Complete Revascularization Research Articles

Complete revascularization of multivessel coronary artery disease in patients with ST elevation acute coronary syndrome - for whom and when? A comprehensive review.

Atherosclerosis is the most common cause of coronary steno-occlusive disease and acute myocardial infarction is the leading cause of death in industrialized countries. In patients with acute ST elevation myocardial infarction (STEMI), there is unquestionable evidence that primary percutaneous coronary intervention providing recanalization of the infarct related artery (IRA) is the preferred reperfusion strategy. Nevertheless, up to 50% of patients with STEMI have multivessel coronary artery disease defined as at least 50% stenosis exclusive of IRA. There is conflicting data regarding the optimal treatment strategy and timing in such patients. Currently, it is assumed that stable patients might benefit from complete revascularization particularly in reducing the need for future unplanned procedures but only culprit lesion should be treated during index procedure in unstable patients. In this article, we provide a comprehensive overview of this important and currently highly debated topic.

Complete anatomic surgical myocardial revascularisation during postinfarction ventricular septal defect and ventricular aneurysm repair is associated with improved short- and long-term outcomes.

Coronary artery bypass grafting (CABG) is recommended during acute postinfarction ventricular septal defect (PIVSD) repair, but clinical benefits of surgical revascularization in patients with subacute PIVSD have not been established. We aimed to evaluate the association of primary complete anatomic surgical myocardial revascularization (CASMR) during PIVSD and ventricular aneurysm (VA) repair on patients' short- and long-term outcomes. This was a retrospective observational study. The inclusion criterion was PIVSD. Patients with previous CABG and those with PIVSD due to vasospasm and normal coronary arteries on angiography were excluded. From March 2002 to April 2021, 53 patients met the eligibility criteria. The median patient age was 65 years, and 28 (53%) were male. Compared to the non-CABG group, CABG patients had higher values of the median postoperative left ventricular (LV) end-diastolic volume, 100 ml, and 128.5 ml, respectively (p = .012), and the mean LV stroke volume, 49 ml, and 61 ml, respectively (p = .048). The mortality rates in the CABG and non-CABG groups were 3.6/100 person-years (95% confidence interval [CI]: 1.5-8.6/100 person-years) and 16.3/100 person-years (95% CI: 8.5-31.3/100 person-years), respectively. Cox regression adjusted for between groups imbalances demonstrated a 4-fold greater mortality risk (hazard ratio = 4.3; 95% CI: 1.1-16.7; p = .036) among the non-CABG patients than in the CABG patients. Kaplan-Meier survival analysis yielded a poorer overall survival of the non-CABG patients (p = .011). Primary CASMR during PIVSD and VA repair is associated with improved postoperative cardiac function, lower hospital mortality, and better long-term survival. We recommend CASMR during PIVSD and VA repair.

Comparison of early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using minimally invasive or conventional off-pump techniques: a propensity-matched study based on SYNTAX score

BackgroundThis study was designed to compare early outcomes associated with coronary artery bypass grafting for multi-vessel disease conducted using either minimally invasive or conventional off-pump techniques.MethodsFrom January 2017 through January 2021, 582 patients with multi-vessel lesion coronary artery disease underwent either minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) or conventional off-pump coronary artery bypass grafting (OPCABG) treatment by our team at Anzhen Hospital. Patients in the MICS CABG group were propensity score-matched with those in the OPCABG at a 1:1 ratio (MICS CABG = 172; OPCABG = 172), using epidemiological data, preoperative clinical characteristics, and SYNTAX score as covariates. Perioperative outcomes and 6-month computed tomography angiography findings were compared between these groups.ResultsNo significant differences between groups were observed with respect to 30-day postoperative mortality, myocardial infarction, and stroke incidence. Surgical data indicated that the MICS CABG procedure was able to cover all three main arterial territories with a relatively low need for circulatory assistance. The MICS CABG procedure was associated with a longer operative duration, but was also associated with higher postoperative hemoglobin and activities of daily living index values as well as a shorter duration of postoperative hospitalization (P < 0.05). No differences in 6-month graft patency were observed between groups.ConclusionsMICS CABG is a safe, less invasive alternative to OPCABG when performing complete revascularization provided patients are properly selected, yielding similar in-hospital outcomes and 6-month graft patency rates together with an earlier return of physical function.

