Complete Coronary Revascularization Research Articles

Is it feasible to treat atrial fibrillation at the time of minimally invasive coronary artery bypass grafting?

Coronary artery bypass grafting remains the most common operation performed by cardiac surgeons. As a result, a cardiac surgeon with a typical practice will most commonly encounter atrial fibrillation when performing coronary artery bypass grafting. In this review, we first emphasize the importance of treating atrial fibrillation in patients undergoing coronary bypass grafting. We review benefits of concomitant surgical ablation and its importance relative to complete coronary revascularization. We then discuss options to treat atrial fibrillation in a more minimally invasive manner in these patients, while still preserving treatment efficacy. Surgical ablation at the time of coronary artery bypass grafting surgery could be as important as complete revascularization. Bi-atrial ablation provides superior rhythm control compared to left-sided ablation only. We highlight various options for surgical ablation at the time of coronary artery bypass grafting surgery, and provide an algorithm for ablation in individual patients.

Completeness of revascularization by FFRCT in stable angina: Association to adverse cardiovascular outcomes

BackgroundThe prognostic impact of complete coronary revascularization relative to non-invasive testing methods is unknown. ObjectivesTo assess the association between completeness of revascularization defined by CTA-derived fractional flow reserve (FFRCT) and cardiovascular outcomes in patients with stable angina. MethodsMulticenter 3-year follow-up study of patients with new onset stable angina and ≥ 30% stenosis by CTA. The lesion-specific FFRCT value (two cm-distal-to-stenosis) was registered in all vessels with stenosis and considered abnormal when ≤ 0.80. Patients with FFRCT ≤ 0.80 were categorized as: Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤ 0.80 revascularized; incompletely revascularized (IR-FFRCT), ≥ 1 vessels with FFRCT ≤ 0.80 non-revascularized. Early revascularization (< 90 days from index CTA) categorized vessels as revascularized. The primary endpoint comprised cardiovascular death and non-fatal myocardial infarction; the secondary endpoint vessel-specific late revascularization and non-fatal myocardial infarction. ResultsAmongst 900 patients and 1759 vessels, FFRCT was ≤ 0.80 in 377 (42%) patients, 536 (30%) vessels; revascularization was performed in 244 (27%) patients, 340 (19%) vessels. Risk of the primary endpoint was higher for IR-FFRCT (15/210 [7.1%]) compared to CR-FFRCT (4/167 [2.4%]), RR: 2.98; 95% CI: 1.01–8.8, p ​= ​0.036, and to normal FFRCT (3/523 [0.6%]), RR: 12.45; 95% CI: 3.6–42.6, p ​< ​0.001. Incidence of the secondary endpoint was higher in non-revascularized vessels with FFRCT ≤ 0.80 (29/250 [12%]) compared to revascularized vessels with FFRCT ≤ 0.80 (5/286 [1.7%]), p ​= ​0.001, and to vessels with FFRCT > 0.80 (10/1223 [0.8%]), p ​< ​0.001. ConclusionIncomplete revascularization of patients with lesion-specific FFRCT ≤ 0.80 is associated to unfavorable cardiovascular outcomes compared to those with complete revascularization or FFRCT > 0.80.

Short-term outcomes of complete coronary revascularization compared to staged revascularization during primary percutaneous coronary intervention in patients with multivessel coronary artery disease: Presenting with ST segment elevation myocardial infarction

