Complex Complex Coronary Artery Disease Research Articles

External validation of the SYNTAX score II 2020 in patients with chronic renal insufficiency.

The SYNTAX score Ⅱ 2020 (SSⅡ-2020) was created as a customized decision-making tool for individuals diagnosed with complex coronary artery disease (CAD). Nevertheless, there has been a scarcity of research investigating the long-term predictive significance of SSⅡ-2020 for patients with both CAD and chronic renal insufficiency (CRI) who undergo percutaneous coronary intervention (PCI). We sought to showcase the prognostic capacity of SSII-2020 in evaluating long-term all-cause mortality (ACM) within this high-risk patient cohort. A retrospective cohort comprising 1156 individuals diagnosed with CRI and exhibiting left main CAD, three-vessel CAD or both was included in this investigation. We categorized participants into three groups based on the optimal SSII-2020 threshold for predicting long-term ACM, determined using the X-tile software. At the median follow-up duration of 6.3 years, the ACM rates were determined to be 10% in the low, 17% in the moderate, and 28% in the high SSII-2020 groups (p < 0.001). Employing multivariate Cox regression analysis, it was observed that the high SSII-2020 group exhibited a 3.289-fold increased risk of ACM (95% confidence interval [CI]: 2.229-4.856, p < 0.001) compared with the low SSII-2020 group, whereas the high SSII-2020 group displayed a 1.757-fold (95% CI: 1.190-2.597, p = 0.005) in comparison to the median SSII-2020 groups. Compared with SSII, the SSII-2020 had an incremental value for predicting 7-year ACM (C-index: 0.662 vs. 0.534, p = 0.007; IDI: 0.016, p < 0.001). SSII-2020 enhances long-term ACM prediction, facilitates improved risk stratification, and improves clinical utility for PCI patients with complex CAD and CRI.

Prognostic Capability of Clinical SYNTAX Score in Patients with Complex Coronary Artery Disease and Chronic Renal Insufficiency Undergoing Percutaneous Coronary Intervention.

The SYNTAX score (SS) is useful for predicting clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). The clinical SYNTAX score (CSS), developed by combining clinical parameters with the SS, enhances the risk model's ability to predict clinical outcomes. However, prior research has not yet evaluated the prognostic capacity of CSS in patients with complex coronary artery disease (CAD) and chronic renal insufficiency (CRI) who are undergoing PCI. We aimed to demonstrate the prognostic potential of CSS in assessing long-term adverse events in this high-risk patient cohort. A total of 962 patients with left main and/or three-vessel CAD and CRI were enrolled in the study spanning from January 2014 to September 2017. The CSS was calculated by multiplying the SS by the modified age, creatinine, and left ventricular ejection fraction (ACEF) score (age/ejection fraction + 1 for each 10 mL of creatinine clearance 60 mL/min per 1.73 ). The patients were categorized into three groups based on their CSS values: low-CSS group (CSS 18.0, n = 321), mid-CSS group (18.0 CSS 28.3, n = 317), and high-CSS group (CSS 28.3, n = 324) as per the tertiles of CSS. The primary endpoints were all-cause mortality (ACM) and cardiac mortality (CM). The secondary endpoints included myocardial infarction (MI), unplanned revascularization, stroke, and major adverse cardiac and cerebrovascular events (MACCE). At the median 3-year follow-up, the high-CSS group exhibited higher rates of ACM (19.4% vs. 6.6% vs. 3.6%, p 0.001), CM (15.6% vs. 5.1% vs. 3.2%, p = 0.003), and MACCE (33.8% vs. 29.0% vs. 20.0%, p = 0.005) in comparison to the low and mid-CSS groups. Multivariable Cox regression analysis revealed that CSS was an independent predictor for all primary and secondary endpoints (p 0 .05). Moreover, the C-statistics of CSS for ACM (0.666 vs. 0.597, p = 0.021) and CM (0.668 vs. 0.592, p = 0.039) were significantly higher than those of SS. The clinical SYNTAX score substantially enhanced the prediction of median 3-year ACM and CM in comparison with SS in complex CAD and CRI patients following PCI.

Safety and feasibility of a real-time electronic heart team decision-making approach in patients with complex coronary artery disease: a protocol for a randomised controlled trial (EHEART trial)

IntroductionThe implementation of a heart team still faces many challenges which may be facilitated with advanced communication technology. There is a knowledge gap to support the use of an electronic...

