Complete Revascularization Group Research Articles

COMPLETE VS CULPRIT–LESION–ONLY MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST: INSIGHTS FROM THE MULTICENTRIC LOMBARDIA CARE REGISTRY

Abstract Background Out–of–hospital Cardiac Arrest (OHCA) is an uncommon yet potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit–lesion–only revascularization, was associated with an improved 1–year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no history of ischemic heart disease. Median ejection fraction (EF) was 40%. MVD was present in 186 patients and was subsequently treated with either complete (32%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1–year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit–lesion–only revascularization group (p–value < 0.001). After correction for EF, hypercholesterolemia, mechanical or pharmacological support, cardiac arrest time and first shockable rhythm, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions in patients resuscitated from OHCA, complete revascularization strategy was confirmed to be associated with an improvement of 1–year survival and with a good neurological outcome. These results highlight the independent impact on survival of a complete percutaneous coronary intervention strategy in patients with OHCA plus MVD.

Complete revascularization based on angiography derived fractional flow reserve versus incomplete revascularization in patients with ST-segment elevation myocardial infarction.

Nearly half of ST-segment elevation myocardial infarction (STEMI) patients present with significant multivessel coronary artery disease, they are at high risk of subsequent adverse events. Whether complete revascularization guided by coronary angiography-derived fractional flow reserve (caFFR) further reduces such events risk is not fully investigated. In this study, 367 consecutive STEMI patients who underwent successful primary percutaneous coronary intervention (PCI) were enrolled. caFFR of all three coronary vessels were measured, including 367 culprit vessels and 703 non-culprit vessels. Complete revascularization was defined as post-PCI caFFR > 0.8 of all three coronary vessels. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, non-fatal recurrent myocardial infarction, ischemia-driven revascularization and non-fatal stroke/transient ischemic attacks) during follow-up. At a median follow-up of 3.8 years, MACE had occurred in 39 patients of the 220 (17.7%) in the complete revascularization group as compared with 49 patients of the 131 (37.4%) in the incomplete revascularization group (hazard ratio [HR] 1.9; 95% confidence interval [CI] 1.2-3.0; p = 0.005). The incomplete revascularization in culprit vessels evaluated by caFFR showed the highest risk for MACE occurrence. In STEMI patients with multivessel coronary artery disease, incomplete revascularization based on caFFR might contribute to identifying patients at high-risk.

Baseline coronary artery stenosis severity is an independent predictor of subsequent poor sleep quality in patients with acute coronary syndrome.

To investigate the relationship between coronary artery lesion severity determined using the baseline SYNTAX score and sleep problems that might occur after discharge determined using the Pittsburgh Sleep Quality Index (PSQI). This prospective study included patients with first acute coronary syndrome (ACS) who underwent percutaneous coronary angiography between February 2019 and August 2019. The severity of coronary artery stenosis was classified according to coronary angiography and SYNTAX scores. Patients were grouped as those with a SYNTAX score of ≤22 and >22. Sleep quality after discharge was classified according to the PSQI. PSQI ≤5 represented good sleep quality, and PSQI >5 represented poor sleep quality. Univariate and multivariate logistic regression was used to investigate the relationship between sleep quality and coronary artery stenosis severity. A total of 424 patients were included in the study. Of these, 294 (69.34%) had a SYNTAX score of ≤22 and 130 (30.66%) had a SYNTAX score of >22. The mean age of all patients was 60.37 ± 12.23 years, 59.69 ± 11.85 years in the SYNTAX ≤22 groups and 61.90 ± 12.98 years in the SYNTAX >22 group (P = 0.086). The majority (78.54%) of the patients were male and there was no significant difference between the SYNTAX ≤22 group and the SYNTAX >22 group in terms of sex distribution (P = 0.383). According to the univariate logistic regression analysis, age (P = 0.014), diabetes (P = 0.027), left ventricular ejection fraction (P = 0.001), estimated glomerular filtration rate (P = 0.039), creatine kinase MB (P = 0.040) and SYNTAX scores (P < 0.001) were significantly associated with high PSQI global scores (>5). However, according to the multivariate logistic regression analysis results, high (>22) SYNTAX scores were the only factor independently associated with the high (>5) PSQI global scores [odds ratio, 3.477; 95% confidence interval (CI), (2.190-5.522); P < 0.001]. Complete revascularization group had significantly higher sleep latency and sleep duration time, sleep efficiency and the percentage of patients with PSQI global score of ≤5 than the incomplete revascularization group (P < 0.001 for all). Among patients with ACS, those with high SYNTAX scores should be monitored more carefully for sleep disorders that may occur later.