Abstract Background Complete revascularization has been recently popularized for management of ST-Segment–Elevation Myocardial Infarction (STEMI) patients with multivessel disease scheduled for Primary Percutaneous Coronary Intervention (PPCI). We assessed the three months outcomes of Compete Revascularization (CR) compared to staged revascularization in patients with multivessel disease undergoing PPCI. Materials and methods We conducted a randomized, open-label, comparative trial on STEMI patients with multivessel disease indicated for PPCI in the setting of STEMI. Patients were randomly assigned to undergo PCI revascularization of the non-culprit lesions during the index procedure, Complete Revascularization (CR) or within 30 days later after discharge, Staged Revascularization (SR). The primary endpoint was the composite of all-cause mortality, re-infarction, Heart Failure (HF), recurrence of angina symptoms, cerebrovascular stroke, and need for revascularization. Results A total of 100 patients were randomized in 1:1 ratio. The primary end point occurred in 24% of the patients in CR and 20% in SR group (p = 0.62). The incidence of HF (14% vs. 12%; p = 0.76), repeated revascularization (4% in each group), persistent angina (8% vs. 2%, p = 0.16), all-cause mortality (2% in each group), MI (4% in each group), stent thrombosis (0% vs. 4%; p = 0.15), and cerebrovascular accident (0% vs. 2%; p = 0.32). Conclusion Staged revascularization provided comparable short-term benefits to complete revascularization in STEMI patients with multivessel disease undergoing PPCI. The present trial demonstrated that complete revascularization was associated with a trend towards higher incidence of stent thrombosis and CVA than staged revascularization. Key words: ST-segment&amp;#x96;elevation myocardial infarction, Primary percutaneous coronary intervention, Revascularization, Multivessel disease. Abbreviations: CAD: Coronary Artery Disease; FFR: Fractional Flow Reserve; PCI: Percutaneous Coronary Intervention; PPCI: Primary Percutaneous Coronary Intervention; STEMI: ST-segment–Elevation Myocardial Infarction; CVA: Cerebrovascular Accidents.

Immediate multivessel revascularization after myocardial infarction: change of strategy?

Multivessel coronary artery disease (MVD) is a frequently encountered condition in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) of the culprit vessel. Several studies have demonstrated the benefit of complete coronary revascularization compared with the treatment of the culprit lesion only in patients with STEMI. Based on this evidence, the current European guidelines recommend that in haemodynamically stable patients with STEMI and MVD, routine complete revascularization should be achieved either during the same procedure in concomitance with the treatment of the culprit lesion (immediate multivessel PCI) or with a subsequent intervention within 45 days from the index PCI of the culprit lesion (deferred multivessel PCI). However, the guidelines do not express a preference for immediate vs. delayed multivessel PCI. Therefore, the optimal timing of the treatment of non-culprit lesions in patients with STEMI and haemodynamic stability is still debated and has been evaluated in recent studies that showed the non-inferiority of immediate vs. delayed multivessel PCI. The article discusses the results and clinical implications of these studies on the timing of complete revascularization of non-culprit lesions in haemodynamically stable patients with STEMI.

Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial

There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.

Revascularization of coronary chronic total occlusions in the elderly: what results? - The insights of a multicentre national registry

Abstract Lately, the remarkable progress in knowledge and treatment of cardiovascular diseases has been significantly impacting society's morbidity and mortality. However, the burden of coronary artery disease (CAD) remains non-negligible. In addition, as a consequence of demographic changes, age, as a non-modifiable cardiovascular risk factor, makes it increasingly important to focus on the elderly. Up to one-fifth of patients with CAD have a chronic total occlusion (CTO) of a coronary artery, defined as a lesion with 100% stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 that exists for more than 3 months. There is current evidence that successful CTO-percutaneous coronary intervention (PCI) is associated with clinical benefits. However, elderly patients are currently underrepresented in CTO-PCI randomized controlled trials and registries, and its clinical impact and safety in this group of patients are still debated. This study aims to characterise patients submitted to CTO-PCI and compare the baseline characteristics, coronary intervention features, intraprocedural complications and in-hospital mortality between patients younger and older than 75. The authors performed a retrospective analysis of adult patients submitted to a CTO-PCI, included in the Portuguese Registry on Interventional Cardiology between January 2019 and December 2022. Comparison tests between groups for parametric and non-parametric variables were performed. A p-value less than 0.05 was considered statistically significant. A total of 353 patients who underwent CTO-PCI were analysed, 271 (76.8%) with 18 to 74 years old (group 1) and 82 (23.2%) with 75 or more years old (group 2). Table 1 shows the most important baseline characteristics, with similar features for both groups except body mass index and smoking habits. Table 2 demonstrates the differences between the groups regarding PCI, with the left main and left anterior descending arteries being more treated among older patients and the right coronary artery in younger patients. Complete coronary revascularization and procedure success rate did not differ significantly between groups (p-value=0.19 and p-value=0.59, respectively). Finally, table 3 presents the main intra-procedural and in-hospital complications, with a significant difference only for occlusion of the side branch, occurring in 2 patients aged over 75 years (p-value=0.01). In conclusion, in our registry, the elderly presents a high success rate in the complete recanalization of CTO lesions, comparable to the group under 75 years of age. However, the presence of side branch occlusion was higher in older patients, without other significant differences in intraprocedural and in-hospital complications, including mortality. Further studies including a large sample and follow-up analysis would be essential to better understand the rate of risks related to PCI-CTO potentially associated with the complexity and comorbidities of the elderly.Table 1Table 2 and 3

Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy.

Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported. From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%). Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%. This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.

The Reduction of Left Ventricle Ejection Fraction after Multi-Vessel PCI during Acute Myocardial Infarction as a Predictor of Major Adverse Cardiac Events in Long-Term Follow-Up.

Background: Revascularisation strategy in patients with multi-vessel coronary disease and acute myocardial infarction (AMI) remains challenging. One of the potential treatment options is complete percutaneous revascularisation during index hospitalisation. This strategy could positively influence left ventricle ejection fraction (LVEF). Aim: To investigate the long-term changes in LVEF and clinical outcome among patients with AMI after complete coronary revascularisation (CCR). Methods: Records of 171 patients with a diagnosis of AMI and multi-vessel coronary artery disease (CAD) on index angiography, in whom CCR was performed as a staged procedure during initial hospitalisation, were analysed. Clinical data were collected from in-hospital medical records and discharge letters. Cardiac ultrasound (CU), with particular assessment of LVEF, was performed one day before discharge. Follow-up (FU) CU was collected from the out-patient department at least six months ± one week after discharge. Follow-up data, including major adverse cardiac events (MACE), were collected during follow-up visits by telephone. Depending on the LVEF change during the follow-up period, patients were divided into two groups. Patients with a decrease in the LVEF (D-LVEF group) were compared with patients with no changes (preserved) or improvement regarding LVEF (P/I-LVEF). Results: The median duration of the follow-up was 19 months (14–24 months). The median change in LVEF during observation was –5.0p% (IQR (–7.0)–(-2.75p.%)) in the D-LVEF group and +4.0% (IQR 1.0–5.0p%) in the P/I-LVEF group. Among patients in the P/I-LVEF group, there was a sub-group of patients with no change in LVEF (28 patients), and one demonstrating improvement in LVEF (104 patients). In the subgroup of patients with improved LVEF, the median change in LVEF was 4.5p% (IQR 2–6.25p%). Among patients with decreasing LVEF, there was a significantly higher risk of MACE (15 vs. 2.3%, p = 0.031), especially non-fatal AMI (10 vs. 0%, p = 0.017). We found the following among predictors concerning increased risk of MACE occurrence: urgent PCI (p = 0.004), hospitalisations regardless of cause (p = 0.028), EF worsening (p = 0.025), fasting glucose serum concentration (p = 0.024) and fasting triglyceride serum concentration (p = 0.027). Conclusions: Complete revascularisation (CR) at baseline (one stage) in patients with AMI and multi-vessel disease is associated with LVEF improvement and MACE rate reduction. Patients with worse LVEF have poor clinical outcome and a higher rate of MACE.

Long-term outcomes of concomitant transcatheter aortic valve implantation and percutaneous coronary intervention.