Coronary computed tomography angiography-based SYNTAX score for comprehensive assessment of advanced coronary artery disease

BackgroundSince the initial attempt to adapt the anatomical SYNTAX score (aSS) to coronary computed tomography angiography (CCTA), CCTA imaging technology has evolved, and is currently used as a “decision-maker” for revascularization strategy in complex coronary artery disease (CAD) and has rendered necessary some updating of the aSS to the CCTA modality. ObjectivesThe aim is to provide updated definitions of the aSS derived from CCTA in patients with complex CAD undergoing CABG. MethodsThe modifications of CCTA-aSS are the following; (i) updated definition and detection criteria of total occlusion (TO) in CCTA based on length assessment, (ii) inclusion of scoring points for serial bifurcations located in one single coronary segment. (iii) inclusion of weighing score points for lesions located distal to a TO, not visualized on conventional coronary angiography, but visible in CCTA, (iv) removal of thrombus and bridging collateral items from the weighing score, considering the limited diagnostic capability of CCTA in detecting these specific lesion characteristics. Resultsthe updated CCTA-aSS was tested in a first-in-man study using the sole guidance of CCTA for the planning and performance of bypass surgery in complex CAD (n ​= ​114). An interobserver analysis showed excellent reproducibility (ICC ​= ​0.96, 95 ​% confidence interval 0.94–0.97). ConclusionThe updated CCTA-aSS was implemented in a cohort of patients with complex CAD undergoing CABG with the sole guidance of CCTA and FFRCT and the Inter-reproducibility of the analysis of the updated score was found excellent. The prognostic value of the modified CCTA-aSS will be examined in future studies.

Outcomes Based on Angiographic vs Functional Significance of Complex 3-Vessel Coronary Disease: FAME 3 Trial

BackgroundThe functional SYNTAX score (FSS), which incorporates functional information as assessed by fractional flow reserve (FFR), is a better predictor of outcome after percutaneous coronary intervention (PCI) in patients with less complex coronary artery disease (CAD). ObjectivesThis study sought to test the prognostic value of the FSS in patients with complex CAD eligible for coronary artery bypass grafting (CABG). MethodsThe FAME 3 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) trial compared FFR-guided PCI with CABG in patients with angiographic 3-vessel CAD. In this prespecified substudy, the angiographic core laboratory calculated the SYNTAX score (SS) and then the FSS by eliminating lesions that were not significant based on FFR. Outcomes in the PCI patients based on the FSS and the SS were compared to each other and to the patients treated with CABG. ResultsThe FSS reclassified more than one-quarter of patients from an SS >22 to an FSS ≤22. In the 50% of PCI patients who had an FSS ≤22, the primary endpoint occurred at a similar rate to patients treated with CABG (P = 0.77). The primary endpoint in patients without functionally significant 3-vessel CAD was similar to the CABG group (P = 0.97). The rate of myocardial infarction and revascularization among all deferred lesions was 0.5% and 3.2%, respectively. ConclusionsBy measuring the FSS, one can identify 50% of patients who have a similar outcome at 1 year with PCI compared with CABG. Lesions deferred from PCI based on FFR have a low event rate.

Impact of periprocedural major adverse events on 10-year mortality after revascularisation.

The long-term prognostic impact of a composite of periprocedural major adverse events (PMAE) following revascularisation for patients with complex coronary artery disease (CAD) has not yet been established. This study aimed to assess the impact on 10-year mortality of non-fatal PMAE following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Other objectives were to evaluate 1) whether PMAE affect mortality predicted by the SYNTAX score II 2020 (SSII-2020) and 2) whether optimal medical therapy (OMT) positively affects the prognosis of patients with non-fatal PMAE. The association between 10-year mortality and non-fatal PMAE occurring within 30 days of PCI or CABG in patients with three-vessel disease and/or left main disease enrolled in the SYNTAXES study was investigated. The main findings are that non-fatal PMAE occurred less frequently following PCI than CABG (11.2% vs 28.2%; p<0.001) and that non-fatal PMAE were an independent predictor of all-cause mortality in the first year post-procedure, but not at 5 or 10 years, in both treatment modalities. PMAE substantially alter the individual predictions of 10-year mortality by the SSII-2020. In patients with non-fatal PMAE, OMT may provide survival benefits during the first year post-procedure as well as in the long term. In patients with complex CAD, non-fatal PMAE were more common following CABG than PCI, but their prognostic impact was similar, being significant in the first year and then diminishing out to 10 years. Patients with non-fatal PMAE may therefore require more careful follow-up and additional preventive treatment in the first year post-procedure.

Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases

IntroductionA multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and...

Diagnostic concordance and discordance between angiography-based quantitative flow ratio and fractional flow reserve derived from computed tomography in complex coronary artery disease

BackgroundBoth quantitative flow ratio (QFR) and fractional flow reserve derived from computed tomography (FFRCT) have shown significant correlations with invasive wire-based fractional flow reserve. However, the correlation between QFR and FFRCT is not fully investigated in patients with complex coronary artery disease (CAD). The aim of this study is to investigate the correlation and agreement between QFR and FFRCT in patients with de novo three-vessel disease and/or left main CAD. MethodsThis is a post-hoc sub-analysis of the international, multicenter, and randomized SYNTAX III REVOLUTION trial, in which both invasive coronary angiography and coronary computed tomography angiography were prospectively obtained prior to the heart team discussion. QFR was performed in an independent core laboratory and compared with FFRCT analyzed by HeartFlow™. The correlation and agreement between QFR and FFRCT were assessed per vessel. Furthermore, independent factors of diagnostic discordance between QFR and FFRCT were evaluated. ResultsOut of 223 patients, 40 patients were excluded from this analysis due to the unavailability of FFRCT and/or QFR, and a total of 469 vessels (183 patients) were analyzed. There was a strong correlation between QFR and FFRCT (R ​= ​0.759; p ​< ​0.001), and the Bland-Altman analysis demonstrated a mean difference of −0.005 and a standard deviation of 0.116. An independent predictor of diagnostic concordance between QFR and FFRCT was the lesion location in right coronary artery (RCA) (odds ratio 0.395; 95% confidence interval 0.174–0.894; P ​= ​0.026). ConclusionIn patients with complex CAD, QFR and FFRCT were strongly correlated. The location of the lesion in RCA was associated with the highest diagnostic concordance between QFR and FFRCT.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Complex Coronary Artery Disease.

The aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]). Patients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR+ PCI vs SAVR+ CABG in such patients. A multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated. A total of 800 patients (598 undergoing SAVR+ CABG and 202 undergoing transfemoral TAVR+ PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95%CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95%CI: 0.41-3.27), and stroke (HR: 0.42; 95%CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR+ PCI group (HR: 5.38; 95%CI: 1.73-16.7). In patients with severe AS and complex CAD, TAVR+ PCI and SAVR+ CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.

Exploring optimal heart team protocol to improve decision-making stability for complex coronary artery disease: a sequential explanatory mixed method study

Abstract Background Although heart team was recommended by guideline for decision-making in patients with complex coronary artery disease (CAD), the decision-making stability was lack of evaluation and optimal protocol remained unknown. Purpose We aimed to assess inter-team agreement for revascularization decision-making and related influencing factors, so as to provide recommendations for optimal protocol. Methods A sequential, explanatory mixed method study was conducted, including (1) a cross-sectional study retrospectively enrolling patients with complex CAD and four heart teams to assess the inter-team decision-making agreement and (2) a qualitative study that semi-structurally interviewed all heart team members to analyze the potential factors associated with decision-making discrepancy. Primary outcome was kappa value of inter-team decision-making agreement. Inductive thematic analysis was used to generate themes and subthemes attributing to decision-making discrepancy. Integrating qualitative and quantitative data, we explained how each subtheme affected decision-making agreement and provided corresponding recommendations based on these explanations. Finally, we provided a detailed heart team protocol by integrating our recommendations, published experience and guideline. Patient sample size was precalculated and interviewee sample size was identified by theoretical saturation. Results A total of 101 patients with complex CAD were randomly enrolled from a consecutive angiography registry. Sixteen specialists were invited and randomly established four heart teams to make decisions for enrolled patients. Inter-team decision-making agreement was moderate (kappa 0.582) (Table 1). Decision-making may be influenced at three themes (specialist quality; team composition; meeting process) and ten subthemes (decision thought; understanding of disease and evidence; understanding of other discipline; personality; learning curve; personnel quality; number of team members; discipline selection; ratio of different disciplines and meeting form). Recommendations at five levels were provided, including (1) specialist selection, (2) specialist training, (3) team composition, (4) team training and (5) meeting process. A detailed implementation protocol to establish and deploy a qualified heart team was generated. Conclusions Agreement between heart teams for revascularization decision-making in patients with complex CAD was moderate. Five recommendations to improve heart team modality were provided based on factors associated with decision-making discrepancy. A detailed heart team implementation protocol came into being. Randomized controlled trial was warranted to further confirm the protocol. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the national key research and development program;Beijing municipal commission of science and technology project Table 1. Inter-team agreement of decision making