Post congress highlights in acute cardiovascular care: a report from the American College of Cardiology 2022 scientific sessions.

The 2022 American College of Cardiology annual scientific sessions were recently held in Washington, DC. The meeting was associated with significant enthusiasm and excitement as it returned to a live in person format, albeit while retaining a strong virtual and on demand presence. By all accounts, the meeting was an outstanding success. A few late breaking highlights relevant to the care of patients in the cardiac intensive care unit are summarized below. The Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI trial (n = 4041) had previously established the benefits of complete revascularization on the endpoint of cardiovascular death or myocardial infarction over 3 years follow-up in the setting of STEMI with multivessel disease (7.8 vs. 10.5%, P = 0.004).1 The investigators extended the benefits of this approach to an improvement in angina related quality of life utilizing the Seattle Anginal Questionnaire at baseline, 6 months and 3 years. Randomization to a multivessel revascularization strategy resulted in a decrease in anginal frequency by 6 months. This was sustained at 3 years, a benefit seen with non-culprit lesions >80% with an improvement in both physical limitation as well as overall treatment satisfaction.

OR10 Complete revascularization improves survival of patients with out-of-hospital cardiac arrest caused by acute myocardial infarction.

OR10 Complete revascularization improves survival of patients with out-of-hospital cardiac arrest caused by acute myocardial infarction.

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock.

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Complete Revascularization Showed A Better Cardiac Function Improvement In Patients With Low Ejection Fraction.

This study aimed to compare postoperative ejection fraction (EF) in response to coronary artery bypass grafting (CABG) among patients with preoperative EF <35% and >35%. A retrospective study was conducted in a single institution using clinical data of 660 patients undergoing elective on-pump CABG in 2018-2019. Patients were classified into two groups based on preoperative left ventricle ejection fraction (<35% and >35%). The primary endpoint was the change of postoperative ejection fraction. In this study, 72 patients had preoperative left ventricle ejection fraction <35% (group A) while the other 588 patients had ejection fraction >35% (group B). Among both groups, the duration of cardiopulmonary bypass (CPB) and aortic clamp (AxC) were not significantly different (P > 0.05). The transformation of pre- and postoperative EF in groups A and B was significantly different (2.91+10.31 vs. -0.14+4.57, P < 0.001). There was a significant difference in the duration of ICU stay (73.42+112.55 vs. 34.43+64.99, P < 0.001) and postoperative ventilatory support (25.54+43.92 vs. 16.42+45.87, P < 0.008) between group A and B. Low preoperative EF showed better improvement in cardiac function after surgery. We concluded that the result could be affected by revascularization of hibernating myocardium.

Health-Related Quality of Life After Complete Versus Infarct Artery-only Percutaneous Coronary Revascularization in Multi-Vessel Disease with St Segment Elevation Myocardial Infarction

Objective: The purpose of this study was to compare the HRQoL of patients who had complete revascularization at the time of the first admission to those who underwent revascularization of the infarct artery alone using the EQ-5D (European quality of life-5 dimensions) self-report questionnaire. Background: The effect of revascularization procedures on health-related quality of life (HRQoL) in patients with multivessel disease who undergo primary percutaneous coronary intervention is the subject of controversy (P-PCI). Methods and Results: There was a significant difference between individuals with STEMI who received revascularization of the infarct-related artery alone and those who got total revascularization. we divided the group by the extent of complete revascularization (n=147) or the extent of IRA-only revascularization (n = 153) during the index admission Mobility, self-care, routine activity, pain or discomfort, anxiety, and sadness were all evaluated using the EQ-5D scale. The prevalence of heart failure and the gender of patients were different at baseline. Patients who had full revascularizations had lower mean ±SD (EQ-VAS and EQ-5D) utility ratings than those who had infarct artery revascularizations alone after 2 years of follow-up. (70.00 (±19.9) vs. 51.04 (±17.8), P &lt; 0.04, and 0.71 (±0.03) vs0.61 (±0.03), P&lt;0.005, respectively). Conclusion: Complete revascularization produced clinically significant increases in quality of life when compared to treating just the IRA at 24 months. Keywords: Complete Revascularization, Infarct-related artery, Primary percutaneous coronary angioplasty, ST-segment elevation.