The safety of concomitant percutaneous coronary intervention (PCI) during transcatheter aortic valve implantation (TAVI) setting is still highly debated. This study aimed to assess the safety and the effectiveness of TAVI and PCI performed in the same session compared with TAVI alone. Patients with severe aortic stenosis and coronary artery disease (CAD) (N.=786) who underwent TAVI from June 2007 to April 2021 were divided into two groups: patients who underwent TAVI alone (N.=633) and patients treated with TAVI and concomitant PCI (N.=153). The propensity-score matching adjustment was used to account for baseline confounding variables. A total of 302 TAVI with CAD patients (151 matched pairs), undergoing either isolated TAVI or TAVI+PCI were compared. In-hospital death (6% vs. 4%; P=0.427), stroke (2% vs. 0.7%; P=0.314), myocardial infarction (MI) (0% vs. 0.7%; P=0.317), major and life-threatening bleeding (14.6% vs. 15.9%; P=0.749), and acute kidney injury (9.3% vs. 10.6%; P=0.700) were similar for both groups. At 3 years, the rates of all-cause death (25.2% vs. 19.2%; P=0.615), the composite endpoints of all-cause death and MI (27.2% vs. 21.2%; P=0.699) and all-cause death, MI, and stroke (28.5% vs. 22.5%; P=0.739) were also comparable between the two groups. Achieving complete coronary revascularization in the TAVI setting did not impact on long-term mortality (P=0.257). In patients with severe aortic stenosis and CAD, concomitant TAVI and PCI was as safe and effective as TAVI alone up to 3-year follow-up.

Assessing the Clinical Influence of Chronic Total Occlusions (CTOs) Revascularization and the Impact of Vascularization Completeness on Patients with Left Ventricular (LV) Systolic Dysfunction.

Objectives This paper intends to assess the clinical influence of chronic total occlusions (CTOs), revascularization, and the impact of vascularization completeness on patients with left ventricular (LV) systolic dysfunction. Background The roles of CTO vascularization in clinical benefits remain conflicting. In addition, data concerning the different results of CTO vascularization and vascularization completeness according to LV systole function were assessed. Methods From an overall 918 consecutive patients with at least one CTO, 281 patients with ejection fraction (EF) ≤40% accepted coronary angiographic analysis between Jan 1, 2012, and Dec 31, 2020, and 29 patients were excluded. Subsequently, 261 patients were grouped into the successful CTO-PCI revascularization group (SCR, n = 135) and the optimal medical therapy group (OMT, n = 126). The prognosis influence of successfully finished CTO-PCI and complete revascularization on survival was evaluated. The primary endpoint was cardiac mortality, and the secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE). Results After a median follow-up time of 38.02 months, the cardiac mortality (p=0.037) and MACCE (p=0.001) were more remarkable in the OMT group than in the SCR group. Moreover, patients with CTO-PCI had survival benefits from complete revascularization for MACCE (p=0.025) and cardiac mortality (p=0.041). Based on multivariable Cox proportional hazards regression analysis, age ≧ 75 years (HR: 3.443, 95% CI 1.719–6.897, p < 0.001) predicted a worse probability of cardiac mortality. Additionally, previous PCI (HR: 1.592, 95% CI 1.034–2.449, p=0.035) and previous MI (HR: 1.971, 95% CI 1.258–3.088, p=0.003) predicted a worse probability of MACCE, and SCR (HR: 0.499, 95% CI 0.320–0.776, p=0.002) was a protection predictor of MACCE. Conclusion In patients with LV systole dysfunction (EF ≤ 40%), successfully finished CTO-PCI is related to long-term survival benefits. The benefits were more remarkable in patients with complete coronary revascularization (CCR).

Coronary sinus reducer for the treatment of chronic refractory angina pectoris.