Impact of established cardiovascular disease on 10-year death after coronary revascularization for complex coronary artery disease

AimsTo investigate the impact of established cardiovascular disease (CVD) on 10-year all-cause death following coronary revascularization in patients with complex coronary artery disease (CAD).MethodsThe SYNTAXES study assessed vital status out to 10 years of patients with complex CAD enrolled in the SYNTAX trial. The relative efficacy of PCI versus CABG in terms of 10-year all-cause death was assessed according to co-existing CVD.ResultsEstablished CVD status was recorded in 1771 (98.3%) patients, of whom 827 (46.7%) had established CVD. Compared to those without CVD, patients with CVD had a significantly higher risk of 10-year all-cause death (31.4% vs. 21.7%; adjusted HR: 1.40; 95% CI 1.08–1.80, p = 0.010). In patients with CVD, PCI had a non-significant numerically higher risk of 10-year all-cause death compared with CABG (35.9% vs. 27.2%; adjusted HR: 1.14; 95% CI 0.83–1.58, p = 0.412). The relative treatment effects of PCI versus CABG on 10-year all-cause death in patients with complex CAD were similar irrespective of the presence of CVD (p-interaction = 0.986). Only those patients with CVD in ≥ 2 territories had a higher risk of 10-year all-cause death (adjusted HR: 2.99, 95% CI 2.11–4.23, p < 0.001) compared to those without CVD.ConclusionsThe presence of CVD involving more than one territory was associated with a significantly increased risk of 10-year all-cause death, which was non-significantly higher in complex CAD patients treated with PCI compared with CABG. Acceptable long-term outcomes were observed, suggesting that patients with established CVD should not be precluded from undergoing invasive angiography or revascularization.Trial registrationSYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.Graphic abstract

Long-term prognosis after percutaneous or surgical revascularization in patients with diabetes mellitus and complex coronary artery disease- a systematic review and meta analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background-Whether Coronary artery bypass grafting (CABG) confers a survival benefit in patients with diabetes mellitus(DM) and complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD) after a follow up period ≥ 5 years remains unknown. Methods- Electronic databases (PubMed, Embase, Scopus, Cochrane) were searched from inception to December 12th 2020. Using a generic invariance weighted random effects model, Hazard ratios (HRs) and their 95% confidence intervals (CIs) from individual studies were converted to Log HRs and corresponding standard errors, which were then pooled. The primary outcome of interest was all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE) which was defined as a composite of death, myocardial reinfarction and stroke at ≥ 5 years. Results-A total of 8 studies with 13336 participants(PCI = 6783, CABG = 6553)were included in our analysis. Mean age was 54.6 and 55.3 in the PCI-DES and CABG groups respectively. The 5-yr follow-up outcomes including all-cause mortality (HR 1.37; 95%CI 1.15-1.65; p = 0.0006, I2 = 0)and MACCE (HR 1.48; 95%CI 1.29-1.69; p &amp;lt; 0.00001, I2 = 0) were significantly higher with PCI as compared to CABG. Furthermore, at &amp;gt;5 year follow-up, all-cause mortality (HR 1.35; 95%CI 1.10-1.66; p = 0.004, I2 = 37) and MACCE (HR 1.98; 95%CI 1.85-2.12; p &amp;lt; 0.00001, I2 = 0) had similar outcomes. Conclusion-Amongst patients with DM and Complex CAD ( left main/MVD), CABG was associated with improved long-term mortality and freedom from MACCEs as opposed to PCI-DES. CABG is the preferred revascularization strategy in patients with complex anatomic disease and concurrent diabetes. Abstract Figure.

Coronary artery bypass graft surgery versus stenting for patients with chronic kidney disease and complex coronary artery disease: a systematic review and meta-analysis.

