Complex Coronary Disease Research Articles

COMPARISON OF CLINICAL AND ANGIOGRAPHIC CHARACTERISTICS OF DIABETIC AND NON-DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Objectives: In this study, we evaluated the differences in clinical and angiographic profiles of ST-segment elevation myocardial infarction (STEMI) patients with and without diabetes mellitus (DM) at a tertiary care cardiac hospital in Karachi, Pakistan. Methodology: This descriptive cross-sectional study was conducted at a tertiary care cardiac hospital in Karachi, Pakistan. The study included consecutive adult patients (≥ 18 years of age) diagnosed with STEMI undergoing primary percutaneous coronary intervention (PCI). Diabetic and non-diabetic patients were compared for clinical and angiographic profiles. Results: The study sample consisted of 43.8% (218) diabetic patients. The mean age was 59.03 ± 9.69 years vs. 49.54 ± 11.53 years; p<0.001, proportion of females was 35.3% (77) vs. 14.6% (41); p<0.001, Killip class III or IV was (17) vs. 2.5% (7), and hypertension was 83% (181) vs. 56.8% (159); p<0.001 among the diabetic and non-diabetic group, respectively. The frequency of multi-vessel disease was 50.9% (111) vs. 39.6% (111), the significant left main disease was 5% (11) vs. 2.5% (7), and initial TIMI III flow was 19.3% (42) vs. 25.4% (71) in diabetic and non-diabetic patients, respectively. Conclusion: In conclusion, diabetes in STEMI setting is associated with complex coronary artery diseases, more hemodynamic instability at presentation, and the presence of multiple co-morbid conditions.

Coronary Revascularization in Diabetes Patients

India has become the diabetes capital of the world. Coronary artery disease in diabetes patients are often silent and complex. Incidence of diffuse and multi vessel disease are more predominant in diabetes patients. Triple vessel disease and diffuse disease are common and often bring challenges in selecting treatment option. The incidence of stent thrombosis, in stent restenosis and repeat interventional procedures are more common in diabetes patients. Though coronary artery bypass surgery is known to achieve better long -term outcome in triple vessel disease in diabetes patients but coronary interventions with latest generation drug eluting stents are also shown to achieve similar type of outcome. Careful selection of cases with consideration of coronary anatomy and a multidisciplinary approach in treatment of complex coronary disease are the keys of success and better long -term result.

Serum copper concentration reflect inflammatory activation in the complex coronary artery disease – A pilot study

IntroductionCoronary artery disease possess inflammatory background related to enzymatic processes with trace elements involvements as co-factors. The aim of the study was to compare serum, urine and salivary copper, magnesium, calcium and zinc levels with inflammatory indices obtained from the whole blood count in patients with complex coronary artery disease. Material and methodFifty-two (42(81 %) males, 10 (19 %) females) consecutive patients (mean (SD) age 68 (9) years with symptomatic complex coronary artery disease were enrolled into prospective single center study in 2021. Serum, saliva and urine samples were collected at the day of admission for trace elements concentration (copper, zinc, magnesium, calcium) and compared with inflammatory indexes obtained from preoperative and perioperative period. ResultsMultivariable regression analysis revealed relation between the copper serum concentration and neutrophil to lymphocyte ratio (NLR) and systemic inflammatory index (SII). ConclusionSerum copper concentration interplay with preoperative inflammatory activation in complex coronary disease measured by NLR and SII. The copper serum concentration possesses the strongest relation to preoperative inflammatory activation in patients reffered for off-pump coronary artery bypass grafting.

Comparative Study on Percutaneous Coronary Intervention with Coronary Artery Bypass Grafting on Endpoint Events in Patients with Complex Coronary Heart Disease

Comparative Study on Percutaneous Coronary Intervention with Coronary Artery Bypass Grafting on Endpoint Events in Patients with Complex Coronary Heart Disease

Quantitative Myocardial Perfusion Predicts Outcomes in Patients With Prior SurgicalRevascularization.

Patients with previous coronary artery bypass graft (CABG) surgery typically have complex coronary disease and remain at high risk of adverse events. Quantitative myocardial perfusion indices predict outcomes in native vessel disease, but their prognostic performance in patients with prior CABG is unknown. In this study, we sought to evaluate whether global stress myocardial blood flow (MBF) and perfusion reserve (MPR) derived from perfusion mapping cardiac magnetic resonance (CMR) independently predict adverse outcomes in patients with prior CABG. This was a retrospective analysis of consecutive patients with prior CABG referred for adenosine stress perfusion CMR. Perfusion mapping was performed in-line with automated quantification of MBF. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular events defined as nonfatal myocardial infarction and unplanned revascularization. Associations were evaluated with the use of Cox proportional hazards models after adjusting for comorbidities and CMR parameters. A total of 341 patients (median age 67 years, 86% male) were included. Over a median follow-up of 638days (IQR: 367-976days), 81 patients (24%) reached the primary outcome. Both stress MBF and MPR independently predicted outcomes after adjusting for known prognostic factors (regional ischemia, infarction). The adjusted hazard ratio (HR) for 1mL/g/min of decrease in stress MBF was 2.56 (95%CI: 1.45-4.35) and for 1 unit of decrease in MPR was 1.61 (95%CI: 1.08-2.38). Global stress MBF and MPR derived from perfusion CMR independently predict adverse outcomes in patients with previous CABG. This effect is independent from the presence of regional ischemia on visual assessment and the extent of previous infarction.