Refractory angina represents the final stage of chronic coronary artery disease, where anginal symptoms persist despite complete epicardial coronary artery revascularization and maximally tolerated pharmacological therapy. Percutaneous narrowing of the coronary sinus with the coronary sinus reducer (Reducer®, Neovasc, Inc., Richmond, Canada) device was first attempted in humans in 2005 and has been shown to improve angina symptoms and the quality of life of patients suffering chronic refractory angina. Itwas recently included in the European guidelines for the management of chronic coronary syndrome and is progressively gaining popularity. The authors hereby provide a review of current literature on the topic, intending to facilitate insights and to promote further research on this device and its clinical applications.

Usefulness of The Syntax Revascularization Index and The Concept of Reasonable Incomplete Revascularization In "All Comers" Patients Undergoing Percutaneous Coronary Intervention

In particular settings, achieving complete coronary revascularization could be very challenging. The Syntax Revascularization Index (SRI) represents a useful tool to assess the degree of coronary revascularization in patients undergoing percutaneous coronary intervention (PCI). This study aimed to assess the prognostic usefulness of the SRI in an

Elderly patients with acute myocardial infarction: Targeted or complete revascularization?

Key Points The benefit of complete coronary revascularization in stable patients with STEMI and multivessel disease is well established; however, the extension of this benefit in older patients or with NSTEMI is uncertain. This observational study including elderly patients presenting with STEMI or NSTEMI showed that a complete as compared with a culprit‐only revascularization may reduce the risk of all‐cause mortality, cardiovascular death and myocardial infarction. Additional evidence from randomized controlled trials is needed to confirm these findings

Chronic total occlusion revascularization: A complex piece to "complete" the puzzle.

Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of “contemporary” strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a “complex” piece to “complete” the puzzle.

Robotically assisted hybrid coronary revascularization-Masterly technique but is it for the masses?

Hybrid coronary revascularization consists of left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and transcatheter revascularization of the non‐LAD stenosis in specific settings to achieve complete coronary revascularization. Technique to perform the LITA to LAD graft has ranged from median sternotomy with cardiopulmonary bypass to robotically assisted totally endoscopic coronary bypass surgery using beating heart revascularization.

Radial Artery Versus Saphenous Vein as Third Conduit in Coronary Artery Bypass Graft Surgery for Multivessel Coronary Artery Disease: a Ten-Year Literature Review.

Coronary artery bypass grafting is the gold standard strategy for obtaining complete coronary revascularization in patients with multivessel coronary artery disease. The recent AHA and EACTS guidelines on myocardial revascularization recommend total arterial revascularization, especially in younger patients, whenever possible. However, the use of saphenous vein grafts in association with single or bilateral internal thoracic artery (SITA, BITA) instead of arterial grafts (radial arteries, right gastroepiploic artery and inferior epigastric artery) is widespread. We analyzed literature from the last ten years (January 2010 to December 2020) looking for evidence in favour of the use of a radial artery compared to a saphenous vein in association with BITA. We identified nine studies (4 Systematic Reviews and Meta-analyses and 6 large cohort observational studies with propensity score-matching) that compared arterial with saphenous grafts as third conduit. The main finding of the review is the higher rate of freedom from any cardiac adverse event in the population which reached Total Arterial myocardial Revascularization (TAR). A probable reason for the limited application of TAR as a strategy is the shortage of Randomized Controlled Trials (RCTs). (www.actabiomedica.it)

The total amount of CRP within the first 72 h after STEMI is crucial for the outcome