Background:The relative role of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stent implantation in patients with chronic kidney disease (CKD) and complex coronary artery disease (CAD) remains debatable due to the lack of randomized controlled trials (RCTs). We therefore performed this meta-analysis to compare the outcomes of the two strategies in CKD patients with multivessel and/or left main disease.Methods:Electronic databases including PubMed, EMBASE and Cochrane Library were comprehensively searched to identify the eligible subgroup analysis of RCTs and propensity-matched registries. The primary endpoint was all-cause mortality during the longest follow-up.Results:Five subgroup analyses of RCTs and six propensity-matched registries involving 26,441 patients were analyzed. Overall, the strategy of CABG was associated with lower risks of long-term mortality [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.74–0.93], myocardial infarction (OR, 0.41; 95% CI, 0.27–0.62), and repeat revascularization (OR, 0.25; 95% CI, 0.16–0.39) compared with PCI in CKD patients with complex CAD. However, CABG was slightly associated with higher risk of stroke than PCI (OR, 1.33; 95% CI, 1.00–1.77). Nonetheless, the higher stroke risk in the CABG group no longer existed during long-term follow-up (OR, 0.92; 95% CI, 0.37–2.25) (>3 years).Conclusion:This meta-analysis supports the current guideline advising CABG for patients with CKD and complex CAD. At the expense of slightly increased risk of stroke, CABG reduces the incidences of long-term all-cause death, myocardial infarction and repeat revascularization compared with PCI.

Impact of periprocedural myocardial infarction on 10-year mortality after percutaneous coronary intervention or coronary artery bypass grafting for multivessel or left main coronary artery disease

Abstract Background Periprocedural myocardial infarction (PMI) occurs frequently after both percutaneous coronary intervention (PCI) and bypass grafting surgery (CABG) in patients with complex coronary artery disease (CAD), and PMI has been shown to have a detrimental impact on mortality. On the other hand, long-term impact of PMI on mortality has not been fully evaluated. Purpose This study aimed to assess the impact of PMI according to SCAI definition on 10-year all-cause death in patients with complex CAD. Methods The SYNTAX Extended Survival (SYNTAXES) study evaluated vital status up to 10 years in 1800 patients with de novo three-vessel disease and/or left main coronary artery disease randomized to treatment with CABG or PCI in the SYNTAX trial. Blood was sampled for creatine kinase (CK) pre- and post-revascularisation, and the cardiac specific MB iso-enzyme (CK-MB) was determined only if the CK ratio ≥2 x the upper limit of normal (ULN). If the CK ratio &amp;lt;2 ULN, CK-MB assessment was not mandated. In this analysis, patients with at least one blood sampling within 48 hours of the procedure were included. PMI was defined as follows; peak CK-MB measured within 48 hours of the procedure ≥10 x ULN, or ≥5 x ULN with new Q-waves in 2 contiguous leads or new persistent left bundle branch block. Results Of 1800 patients, 1679 (93.2%) patients were included. Of 877 patients treated with PCI, PMI occurred in 26 patients (3.0%), whereas 14 (1.7%) PMIs were observed in 802 patients treated with CABG. Compared with patients without PMI, patients with PMI presented with unstable angina more frequently (45.0% vs. 28.7, p=0.033), and had a higher rate of bifurcation lesion (87.5% vs. 72.5, p=0.046). PMI was associated with a higher all-cause mortality at 10 years compared with no PMI (55.3% vs. 25.4%; Log-rank p&amp;lt;0.001, Figure), which was mainly driven by a high mortality rate within 1 year. In patients undergoing PCI, the mortality rates were significantly higher in patients with PMI not only within 1 year (Log-rank p&amp;lt;0.001) but also beyond one year (Log-rank p=0.016), compare to patients without PMI (Figure). On the other hand, in patients undergoing CABG, a higher mortality rate in patients with PMI was observed until 1 year (Log-rank p&amp;lt;0.001), but the impact of PMI on mortality beyond one year after CABG subsided (Log-rank p=0.308) (Figure 1). Conclusion PMI was associated with a poor prognosis at 10 years. The impact of PMI on mortality was strong within one year. Of note, the impact of PMI on mortality persisted beyond 1 year only in patients undergoing PCI. Patients who were treated with PCI and suffered PMI need careful follow-up beyond one year after revascularization. Figure 1 Funding Acknowledgement Type of funding source: None