Successful Percutaneous Fogarty Thrombectomy for Subacute Lower Limb Ischemia Due to Resistant Thrombus in the Popliteal Artery

Patient: Male, 73-year-old Final Diagnosis: Subacute lower limb ischemia Symptoms: Coldness • pallor • numbness • rest pain of the right toes Medication: — Clinical Procedure: Percutaneous Fogarty thrombectomy Specialty: Cardiac Surgery • Cardiology Objective: Unusual setting of medical care Background:Subacute lower limb ischemia occurs more than 14 days and less than 3 months from symptom onset. Although endovascular procedures are the preferred treatment choice for a viable and not immediately threatened limb in patients with acute lower limb ischemia (<14 days), percutaneous catheter-directed thrombolysis, percutaneous mechanical thrombectomy, or percutaneous thromboaspiration are not recommended, and no treatment strategy has yet been established for nonacute lower limb ischemia (>14 days). A percutaneous Fogarty thrombectomy, an endovascular thrombus removal procedure with the use of a large-caliber sheath and a Fogarty balloon catheter, has recently been reported as a less invasive alternative to open surgery in patients with acute lower limb ischemia. In this report, we use this technique for a case of subacute lower limb ischemia caused by a resistant thrombus.Case Report:A 73-year-old man with a diagnosis of essential thrombocythemia presented with symptoms of right lower limb ischemia, which started about a month before. The diagnosis was subacute lower limb ischemia due to a resistant thrombus in the popliteal artery. First, we attempted percutaneous thromboaspiration and prolonged dilation with a large-caliber balloon catheter, but there were still severe residual stenoses with delayed blood flow. Although vascular scaffold implantation might have achieved complete revascularization, we avoided it because of a high probability of stent fracture in the popliteal artery. Thus, we performed a subsequent percutaneous Fogarty thrombectomy immediately after the conventional endovascular recanalization failed, achieving complete revascularization and next-day discharge without any complications.Conclusions:A percutaneous Fogarty thrombectomy could be a new treatment option for subacute lower limb ischemia due to a resistant thrombus, which can be performed immediately after failure of the conventional endovascular recanalization.

P211 LONG–TERM OUTCOME OF PATIENTS WITH STEMI AND CARDIOGENIC SHOCK TREATED BY PPCI

Abstract Background There is little data on the long–term outcome of patients with cardiogenic shock (CS) treated with primary angioplasty (PPCI) in the setting of acute ST–segment elevation myocardial infarction (STEMI). The aim of this study was to assess long–term mortality among hospital STEMI survivors who received a PPCI procedure, based on the presence of acute–phase CS. Methods We analyzed long–term follow–up data in a series of consecutive patients admitted to our institution for STEMI from 2009 to 2019 who were treated with PPCI. Results Of the 1288 patients who presented with STEMI, 1137 received a PPCI procedure. CS occurred in 111 (9.8%) of these patients. The in–hospital mortality rate was 5.6%; 2.9% in patients without and 30.6% in those with shock (P &amp;lt; 0.001)). The 1073 patients who survived the acute phase were followed up for 9 + 5 years. Survivors with CS had a more severe clinical profile and more frequent concomitant hospital complications. Long–term survival was 75.6% in patients with shock versus 84.0% in those without shock (P &amp;lt; 0.05). Patients with complete revascularization at the index procedure had similar survival compared to other patients with CS (survival rate 75% vs 75.4%; P = ns). Conclusions CS carries an increased risk of death during the hospital phase and at long–term follow–up: complete revascularization at the index procedure does not appear to offer any additional benefit on outcome