Timing of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel disease: Rationale and design of the OPTION-STEMI trial

Current guidelines recommend complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD). With regard to the timing of percutaneous coronary intervention (PCI) for non-infarct-related artery (non-IRA), recent randomized clinical trials have revealed that immediate CR was non-inferior to staged CR. However, the optimal timing of CR remains uncertain. The OPTION-STEMI trial compared immediate CR and in-hospital staged CR guided by fractional flow reserve (FFR) for intermediate stenosis of the non-IRA. The OPTION-STEMI is a multicenter, investigator-initiated, prospective, open-label, non-inferiority randomized clinical trial. The study included patients with at least one non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into two groups at a 1:1 ratio: immediate CR (i.e., PCI for the non-IRA performed during primary angioplasty) or in-hospital staged CR. In the in-hospital staged CR group, PCI for non-IRA lesions was performed on another day during the index hospitalization. Non-IRA lesions with 50-69% stenosis by visual estimation were evaluated by FFR, whereas those with ≥70% stenosis were revascularized without FFR. The primary endpoint was the composite of all-cause death, non-fatal myocardial infarction, and all unplanned revascularization at 1 year after randomization. Enrolment began in December 2019 and was completed in January 2024. The follow-up for the primary endpoint will be completed in January 2025, and primary results will be available in the middle of 2025. The OPTION-STEMI is a multicenter, non-inferiority, randomized trial that evaluated the timing of in-hospital CR with the aid of FFR in patients with STEMI and MVD. URL: https://www. gov. Unique identifier: NCT04626882; and URL: https://cris.nih.go.kr. Unique identifier: KCT0004457.

FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction

BackgroundThe benefit of fractional flow reserve (FFR)–guided complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear.MethodsIn this multinational, registry-based, randomized trial, we assigned patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease who were undergoing primary percutaneous coronary intervention (PCI) of the culprit lesion to receive either FFR-guided complete revascularization of nonculprit lesions or no further revascularization. The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The two key secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularization.ResultsA total of 1542 patients underwent randomization, with 764 assigned to receive FFR-guided complete revascularization and 778 assigned to receive culprit-lesion-only PCI. At a median follow-up of 4.8 years (interquartile range, 4.3 to 5.2), a primary-outcome event had occurred in 145 patients (19.0%) in the complete-revascularization group and in 159 patients (20.4%) in the culprit-lesion-only group (hazard ratio, 0.93; 95% confidence interval [CI], 0.74 to 1.17; P=0.53). With respect to the secondary outcomes, no apparent between-group differences were observed in the composite of death from any cause or myocardial infarction (hazard ratio, 1.12; 95% CI, 0.87 to 1.44) or unplanned revascularization (hazard ratio, 0.76; 95% CI, 0.56 to 1.04). There were no apparent between-group differences in safety outcomes.ConclusionsAmong patients with STEMI or very-high-risk NSTEMI and multivessel coronary artery disease, FFR-guided complete revascularization was not shown to result in a lower risk of a composite of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only PCI at 4.8 years. (Funded by the Swedish Research Council and others; FULL REVASC ClinicalTrials.gov number, NCT02862119.)