Clinical outcome comparison of percutaneous coronary intervention and bypass surgery in diabetic patients with coronary artery disease: a meta-analysis of randomized controlled trials and observational studies

BackgroundThe optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial. The current study aimed to compare adverse clinical endpoints of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM).MethodsRelevant studies were found from MEDLINE, OVID, Science Direct, Embase and the Cochrane Central database from January 2010 to April 2019. Risk ratio (RR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables. Outcomes evaluated were all-cause mortality, major adverse cardiac/cerebrovascular events (MACCE), cardiac death, myocardial infarction, stroke, and repeat revascularization.ResultsSixteen studies were included (18,224 patients). PCI was associated with the increase risk for MACCE (RR 1.59, 95% CI 1.38–1.85), cardiac death (RR 1.76, 95% CI 1.11–2.80), MI (RR 1.98, 95% CI 1.53–2.57), repeat revascularization (RR 2.61, 95% CI 2.08–3.29). The risks for all-cause mortality (RR 1.23, 95% CI 1.00–1.52) and stroke (RR 0.71, 95% CI 0.48–1.03) were similar between two strategies. Stratified analysis based on studies design and duration of follow-up showed largely similar findings with the overall analyses, except for a significant increased risk of all-cause mortality (RR 1.32, 95% CI 1.04–1.67) in long-term group, and CABG was associated with a higher stroke rate compared to PCI, which are results that were found in RCTs (RR 0.47, 95% CI 0.28–0.79) and mid-term groups (RR 0.39, 95% CI 0.23–0.66).ConclusionsCABG was superior to PCI for diabetic patients with complex CAD (including left main CAD and/or MVD), but might be associated with a higher risk of stroke mid-term follow-up.Number of Protocol registration PROSPERO CRD 42019138505.

P4587Impact of diabetes mellitus on myocardial revascularisation method in the light of the 2018 ESC/EACTS guidelines: Results from the PROUST Study

Abstract Background/Introduction Results of currently available randomized trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The 2018 ESC/EACTS guidelines on myocardial revascularization do not recommend PCI in patients with diabetes and SYNTAX score ≥23. Purpose We aimed to compare the all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics. Methods The study group comprised consecutive diabetics with angiographically proven three-vessel CAD (≥50% diameter stenosis) and/or unprotected left main CAD (≥50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG between 2008 and 2010. All-cause mortality was ascertained by telephone contacts and/or from Mortality Registries. Results Using the hospital data system, 5145 patients were screened and 4803 elected not to follow the inclusion criteria. Out of 342 included patients, 177 patients underwent PCI and 165 patients were referred for CABG. Patients with whom CABG was performed were significantly older (64.69±8.8 vs. 62.6±9.4, p=0.03), more often on insulin treatment (91/165=55.2% vs. 26/177=14.7%, p&lt;0.01), had more complex anatomical characteristics i.e. higher SYNTAX scores (32.5 IQR (15) vs. 18.0 IQR (15), p&lt;0.01) and with left main stenosis (70/165=42.4% vs. 7/177=4.0%, p&lt;0.01), compared to patients treated with PCI. The cumulative incidence rates of all-cause death were significantly different between PCI and CABG at 4 years (16/177=9.0% vs. 26/165=15.7%, respectively, log-rank p=0.03). There was a higher incidence of all-cause mortality in PCI patients with intermediate (23–32) and high (≥33) SYNTAX scores compared with those with low (0–22) SYNTAX scores (6/32=18.8% vs. 6/124=4.8%, log-rank p=0.01; 4/21=19.1% vs. 6/124=4.8%, log-rank p=0.02, respectively). On the contrary, patients who underwent CABG displayed similar morality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 5/34=14.7%; SYNTAX 23–32: 9/54=16.7%; SYNTAX ≥33: 12/77=15.6%; log-rank p=0.9). Finally, when compared with CABG, more deaths were observed following PCI with intermediate and high SYNTAX scores (intermediate SYNTAX (23–32) PCI: 6/32=18.8% vs. CABG: 26/165=15.8%, log-rank p=0.94; high SYNTAX (≥33) PCI: 4/21=19.1% vs. CABG 26/165=15.8%, log-rank p=0.87). Conclusions During a 4-year follow-up, CABG in comparison with PCI was associated with a higher rate of all-cause death, which can be accounted for by older age and comorbidities. In diabetics, our analysis is suggestive that PCI probably should be avoided in patients with SYNTAX ≥23, which is in concordance with the most recent guidelines. Individualized risk assessment as well as quantification of CAD by SYNTAX score remains essential in choosing appropriate revascularization method in patients with diabetes and complex CAD. Acknowledgement/Funding None

Long-Term Outcomes Following Heart Team Revascularization Recommendations in Complex Coronary Artery Disease.