P201 PURSUING COMPLETENESS OF CORONARY REVASCULARIZATION IN ACUTE SETTING: TIMING AND STRATEGIES

Abstract Patient Presentation A 59 y/o male with history of arterial hypertension and allergic asthma was admitted to our Coronary Care Unit because he went to a spoke emergency department after complaining oppressive and not continuous chest pain for a couple of hours travelling up to the left arm. Increase in cardiac troponin and mild ST–elevation in D3 lead were found. At the spoke cardiology department was treated with intravenous nitrates with relief and Ticagrelor loading dose was administered. He underwent two coronary angiographies, the first one aimed to treat the culprit lesion and the second one to complete revascularization before discharge Management: A heart ultrasound (US) described normal left ventricle ejection fraction (LVEF) with some of the right coronary segments akinesis. The first coronary angiography showed eccentric stenosis (80%) of distal right coronary artery (RCA) with endoluminal thrombosis; intraluminal filling defect of the left main coronary artery (LMCA) which request Optical Coherence Tomography evaluation that showed plaque rupture and red thrombus of LMCA; chronic total occlusion of left anterior descending artery (LAD) with several stenosis up to the apical segments. Glycoprotein IIb/IIIa receptor antagonist infusion was started, and we’ve been forced to treat first the LMCA with drug–eluting stent and then the culprit lesion with angioplasty and two drug–eluting stents complicated by intrastent thrombosis treated with mechanic and rheolytic thrombectomy. Seven days later rotational atherectomy was performed due to LAD artery’s severe calcifications complicated by LMCA intrastent thrombosis caused by stenting crush; cardiopulmonary arrest occurred. Impella ventricular assist device was placed. After LMCA stent optimization, one more drug–eluting stent was placed. Eight days later, heart US described LVEF 37% with apex and right coronary segments hypo–akinesis. Discussion According to latest NSTEMI guidelines, a single stage pursuing of completeness revascularization on multiple vessel disease would have been the best option. In this case, completeness of revascularization hasn’t been achievable due to LMCA plaque rupture. From a technical point of view, considering the complexity of the few days earlier treated LMCA lesion, proximal to LAD lesions we were going to treat, it would have been suitable waiting about four weeks to complete stent endothelization. By the way, it would have been out–guidelines approach.

P234 A RARE CASE OF ACUTE RIGHT HEART FAILURE PRESENTED IN A CASE REPORT

Abstract Case Summary A 62–year–old male with multiple cardiovascular risk factors, presented at the ED with signs and symptoms of right heart failure, Doppler echocardiography showed a severe dilatation and dysfunction of the right ventricle and left ventricular diastolic dysfunction. After initial stabilization with diuretics and inotropes, the patient performed a coronary angiogram with evidence of severe multivessel coronary artery disease and combined pre–capillary and post–capillary pulmonary hypertension as shown by the right heart catheterization. After complete revascularization, the diastolic function of the left ventricle improved dramatically, and the right ventricle recovered completely. Discussion We presented a paradigmatical case of acute right heart failure secondary to left ventricular diastolic impairment in a patient affected by severe ischemic coronary artery disease. Several risk factors are associated with RVD in HFpEF: atrial fibrillation, male sex, chronic obstructive pulmonary disease. Diastolic performance of the LV is one of the main determinants of the right ventricular function, which, in turn, is proven to have prognostic implication in HFpEF. Nowadays, there is no evidence–based treatment for right heart failure secondary to decompensated HFpEF and therapy should be tailored to the individual patient’s response.

P195 A CASE REPORT OF TYPE TWO KOUNIS SYNDROME

Abstract A 81–years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre–existing LBBB. HS–T–Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn’t show any new ischemic abnormalities in the setting of pre–existing LBBB. The peak CK–MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK–MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre–existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm. Take Home Message We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.

C79 LONG–TERM OUTCOME IN PATIENTS UNDERGOING HIGH–RISK PERCUTANEOUS CORONARY INTERVENTION WITH THE SUPPORT OF IMPELLA CP: A SINGLE CENTER EXPERIENCE