Revascularization for Patients With Heart Failure With Preserved Ejection Fraction and Coronary Artery Disease

Coronary artery disease (CAD) is one of the main causes of heart failure (HF) with preserved ejection fraction (HFpEF). The efficacy of revascularization therapy in patients with HFpEF and CAD, however, remains unclear. Patients who underwent coronary angiography from January 2017 to December 2019 were included in this retrospective study if they further satisfied the diagnosis of HFpEF (left ventricular ejection fraction ≥50% plus plasma N-terminal pro-BNP ≥125pg/ml) and CAD (patients had a history of confirmed myocardial infarction or ≥50% stenosis in at least 1 epicardial coronary vessel). Clinical data, way of revascularization, and outcome events (unplanned repeated revascularization, HF readmission, cardiovascular death, readmission of cerebral hemorrhage/stroke or gastrointestinal bleeding, and all-cause death) were recorded and analyzed. A total of 1,111 patients were enrolled for the present analysis. Based on whether the revascularization was complete or not, the patients were divided into the complete revascularization group (n=780) and the incomplete/no revascularization group (n=331). All patients were followed up with a median of 355days. The overall rates of unplanned repeated revascularization, HF readmission, and cardiovascular death were 6.6%, 5.0%, and 0.4%, respectively. Compared with incompletely/not revascularized patients, completely revascularized patients had a lower rate of unplanned repeated revascularization (10.9% vs 4.7%, p <0.001) and cardiovascular death (0.9% vs 0.1%, p=0.048). However, HF readmission, readmission of cerebral hemorrhage/stroke or gastrointestinal bleeding, and noncardiac death were comparable between the 2 groups. The regression analysis showed that hyperlipidemia, previous myocardial infarction, in-stent restenosis, and way of revascularization were associated with the composite events of unplanned repeated revascularization, HF readmission, and cardiovascular death during the follow-up. Complete revascularization may reduce unplanned repeated revascularization and cardiovascular death for patients with HFpEF and CAD.

REASONABLE INCOMPLETE REVASCULARIZATION USING MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING TECHNIQUES

HighlightsIn multivessel coronary artery disease coronary artery bypass grafting under cardiopulmonary bypass using the internal thoracic artery is the accepted standard of revascularization, however, it is characterized by high trauma. Minimally invasive techniques offset this disadvantage but cannot always provide complete revascularization. Determination of feasibility and combined use of incomplete revascularization with minimally invasive techniques of coronary artery bypass may be a worthy alternative to traditional coronary bypass in a certain group of patients. At the same time, literature the data are ambiguous and deficient in the world. Aim. To justify the use of minimally invasive coronary artery bypass technique in incomplete myocardial revascularization in patients with stable ischemic heart disease from the standpoint of efficacy and safety.Methods. The retrospective study focuses on the analysis of minimally invasive coronary artery bypass grafting (minimally invasive direct coronary artery bypass grafting and off-pump coronary artery bypass surgery using sternotomy) and traditional CABG with cardiopulmonary bypass in patients with multivessel coronary artery disease (n = 429) performed in the period from 2013 to 2017. Depending on the CABG technique and the type of revascularization (complete/incomplete), all patients were divided into 3 groups with two comparison subgroups in each. The completeness of revascularization was assessed using the residual SYNTAX score (rSS). The SYNTAX revascularization index (SRI) was calculated using the following formula: SRI = [1 – (rSS/bSS)] × 100. Subsequently, a two-stage (short- and long-term) analysis of the adverse events frequency was carried out.Results. The minimally invasive incomplete revascularization (IR) group and the traditional complete revascularization (CR) group. The rSS in the IR group was 3.0 [2.0; 5.0] compared with the group without traditional CABG, whereas the SRI was 84.31 [75.00; 89.19] % compared with 100.00 [100.00; 100.00] %, respectively (p&lt;0.001). The analysis of in-hospital period did not reveal significant differences in the number of primary and secondary endpoints. Taking into account the additional endpoints, the IR group had a lower level of intraoperative blood loss – 300 [200; 310] mL compared with 500 [400; 500] mL in the CR group (p&lt;0.001). Moreover, the need for blood transfusion was significantly lower – by 4.27 times (95% CI: 0.124–0.441, p&lt;0.001). The length of patients stay with IR in the intensive care unit was 4.12 times shorter (95% CI: 1,954–8,994, p&lt;0.001). The 1-year follow-up visit revealed full comparability between the groups in terms of frequency of both primary and secondary endpoints. There were no differences in freedom from MACCE and mortality.The minimally invasive CR group and the traditional CR group. The in-hospital period and 1-year follow-up visits showed similar outcomes, comparable to the minimally invasive IR and traditional CR groups. The minimally invasive IR group and the minimally invasive CR group. The analysis of in-hospital period and 1-year follow-up visits did not reveal any differences in endpoints. Freedom from MACСE and death was similar as well.Conclusion. The data obtained indicate a similar safety profile and effectiveness of IR. Minimally invasive IR is appropriate with rSS ≤3 and SRI ≥84.3% and can be considered as an alternative approach to myocardial revascularization in patients for whom traditional CABG is undesirable.