BackgroundThe Heart Team (HT) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease (CAD). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion.Methods and ResultsThis observational study was conducted at St Thomas’ Hospital (London, UK). Case mixture included unprotected left main, 2‐vessel (including proximal left anterior descending artery) CAD, 3‐vessel CAD, or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy (OMT) alone, OMT+percutaneous coronary intervention (PCI), or OMT+coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23–39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3‐vessel CAD. Three‐year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT+PCI cohort, and 90.2% in the OMT+coronary artery bypass grafting cohort (92 of 102).ConclusionsIn our experience, the HT approach involved a careful selection process resulting in appropriate patient‐specific decision making and good long‐term outcomes in patients with complex CAD.

REVASCULARIZATION OF COMPLEX CORONARY ARTERY DISEASE BY THE PRESENCE OF HEART TEAMS IN THE UNITED STATES: RESULTS FROM THE TRANSLATING OUTSTANDING PERFORMANCE IN PERCUTANEOUS CORONARY INTERVENTION (TOP PCI) STUDY

ACC/AHA guidelines recommend a multidisciplinary heart team (MHT) approach in managing patients with complex coronary artery disease (CAD). It is unknown whether revascularization patterns of complex CAD differ by the presence or absence of MHTs. We surveyed 405 hospitals in the NCDR CathPCI

SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization in the FREEDOM Trial

BackgroundDiabetes mellitus (DM) is associated with complex coronary artery disease (CAD), which in turn results in increased morbidity and mortality from cardiovascular disease. ObjectivesThis study sought to evaluate the utility of SYNTAX score (SS) for predicting future cardiovascular events in patients with DM and complex CAD undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). MethodsThe FREEDOM (Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease) trial randomized patients with DM and multivessel CAD to undergo either PCI with drug-eluting stents or CABG. The SS was calculated retrospectively by a core laboratory. The endpoint of hard cardiovascular events (HCE) was a composite of death from any cause, nonfatal myocardial infarction, and nonfatal stroke, while the endpoint of major adverse cardiac and cerebrovascular events (MACCE) was a composite of HCE and repeat revascularization. ResultsA total of 1,900 patients were randomized to PCI (n = 953) or CABG (n = 947). The SS was considered an independent predictor of 5-year MACCE (hazard ratio per unit of SS: 1.02; 95% confidence interval: 1.00 to 1.03; p = 0.014) and HCE (hazard ratio per unit of SS: 1.03; 95% confidence interval: 1.01 to 1.04; p = 0.002) in the PCI cohort, but not in the CABG group. There was a higher incidence of MACCE in PCI patients with low, intermediate, and high SS compared with those who underwent CABG (36.6% vs. 25.9%, p = 0.02; 43.9% vs. 26.8%, p < 0.001; 48.7% vs. 29.7%, p = 0.003, respectively). ConclusionsIn DM patients with multivessel CAD, the complexity of CAD evaluated by the SS is an independent risk factor for MACCE and HCE only in patients undergoing PCI. The SS should not be utilized to guide the choice of coronary revascularization in patients with DM and multivessel CAD. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450)

FFRCT for Complex Coronary Artery Disease Treatment Planning: New Opportunities.

Coronary computed tomography (CT) is well established for the assessment of symptomatic patients with suspected but not yet confirmed coronary artery disease with high diagnostic accuracy and risk prediction. Until recently, coronary computed tomography angiography (CTA) has played a limited role in the management of complex coronary artery disease (CAD) and in planning revascularisation strategies. With the advent of FFRCT, enabling anatomy and physiology with a single study and the ability to adjudicate lesion specific pressure loss, the potential of combined coronary CT angiography (CCTA) and fractional flow reserve (FFR) computed from non-invasive CT angiography (FFRCT) to inform treatment decision-making and help guide revascularisation has been recognised. In this review, we highlight the evolving role of FFRCT in the management of complex CAD; the opportunities, the data and the unanswered questions.