Abstract Background Nowadays use of the Impella for high–risk percutaneous coronary intervention (PCI) is increasing worldwide. The aim of this study is to evaluate in–hospital and long–term outcomes of patients treated for high–risk PCI with the use of Impella CP device. Methods This is a single center registry, which enrolled all consecutive patients treated at Cannizzaro Hospital for high–risk PCI with the use of Impella CP. Data were prospectively entered into a dedicated database. Results From January 2019 to December 2021, 16 patients were enrolled of which 75% were male. The clinical presentation at admission was an acute coronary syndrome in 87.5% of cases (myocardial infarction in 13 patients, unstable angina in 1 subject). The mean left ventricular ejection fraction at admission was 35 ± 7.6%. Ten subjects (62.5%) had diabetes treated with insulin in 90% of cases. The Syntax score was 29 ± 12.3 and the mortality STS score was 8.1 ± 10.4. Left main disease involved 8 (50%) patients, whereas a 3–vessels disease was present in 56% of cases. In most cases –14 (87.5%) patients– the Impella CP was introduced through the femoral artery with percutaneous access, whilst only in 2 (12.5%) subjects a surgical access was necessary. An anatomical complete revascularization was performed in 7 (43.8%) patients. For a total of 2 ± 1 vessels treated for patient and 3 ± 1.3 lesions undergoing PCI, 3 ± 1.8 stent were implanted with a mean total stent length of 81 ± 44.3 mm. In all cases, the Impella CP device was placed in left ventricle before PCI and removed a few minutes after the end of procedure, with a mean duration of mechanical circulatory support of 2.7 ± 0.8 hours. Only 1 (6.2%) patient died in hospital due to sepsis, whereas a clinically–evident bleeding occurred in 5 (31.3%) subjects (4 were access–site bleeding) and 4 (25%) patients underwent red blood cells transfusion; no acute limb ischaemia or aortic/left ventricle injury occurred. On a mean follow–up of 13 months from procedure date, any myocardial revascularization occurred in 2 (12.5%) patients, of whom 1 (6.2%) was a target–vessel revascularization. Four (25%) patients died but only 1 (6.2%) due to cardiac death: 2 subjects died as result of sepsis following pneumonia and 1 sepsis complicating gangrene. Conclusion Our study demonstrates the feasibility and efficacy of high–risk PCI protected by Impella CP, showing an acceptable long–term clinical outcome in a very high risk cohort of patients.

Immediate versus staged revascularisation of non-culprit arteries in patients with acute coronary syndrome: asystematic review and meta-analysis.

Although there is robust evidence that revascularisation of non-culprit vessels should be pursued in patients presenting with an acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD), the optimal timing of complete revascularisation remains disputed. In this systematic review and meta-analysis our results suggest that outcomes are comparable for immediate and staged complete revascularisation in patients with ACS and MVD. However, evidence from randomised controlled trials remains scarce and cautious interpretation of these results is recommended. More non-biased evidence is necessary to aid future decision making on the optimal timing of complete revascularisation.Supplementary InformationThe online version of this article (10.1007/s12471-022-01687-7) contains supplementary material, which is available to authorized users.

Impact of complete revascularization on long-term clinical outcomes for patients with diabetes mellitus and coronary chronic total occlusion lesion.

Diabetes mellitus (DM) is a substantial risk factor in developing coronary artery disease (CAD), coronary chronic total occlusion (CTO) lesions are discovering 10-35% in patients who underwent coronary angiography. This study compares the long-term clinical outcomes of two treatment strategies, percutaneous coronary intervention (PCI) with complete recanalization versus medication therapy (MT) with CTO lesion in DM patients with CTO. This study is a single-center, prospective, all-comer registry designed to reflect "real world" practice since 2004. Of a total of 4909 consecutive patients were diagnosed with significant CAD by coronary angiography (CAG). A total of 372 patients has DM and CTO lesions. Patients were divided into the PCI group (n = 184) and the MT group (n = 179). The primary endpoint, defined as the composite of death or myocardial infarction (MI), was compared between the two groups up to 5years. In addition, inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust for potential confounders. Compared to the MT group, the PCI group was associated with a significantly reduced incidence of the primary endpoint before [hazard ratio; HR 0.267, 95% confidence interval (CI) 0.116-0.614] and after (HR 0.142, 95% CI 0.032-0.629) adjusting confounding factors by IPTW. Complete revascularization by CTO-PCI with MT in DM patients should be the preferred treatment strategy compared with the MT alone strategy since it reduces the composite of death or MI up to 5years.