Assessment of left ventricular systolic function in patients with chronic coronary syndrome and heart failure with reduced ejection fraction after percutaneous coronary intervention

Objective: Describe the characteristic and change of left ventricular systolic function after percutaneous coronary intervention in patients with chronic coronary syndrome and heart failure with reduced ejection fraction after percutaneous coronary intervention. Methods: This prospective study involved the monitoring of 40 patients who had an ejection fraction of 40% or less and were diagnosed with chronic coronary artery disease. These patients underwent a successful percutaneous coronary intervention at the Vietnam National Heart Institute and Hanoi Medical University Hospital between September 2022 and August 2023. The main objective is to evaluate the left ventricular systolic function following the intervention using 2D echocardiography. Results: A total of 40 patients (34 male and 6 females) with a mean age of 68.3 ± 10.2, were assessed for left ventricular systolic function using 2D echocardiography before and after the intervention. In paired assessment at 90-day follow-up, baseline LVEF improved significantly (before intervention: 32.8 ± 7.2% and after: 38,7 ± 7,3%, p &lt; 0.01). Left ventricular longitudinal strain improved significantly on all cross-sections such as: 4-chamber GLS (before: -10.4 ± 3.97%, after: -13.6 ± 4.3%, p &lt; 0.01), 2-chamber GLS (before: -10.6 ± 3.8%, after: -13.1 ± 4.2%, p &lt; 0.01), 3-chamber GLS (before: -9.8 ± 3.7%, after: -12.3 ± 4.6%, p &lt; 0.01), GLS Avg (before: -10.3 ± 3.6%, after: -13 ± 4.1%, p&lt; 0.01), basal GLS (before: -11.2 ± 3.8%, after: -14 ± 4.5%, p &lt; 0.01), middle GLS (before: -9.3 ± 4.4%, after: -11.8 ± 3.9%, p &lt; 0.01), apical GLS (before: -11.5 ± 5.1%, after: -14.3 ± 5.9%, p &lt; 0.01). In comparison with the incomplete-revascularization group, there was a significant improvement in left ventricular systolic function in the complete-revascularization group (OR= 22.17, p &lt; 0.01). Conclusions: In patients with chronic coronary syndrome and a reduced left ventricular ejection fraction, the systolic function of the left ventricle was enhanced following percutaneous coronary intervention, particularly in the group that underwent complete revascularization.

Chronic kidney disease's impact on revascularization and subsequent major adverse cardiovascular events in patients with chronic coronary syndrome

ObjectiveTo determine the impact of CKD on the completeness of revascularization and major adverse cardiovascular events (MACE) in patients with chronic coronary syndrome (CCS). Patients and methodsThe study enrolled 400 CCS patients who underwent revascularization by PCI. They were separated into two categories according to their eGFR levels: the control group: 200 patients with eGFR ≥60mL/min/1.73m2, and the CKD Group: 200 patients with eGFR< 60ml/min/1.73m.2 Patients were reclassified according to revascularization into complete and incomplete revascularization groups with one-year follow-up to assess the MACE. ResultsCKD patients were significantly older (65.78 ± 6.41 vs. 56.70 ± 9.20 years, P=<0.001). They had higher syntax scores (P = 0.005), CIN (P = 0.001), all-cause mortality (P = 0.02), MACE (P = 0.037), and heart failure (P = 0.014). After reclassification according to revascularization. GFR was significantly reduced among patients with incomplete revascularization (51.08 ± 28.15 vs. 65.67 ± 26.62, respectively, P =<0.001). Repeated revascularization (P < 0.001), STEMI (P = 0.003), stent thrombosis (P = 0.015), MACE (P < 0.001), stroke (P < 0.001), and all-cause mortality (P < 0.001) were more prevalent among patients with incomplete revascularization. Multivariate regression analysis revealed eGFR (P = 0.001) and Syntax score (SS) (P=<0.001) as independent predictors of incomplete revascularization. The optimal eGFR cutoff value for predicting partial revascularization is 49.50mL/min/1.73m2, with 58.8% sensitivity and 69.3 % specificity. ConclusionChronic kidney disease is associated with a higher syntax score and incomplete revascularization prevalence in CCS patients. Additionally, incomplete revascularization is associated with an increased incidence of major adverse cardiac events. In patients with CCS, CKD predicts partial revascularization and subsequent MACE.

