%/year vs 7.67%/year, adjusted HR 1.30 (1.12-1.52, P < .001). ConclusionCompared to MT, revascularization was associated with reduced risk of death, death + MI, and MACE in patients with moderate-severe ischemia, incremental over optimal statin therapy. In mild ischemia, revascularization was associated with higher risk of MACE, driven by late revascularization, with no impact on death and death + MI.

Long-term prognostic value of stress CMR-related coronary revascularization to predict death: a large registry with &amp;gt; 200,000 patient-years of follow-up

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND While the benefit of coronary revascularization in patients with stable coronary artery disease (CAD) is debated, data assessing the potential interest of stress CMR to guide coronary revascularization are limited. PURPOSE To assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry. METHODS Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range: 5.0-8.0) included all consecutive patients referred for stress CMR. Stress CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the electronic National Death Registry. RESULTS Among the 31,752 consecutive patients (mean age 63.7 ± 12.1 years and 65.7% males), 2,679 (8.4%) died at 206,453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement (LGE) by CMR were associated with death (both p &amp;lt; 0.001). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of death (HR = 1.61; 99.5%CI 1.41-1.84; HR = 1.62; 99.5%CI 1.41-1.86, respectively; p &amp;lt; 0.001). CMR-related coronary revascularization was an independent predictor of greater survival (HR: 0.66; 99.5%CI: 0.52-0.84; p &amp;lt; 0.001). CMR-related revascularization was associated with a lower incidence of death in patients with severe inducible ischemia (p &amp;lt; 0.001), but showed no benefit in patients with mild or moderate ischemia (p = 0.109). CONCLUSIONS In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality.

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p < 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.

New Paradigm of Complete Revascularization in Acute Coronary Syndrome with Multivessel Coronary Artery Disease: Is it Reasonable in Clinical Practice?

Coronary artery disease is the leading cause of illness and death in older adults. Around 40% to 50% of patients with ST-segment elevation myocardial infarction (STEMI) have multiple coronary artery disease. Multiple vessel coronary disease has been shown to improve cardiac outcomes and survival in patients who have undergone complete revascularization (CR) versus patients who have undergone only incomplete revascularization (ICR). When coronary angiography and PCI of the source of the infarction are performed on patients with STEMI, the risk of adverse cardiac death or myocardial infarction is significantly reduced. Additional research is needed to determine the efficacy of PCI of non-critical lesions. However, following procedures such as CABG or PCI, these procedures may be impossible to perform due to a variety of personal, anatomical, technical, and logistical barriers. In this review, we discussed about benefit of complete revascularization in patient acute coronary syndrome (ACS) with multivessel disease and which patient can be performed aggressive revascularization to achieved CR in clinical practice.

European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis.

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.

Long-term prognostic value of stress CMR-related coronary revascularization to predict death: A large registry with > 200,000 patient-years of follow-up

While the benefit of coronary revascularization in patients with stable coronary artery disease (CAD) is debated, data assessing the potential interest of stress CMR to guide coronary revascularization are limited. To assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry. Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range: 5.0–8.0) included all consecutive patients referred for stress CMR. Stress CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the electronic National Death Registry. Among the 31,752 consecutive patients (mean age 63.7 ± 12.1 years and 65.7% males), 2679 (8.4%) died at 206,453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement (LGE) by CMR were associated with death (both P < 0.001). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of death (HR = 1.61; 99.5% CI 1.41–1.84; HR = 1.62; 99.5% CI 1.41–1.86, respectively; P < 0.001). In 1680, 1:1 matched patients using a limited number of variables (840 revascularized, 840 non-revascularized), CMR-related revascularization was associated with a lower incidence of death only in patients with severe inducible ischemia (> 5 segments, P < 0.001), but showed no benefit in patients with mild or moderate ischemia (≤ 5 segments, P = 0.109) Fig. 1 ). In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis.

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients WithNon-ST-Segment Elevation Myocardial Infarction and CardiogenicShock.

The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock. The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain. Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis. Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend<0.001). After 1:1 propensity matching (n=7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p<0.001; odds ratio [OR]: 0.85; 95%CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p<0.001; OR: 1.26; 95%CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p=0.001; OR: 1.26; 95%CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95%CI: 0.87 to 1.03; p=0.20). Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization.

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.