Complete revascularization improves survival of patients resuscitated after an out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Sudden cardiac death is a major issue in industrialised countries and survival of patients who suffered from an out-of-hospital cardiac arrest (OHCA) remains awfully low. An acute myocardial infarction is the principal cause of OHCA and myocardial revascularisation plays a positive role in survival. In this particular setting little is known about the role of complete versus culprit-only revascularisation on survival. Purpose The aim of the present study was to assess whether a complete revascularisation could lead to a better one-year survival as compared to culprit-only revascularisation. Methods All the patients prospectively enrolled in the OHCA registry of the Lombardy region (Lombardia CARe) from January 1, 2015 to May 1, 2021 in the province of Pavia who underwent a coronary angiography at our Polyclinic were enrolled in the study. All the coronary angiographies were retrospectively reviewed by two interventional cardiologists and angiographic features were inserted in the database. Prehospital data and survival were retrieved from the registry according to the Utstein style. Results We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; presenting shockable rhythm 84.1%; acute myocardial infarction at post ROSC ECG 67.9%; ejection fraction 37% (30-45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with a multi-vessel disease 82 (69%) received an incomplete revascularisation whereas 37 (31%) were completely revascularised [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5-10) days]. This latter group showed a significantly higher one-year survival (54.9% vs 16.2%, p&amp;lt;0.001). At univariable logistic regression only a shockable presenting rhythm and the presence of a chronic coronary occlusion were found to be significantly associated with the probability of receiving a complete revascularisation [OR 5.1 (95% CI 1.1-22), p=0.03; OR 0.37 (95% CI 0.16-0.85), p=0.02 respectively]. However, at multivariable regression analysis only the presence of a chronic coronary occlusion was confirmed to be significantly associated with the probability of receiving a complete revascularisation [OR 0.36 (95%CI 0.15-0.9), p=0.007]. At Cox multivariable regression model cardiac arrest duration (longer that the median value of 24 min) and a complete revascularisation were shown to be independently associated with the probability of death [HR 3.6 (95%CI 1.9-6.9), p&amp;lt;0.001; HR 0.2 (95%CI 0.1-0.9), p=0.02]. Similarly, cardiac arrest duration, a complete revascularisation and a shockable presenting rhythm were associated with the probability of death or poor neurologic outcome [HR 3.3 (95%CI 1.8-6), p&amp;lt;0.001; HR 0.5 (95%CI 0.3-0.9), p=0.03 and HR 0.2 (95%CI 0.1-0.5), p&amp;lt;0.001]. Conclusions A complete revascularisation is independently associated with a better one-year survival in patients resuscitated from an out-of-hospital cardiac arrest.

Percutaneous coronary intervention for true bifurcation lesions: a single-center experience including the setting of acute coronary syndromes

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous coronary intervention (PCI) for true coronary bifurcation lesions is challenging. Purpose To describe procedural and clinical outcomes of true bifurcation PCI. Methods Single-center retrospective study of consecutive patients (pts) submitted to PCI for true bifurcation lesions (06/2018-06/2020). MACE comprised death, myocardial infarction (MI), stroke, restenosis and reintervention. Results During the study period, 1678 PCI were performed, of which 7% were for true bifurcation lesions (Medina x,x,1). 118 pts (mean age 66.4 ± 11.0 years; 74.6% male; 32.2% diabetic; mean left ventricular ejection fraction 49.8 ± 8.4%) were included. Most pts (64.7%) were treated in the setting of an acute coronary syndrome (ACS): 26.7% ST-elevation MI, 31.9% non-ST-elevation MI, 6.0% unstable angina. 35.3% were treated for a chronic coronary syndrome. 24.8% of pts presented with 3-vessel disease and 11.1% had a left main (LM) lesion. The most frequently diseased main branch was the left anterior descending artery: 21.2% (68), followed by the left circumflex: 17.8% (21), right coronary artery: 12.7% (15) and LM: 11.9% (14). In terms of bifurcation classification, lesions were mainly Medina 1,1,1 (71.2%), followed by 0,1,1 (13.6%); 1,0,1 (9.2%) and 0,0,1 (5.9%). PCI was mainly performed via radial artery (73.7%). Mean number of stents: 1.4 ± 0.6. Lesions were predominantly treated with single stenting technique (80.3%). Double-stenting was used in 23 (19.7%) pts: TAP was the most used technique (10), followed by culotte (3), crush (2), double kissing crush (2) and T-stent (1). Proximal optimization technique and kissing balloon inflation were performed in 38.1% and 44.9% of cases, respectively. Rotational atherectomy was used in 10.4%. Ventricular support devices were used in 3 pts (1 Impella, 2 intra-aortic balloon pump). Intracoronary imaging was used in 13 pts: intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in 8 and 5 pts, respectively; its use was more frequent in cases of LM PCI (p=.002). OCT was associated with higher contrast doses (350 vs 224 ml, p&amp;lt;.001), with no increase in acute kidney injury incidence (p=.413). Fluoroscopic time (p=.684) and radiation dose (p=.916) did not differ. Side branch occlusion occurred in 5 pts and iatrogenic coronary dissection in 7 pts. At a mean follow-up time of 17.3 ± 8.1 months, MACE and mortality rates were 13.3% and 6.9%. MACE occurred more frequently in pts with LM lesion (p&amp;lt;.001) and less often in cases where complete revascularization was achieved (p=.006). Conclusions True bifurcations represented a relatively small percentage of PCI lesions and were mainly performed in ACS setting. In line with literature, single stenting was the most used technique. MACE rate was globally low and was decreased by complete revascularization. Still, LM bifurcation PCI was associated with increased MACE.