Abstract 15875: Immediate Complete Revascularization Reduces Recurrent Myocardial Infarction and Repeat Revascularization in Patients Presenting With Acute Myocardial Infarction

Introduction: Studies have suggested that complete revascularization has better outcome compared with culprit-only revascularization for the treatment of enzyme-positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a meta-analysis of randomized controlled trials (RCT) comparing immediate complete revascularization with staged revascularization in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) with multi-vessel disease. Methods: We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed and clinicaltrials.gov databases for RCT comparing immediate complete revascularization with staged revascularization in patients with enzyme-positive acute coronary syndrome. The pooled outcome were major cardiovascular adverse event (MACE), all-cause death, cardiovascular death, recurrent MI and repeat revascularization. The random effect and Mantel-Haenszel method was used to analyze the data. Heterogeneity was measured using I 2 . Results: Five studies met the inclusion criteria ( 1187 patients in immediate complete revascularization group and 1176 patients in staged revascularization group). We did not find any significant difference in the rate of MACE (OR: 0.75 [95 % CI: 0.44-1.29] I 2 : 35%, p value = 0.30). Similarly, there was no significant difference in the rates of all-cause death (OR: 0.93 [95 % CI: 0.47-1.86] I 2 : 40%, p value = 0.84)and cardiac death (OR: 1.02 [95 % CI: 0.52-1.98] I 2 : 14%, p value = 0.96). However, immediate complete revascularization group had significant reduction in the rates of repeat revascularization (OR: 0.59 [95 % CI: 0.43-0.82] I 2 : 0%, p value = 0.002) and recurrent MI (OR: 0.52 [95 % CI: 0.32-0.84] I 2 : 1%, p value = 0.008). Subgroup analysis including STEMI patients only showed similar rate of MACE ((OR: 0.92 [95 % CI: 0.60-1.41] I 2 : 0%, p value = 0.70). Conclusions: Our results suggest that immediate complete revascularization is safe. There was significant reduction in recurrent MI and need for repeat revascularization in patients undergoing immediate complete revascularization.

Prognostic Values of Fractional Flow Reserve Based on Clinical Outcomes in Patients on Chronic Hemodialysis

The fractional flow reserve (FFR) cut-off values of 0.75 or 0.8 have been widely used; however, whether they apply to patients on hemodialysis remains unknown. We aimed to investigate the cut-off value of FFR associated with clinical outcomes in patients on hemodialysis. Using the Japanese multicenter registry, we analyzed data of patients on hemodialysis with measured FFR between January 2010 and December 2016. Survival classification and regression tree analysis for the composite primary outcome of cardiovascular mortality, myocardial infarction, and target vessel revascularization revealed a threshold FFR of 0.83. Multivariate Cox regression analyses were performed for the clinical outcomes. Additionally, the primary outcome was analyzed using propensity score matching by dividing the patients into complete and incomplete revascularization groups according to the presence of residual lesions with an FFR of ≤0.83 after the intervention. Of the 212 included patients, 112 (52.8%) had lesions with an FFR of ≤0.83. After adjusting for confounders, an FFR of ≤0.83 was associated with a higher risk for the primary outcome (adjusted hazard ratio 2.01, 95% confidence interval 1.11 to 3.66, p=0.021). Propensity score matching showed that complete revascularization for lesions with an FFR of ≤0.83 was associated with a reduced risk for the primary outcome compared with incomplete revascularization (hazard ratio 0.38, 95% confidence interval 0.20 to 0.71, log-rank p=0.0016). In conclusion, an FFR of ≤0.83 was an independent predictor of clinical events in patients on hemodialysis. Furthermore, complete revascularization was associated with better clinical outcomes. Thus, this population may require a distinct FFR cut-off value.