Abstract Background The CAMI-1 study dealt with the depletion of CRP by apheresis in patients with acute myocardial infarction (AMI). CRP, the prototype human acute phase protein, has been known as a marker of poor prognosis in AMI and independently predicts 30-day mortality. Methods 66 STEMI patients were enrolled following complete coronary revascularization (2–12 h after AMI). 32 patients received CRP apheresis, whereas 34 patients treated by standard protocols served as controls. CRP apheresis started 24±12 h and 48±12 h after onset of symptoms. A specific CRP adsorber removed ≤79% of the original CRP. 6000 ml of plasma was treated via peripheral venous access. Primary endpoint was myocardial infarction size as determined by Cardiac Magnetic Resonance Imaging (CMR) 3–9 days after STEMI. Results Aphereses sessions were well tolerated with no relevant side effects. The expected peak CRP level after AMI can be calculated precisely with 2–3 CRP quantifications during the first 24h after the onset of symptoms (CRP gradient). The regression coefficient for this analysis is 0.91. This mathematical step allows for the comparison of the CRP-apheresis group and the controls on the basis of their individual CRP gradients. The mean CRP gradient does not differ between both groups, whereas the mean area under the curve (AUC) of CRP within the first 72 h after AMI does. Thus, there was no bias in CRP kinetics between the two groups. The AUC of CRP is a significant indicator for infarct size (p=0.002), LVEF (p&amp;lt;0.001), circumferential strain (p&amp;lt;0.001), longitudinal strain (p=0.021). Therefore, the aphereses patients performed significantly better at all endpoints than the controls. The CRP apheresis significantly reduced myocardial damage by a reduction of the AUC of CRP. To our surprise, two apheresis patients had an infarct size of 0%. Conclusions For the first time we find an unequivocal association between myocardial infarct size and the AUC of CRP. The results show a significant beneficial effect of CRP apheresis on myocardial infarction size and wall motion. Selective CRP apheresis is now being further evaluated as a therapeutic approach in the treatment of acute myocardial infarction in a registry (CAMI registry). Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Pentracor GmbH

Complete surgical revascularization: Different definitions, same impact?

There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.

Mortality Outcomes of Single-staged versus Multi-staged Complete Coronary Revascularization in Multivessel Non-ST Elevation Myocardial Infarction Patients

Aim: The aim of this study was to compare the short-term and long-term mortality results of single-stage percutaneous coronary intervention (SS-PCI) and multi-stage percutaneous coronary intervention (MS-PCI) strategies in patients diagnosed with non-ST segment elevation myocardial infarction (NSTEMI) with multivessel disease. Material and Methods: A total of 298 consecutive patients diagnosed with multivessel NSTEMI (71 (23.8%) patients in the SS-PCI group and 227 (76.2%) patients in the MS-PCI group) were included in this study. Data regarding mortality were obtained from the health information system of our institute and national health registry. Results: Although in-hospital mortality rates were found to be significantly higher in univariate analysis in the SS-PCI group compared to the MS-PCI group (14.1% (n=10) vs 4.0% (n=9); p=0.005), it was not independently associated with total mortality in multiple model. Among the parameters predicted mortality determinants, low hemoglobin (odds ratio (OR)=0.485, 95% confidence interval (CI)=0.332-0.708; p=0.002), No-reflow occurrence (OR=6.194, 95% CI=1.310-29.300, p=0.021), not using post dilatation (OR=0.287, 95% CI=0.085-0.970, p=0.045) were independently associated with total mortality. Conclusion: There was no statistical difference in overall mortality between the two study groups in multivessel NSTEMI patients who underwent complete coronary revascularization with the SS-PCI and MS-PCI strategy, while low hemoglobin, No-reflow phenomenon, and not using post-dilatation were found as independent predictors of mortality.

Functionally Complete Coronary Revascularisation in Patients Presenting with ST-elevation MI and Multivessel Coronary Artery Disease.

Up to half of patients undergoing primary percutaneous coronary intervention of a culprit stenosis in the context of the ST-elevation MI may present with multivessel disease. The presence of non-culprit stenoses have been shown to affect the outcomes of these patients, and the results of the more recent randomised trials highlight the importance of complete coronary revascularisation. In this paper, the authors review the main trials published on the topic and discuss tools for the assessment of non-culprit stenoses, while considering the right time for carrying out a complete coronary revascularisation.