Patient characteristics and periprocedural outcomes of percutaneous coronary intervention of the left main coronary artery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left main (LM) disease is found in 5 to 6% of all coronary angiograms. Revascularization has a class IA recommendation, but the choice of the revascularization method whether by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is currently under debate. The selection depends on patient’s characteristics (age, sex, comorbidities, frailty), as well as anatomical considerations. We aim to describe the patients with LM disease that were treated with PCI and report their short-term outcomes in a tertiary center. Methods Single-center retrospective study including all patients who underwent LM PCI from 2013 to 2019. The basal characteristics were retrieved from the electronic medical records. Acute kidney injury was defined as an absolute increase in serum creatinine of ≥ 0.3 mg/dL or ≥ 1.5-fold from baseline. Type IVa myocardial infarction was assessed by the Third Universal Definition. Results A total of 110 procedures were performed during the study period (table 1). Most of the patients were male, with a median age of 61 years. A considerable number of patients showed a reduced ejection fraction (41.2%). The left main lesions were most frequently distal and associated with left anterior descending artery disease. Radial access was used in a minority of cases (33.6%), although most were IVUS-guided (93.6%). Complete revascularization was achieved in 55.5%. The number of procedures over time is depicted in figure 1. There was only 1 death (0.9%) during index hospitalization. There was a high incidence of type IVa myocardial infarction (19.1%) and acute kidney injury (10%), and a low incidence of TIMI major bleeding (1.8%). Conclusion Current practice shows an increase of left main PCI over time, particularly from 2016, after the EXCEL trial results were published. This can be due to improved technical aspects such as IVUS guidance, which was used in most patients. Noticeable, almost half of the patients had a reduced ejection fraction. Although there was a very low short-term mortality associated with the procedure (1%), as well as a low bleeding risk (4.8%), there was a high incidence of type IVa myocardial infarction (20.2%). Only 55.5% archived a complete revascularization. Despite promising immediate results in clinical practice, long term follow up will be essential to determine the future role of left main PCI.

Protocolized Post-Cardiac Arrest Care with Targeted Temperature Management.

Improvements in teamwork and resuscitation science have considerably increased the success rate of cardiopulmonary resuscitation. Cerebral injury, myocardial dysfunction, systemic ischemia and reperfusion response, and precipitating pathology after the return of spontaneous circulation (ROSC) constitute post-cardiac arrest syndrome. Because the entire body is involved in cardiac arrest and the early post-arrest period, protocolized post-arrest care consisting of cardiovascular optimization, ventilation and oxygenation adjustment, coronary revascularization, targeted temperature management (TTM), and control of seizures and blood sugar would benefit survival and neurological outcomes. Emergent coronary angiography is suggested for cardiac arrest survivors suspected of having ST-elevation myocardial infarction, however the superiority of culprit or complete revascularization in patients with multivessel coronary lesions remains undetermined. High-quality TTM should be considered for comatose patients who are successfully resuscitated from cardiac arrest, however the optimal target temperature may depend on the severity of their condition. The optimal timing for making prognostication should be no earlier than 72 h after rewarming in TTM patients, and 72 h following ROSC in non-TTM patients. To predict neurological recovery correctly may need the use of several prognostic tools together, including clinical neurological examinations, brain images, neurological studies and biomarkers.