Comparison of long-term outcomes of complete vs. incomplete revascularization in elderly patients (≥75 years) with acute coronary syndrome and multi-vessel disease undergoing percutaneous coronary intervention.

The optimal revascularization strategy for elderly patients with acute coronary syndrome (ACS) remains uncertain. We evaluated the impact of complete revascularization (CR) vs. incomplete revascularization (IR) in elderly ACS patients with multivessel disease (MVD) undergoing percutaneous coronary intervention (PCI). Using registry data from 2011 to 2019, we conducted a propensity-score matched cohort study. Elderly patients (≥75 years) with ACS and MVD who underwent PCI were divided into CR and IR groups based on angiography during index hospitalization. Major adverse cardiovascular events (MACEs), including all-cause mortality, recurrent non-fatal myocardial infarction, and any revascularization, were assessed at 3-year follow-up. Among 1,018 enrolled patients, 496 (48.7%) underwent CR and 522 (51.3%) received IR. After 1:1 propensity-score matching, we analyzed 395 pairs. At 3-year follow-up, CR was significantly associated with lower MACE risk compared to IR (16.7% vs. 25.6%, HR = 0.65, 95% CI: 0.47-0.88, p = 0.006), driven by reduced all-cause mortality. This benefit was consistent across all pre-specified subgroups, particularly in ST segment elevation (STE)-ACS patients. In non-STE (NSTE)-ACS subgroup analysis, CR was also associated with a lower risk of cardiac mortality compared to IR (HR = 0.30, 95% CI: 0.12-0.75, p = 0.01). In elderly ACS patients with MVD undergoing PCI, CR demonstrates superior long-term outcomes compared to IR, irrespective of STE- or NSTE-ACS presentation.

Propensity Matched Comparison of Clinical Outcome After Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome and Multivessel Disease

Complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD) improves clinical outcomes compared with culprit-only revascularization, but the optimal timing for non-culprit lesions treatment remains unclear. This study evaluated patients presenting with ACS and MVD admitted between January 2015 and September 2021 at the Erasmus University Medical Center. Clinical outcomes were compared between immediate and staged CR in terms of major adverse cardiac and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction, stroke, and any unplanned revascularization. A total of 1,400 patients presenting with ACS and MVD who underwent immediate or staged CR were included in this study. Using 1/many propensity score matching without replacement, 299 patients in the staged CR group were matched to 598 patients in the immediate CR group (mean 1:2 ratio), rendering a total of 897 patients for analysis. The median follow-up period was 648days. MACCE rate was significantly higher in the staged CR group than in the immediate CR group (adjusted hazard ratio [95% confidence interval] 1.60 [1.05 to 2.45], p=0.03). Furthermore, number of stents, stent length, and contrast usage were significantly greater in the staged revascularization group. Immediate CR was associated with less risk of MACCE than was staged CR. Staged CR required overall more contrast and stent material.

Complete revascularization is associated with higher mortality in patients with ST-elevation myocardial infarction, multi-vessel disease and shock defined by hyperlactataemia: results from the Harefield Shock Registry incorporating explainable machine learning.

Revascularization strategy for patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease varies according to the patient's cardiogenic shock status, but assessing shock acutely can be difficult. This article examines the link between cardiogenic shock defined solely by a lactate of ≥2 mmol/L and mortality from complete vs. culprit-only revascularization in this cohort. Patients presenting with STEMI, multi-vessel disease without severe left main stem stenosis and a lactate ≥2 mmol/L between 2011 and 2021 were included. The primary endpoint was mortality at 30 days by revascularization strategy for shocked patients. Secondary endpoints were mortality at 1 year and over a median follow-up of 30 months. Four hundred and eight patients presented in shock. Mortality in the shock cohort was 27.5% at 30 days. Complete revascularization (CR) was associated with higher mortality at 30 days [odds ratio (OR) 2.1 (1.02-4.2), P = 0.043], 1 year [OR 2.4 (1.2-4.9), P = 0.01], and over 30 months follow-up [hazard ratio (HR) 2.2 (1.4-3.4), P < 0.001] compared with culprit lesion-only percutaneous coronary intervention (CLOP). Mortality was again higher in the CR group after propensity matching (P = 0.018) and inverse probability treatment weighting [HR 2.0 (1.3-3.0), P = 0.001]. Furthermore, explainable machine learning demonstrated that CR was behind only blood gas parameters and creatinine levels in importance for predicting 30-day mortality. In patients presenting with STEMI and multi-vessel disease in shock defined solely by a lactate of ≥2 mmol/L, CR is associated with higher mortality than CLOP.

Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy

ObjectiveIn patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. MethodsWe retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. ResultsThe overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. ConclusionsIn patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Association between complete revascularization of the coronary artery and clinical outcomes in peripheral artery disease: a sub-analysis of the I-PAD Nagano registry

Peripheral artery disease (PAD) is commonly caused by atherosclerosis and has an unfavorable prognosis. Complete revascularization (CR) of the coronary artery reduces the risk of major adverse cardiovascular event (MACE) in patients with coronary artery disease (CAD). However, the impact of CR in patients with PAD has not been established to date. Therefore, we evaluated the impact of CR of CAD on the five-year clinical outcomes in patients with PAD. This study was based on a prospective, multicenter, observational registry in Japan. We enrolled 366 patients with PAD undergoing endovascular treatment. The primary endpoint was MACE, defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke. After excluding ineligible patients, 96 and 68 patients received complete revascularization of the coronary artery (CR group) and incomplete revascularization of the coronary artery (ICR group), respectively. Freedom from MACE in the CR group was significantly higher than in the ICR group at 5 years (66.7% vs 46.0%, p < 0.01). Multivariate analysis revealed that CR emerged as an independent predictor of MACE (Hazard ratio: 0.56, 95% confidential interval: 0.34–0.94, p = 0.03). CR of CAD was significantly associated with improved clinical outcomes in patients with PAD undergoing endovascular treatment.

Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial

In patients with acute coronary syndrome and multivessel coronary disease, complete revascularisation by percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. We aimed to investigate whether PCI for non-culprit lesions should be attempted during the index procedure or staged. This prospective, open-label, non-inferiority, randomised trial was done at 29 hospitals across Belgium, Italy, the Netherlands, and Spain. We included patients aged 18-85 years presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome and multivessel (ie, two or more coronary arteries with a diameter of 2·5 mm or more and ≥70% stenosis based on visual estimation or positive coronary physiology testing) coronary artery disease with a clearly identifiable culprit lesion. A web-based randomisation module was used to randomly assign patients (1:1), with a random block size of four to eight, stratified by study centre, to undergo immediate complete revascularisation (PCI of the culprit lesion first, followed by other non-culprit lesions deemed to be clinically significant by the operator during the index procedure) or staged complete revascularisation (PCI of only the culprit lesion during the index procedure and PCI of all non-culprit lesions deemed to be clinically significant by the operator within 6 weeks after the index procedure). The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1 year after the index procedure. Secondary outcomes included all-cause mortality, myocardial infarction, and unplanned ischaemia-driven revascularisation at 1 year after the index procedure. Primary and secondary outcomes were assessed in all randomly assigned patients by intention to treat. Non-inferiority of immediate to staged complete revascularisation was considered to be met if the upper boundary of the 95% CI of the hazard ratio (HR) for the primary outcome did not exceed 1·39. This trial is registered with ClinicalTrials.gov, NCT03621501. Between June 26, 2018, and Oct 21, 2021, 764 patients (median age 65·7 years [IQR 57·2-72·9] and 598 [78·3%] males) were randomly assigned to the immediate complete revascularisation group and 761 patients (median age 65·3 years [58·6-72·9] and 589 [77·4%] males) were randomly assigned to the staged complete revascularisation group, and were included in the intention-to-treat population. The primary outcome at 1 year occurred in 57 (7·6%) of 764 patients in the immediate complete revascularisation group and in 71 (9·4%) of 761 patients in the staged complete revascularisation group (HR 0·78, 95% CI 0·55-1·11, pnon-inferiority=0·0011). There was no difference in all-cause death between the immediate and staged complete revascularisation groups (14 [1·9%] vs nine [1·2%]; HR 1·56, 95% CI 0·68-3·61, p=0·30). Myocardial infarction occurred in 14 (1·9%) patients in the immediate complete revascularisation group and in 34 (4·5%) patients in the staged complete revascularisation group (HR 0·41, 95% CI 0·22-0·76, p=0·0045). More unplanned ischaemia-driven revascularisations were performed in the staged complete revascularisation group than in the immediate complete revascularisation group (50 [6·7%] patients vs 31 [4·2%] patients; HR 0·61, 95% CI 0·39-0·95, p=0·030). In patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia-driven revascularisation. Erasmus University Medical Center and Biotronik.

Timing of Complete Revascularization in Patients with STEMI and Multivessel Disease: A Systematic Review and Meta-Analysis

Background: About half of patients with ST-segment Elevation Myocardial Infarction (STEMI) have multivessel coronary artery disease (MVD). Our aim was to provide a quantitative comparison of single-stage complete revascularization during the index revascularization versus deferred staged complete revascularization in STEMI patients with MVD. Methods: All studies evaluating patients with STEMI and MVD were included. The primary endpoint was a composite of all-cause death, myocardial infarction and repeat revascularization. Secondary endpoints were cardiovascular death, acute kidney injury and trial defined major bleeding. Results: Eight studies and 2256 patients with STEMI and MVD were included. No difference was evident in the rate of the primary composite endpoint among the study group (Risk Ratio 0.95; 95% CI 0.71–1.27, p = 0.74), while meta-regression showed a significant interaction with drug eluting stent (DES) use (Coefficient –0.005; 95% CI –0.01 to –0.001; p = 0.007). Higher rates of cardiovascular (CV) death were found in the immediate complete revascularization group (5.0% vs 2.6%; Risk Ratio 0.39; 95% CI 0.25–0.62; p &lt; 0.01). Conclusions: Our analysis documented similar clinical outcomes with either single-stage immediate complete revascularization and delayed staged complete revascularization. Secondary analyses suggest that an increase in cardiovascular death might be expected with single-stage percutaneous coronary intervention (PCI). While new randomized trials on the topic are ongoing, revascularization can be personalized and guided by the acute clinical setting, patients’-related factors and workflow logistics.

The Effect and Possible Mechanism of Cardiac Rehabilitation in Partial Revascularization Performed on Multiple Coronary Artery Lesions.

To observe the effect of cardiac rehabilitation (CR) in patients with partial revascularization performed on multiple coronary artery lesions and explore its possible mechanism. A total of 400 patients with multiple coronary artery lesions were enrolled and randomly divided into a complete revascularization group and a CR group, with 200 cases in each group. Target lesion revascularization was performed radically in the complete revascularization group, while it was partially completed in the CR group, and postoperative CR was performed. All the patients were put under conventional treatment. Left ventricular end diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF), 6-minute walking distance (6-MWD), quality-of-life scores, safety and levels of serum nitric oxide (NO), nitric oxide synthase (NOS), superoxide dismutase (SOD), and vascular endothelial growth factor (VEGF) were evaluated and compared between two groups before and after training. There was no significant difference in LVEDD, LVEF, 6-MWD, quality-of-life scores, levels of serum NO, NOS, SOD, and VEGF between two groups before training (p>0.05). 1 year later, compared with the complete revascularization group, the occurrence of major adverse events in the CR group declined (p>0.05); the measurements of LVEDD decreased and LVEF increased (p>0.05), 6-MWD increased significantly (p<0.05), quality-of-life scores were higher (p<0.05), the levels of serum NO, NOS, and SOD increased noticeably, and the levels of serum VEGF decreased significantly in the CR group (p<0.05). There were significant differences within the same group, before and after training (p<0.05). Cardiac rehabilitation training, not increase in the incidence of adverse events, is effective and safe after partial revascularization in patients with multiple coronary artery lesions, which has notable clinical advantages in promoting patients' exercise endurance and quality-of-life by improving the nitric oxide synthase system and antioxidant system and reducing the level of VEGF.

Complete Revascularization vs Culprit Lesion–Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction

In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown. To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD. This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021. Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization. Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end. Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02). In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.