OR11. Association between T peak-T end interval and mortality in patient with complex coronary lesion scheduled for Coronary Artery Bypass Graft procedure

Abstract Aim Patient with complex coronary lesion face a mortality risk caused by sudden cardiac death (SCD). The Tpeak-Tend (TpTe) interval is a measure of dispersion of ventricular repolarization. Our aim is to investigate the relationship between the TpTe interval in patient’s resting 12-lead electrocardiogram (ECG) and the mortality incidence of patient waiting for Coronary Artery Bypass Graft (CABG) procedure. Methods and result Total of 175 patient scheduled for CABG procedure between January 2018 to December 2020. ECG was taken from medical record, interval of TpTe is calculated in V2 lead with tangent method ECG analysis. Association between variables analysed with Pearson chi-square test. Baseline characteristic showed age 58.7 ± 6.8 years old, syntax score 30.66 ± 4.0 and left ventricle ejection fraction 47.8% ±14.4. There is significant association between prolonged TpTe interval (>85 ms) and mortality incidence before CABG with odds ratio 3.821 (95% CI 1.727 – 8.454; p = 0.001). Conclusion TpTe interval is a feasible parameter that associate with the mortality in patient with complex coronary disease.

Ensayos cl�nicos aleatorizados en desarrollo en intervencionismo coronario complejo: estudios guiados por imagen intravascular

Percutaneous coronary intervention of complex coronary artery disease remains challenging and is still associated with suboptimal cardiovascular outcomes. Over the years, different strategies and technologies have been developed to improve these results. Particularly, the development and evolution of intravascular imaging modalities to guide the procedure have improved lesion assessment and preparation, and stent optimization. However, whether these advantages are beneficial in this particular setting is still under discussion. In this article we intend to briefly summarize previous imaging-guided trials and give an outline on the ongoing large trials that are being conducted on imaging-guided interventions in complex coronary disease.

In-hospital clinical outcomes of percutaneous coronary intervention for patients deemed ineligible for surgical revascularization

Abstract Background Ineligibility for surgical revascularization remains subjective with limited data. Coronary artery bypass graft surgery (CABG)-ineligible patients usually have a high prevalence of risk factors and complex coronary disease, which lead to worse clinical outcomes. Aim We aimed to evaluate CABG surgical ineligibility reasons and in-hospital percutaneous coronary intervention (PCI) outcomes at a large tertiary centre. Methods Anonymized, prospectively collected data from the institutional electronic records between April 2013 and November 2020 were analysed retrospectively. All patients who were formally turned down for CABG and had PCI were included. Results There were 473 patients in total. Perceived frailty of the patient with associated comorbidities and/or the quality of distal coronary arteries were the main documented reasons for surgical ineligibility in 52.4% of patients. Mean age was 72±11 years, mean body mass index was 29±6 kg/m2 and 69.8% were male. Stable angina constituted 216 patients (45.7%) and 257 patients (54.3%) had acute coronary syndromes. Mean hospital stay was 4±5 days. Procedural success was documented in 457 out of 473 patients (96.6%). PCI adjunctive tools included coronary imaging in 97 patients (20.5%), rotational atherectomy in 96 patients (20.3%), laser atherectomy in 12 patients (2.5%), lithotripsy in 3 patients (0.6%) and physiological assessments in 34 patients (7.2%). In-hospital major adverse cardiac events were experienced in 32 patients (6.8%), death in 12 patients (2.5%), myocardial infarction in 21 patients (4.4%), ischaemic stroke in 1 patient (0.2%), coronary perforation in 7 patients (1.5%), repeat target vessel revascularization in 6 patients (1.3%), major access-site bleeding in 2 patients (0.4%), aortic dissection in 1 patient (0.2%) and new acute kidney injury requiring dialysis in 1 patient (0.2%). Conclusions PCI in surgically ineligible patients is generally safe and effective. The process of determining suitability for surgical revascularization remains complex in the real-world. Funding Acknowledgement Type of funding sources: None.

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discuss strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization.

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discusses strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.

Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease.

Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.

Abstract 16759: In-Hospital Outcomes of Coronary Artery Bypass Grafting Candidates Undergoing Percutaneous Coronary Intervention During the Intensive Care Unit Restricted Covid-19 Pandemic: The Multi-Centre Prospective UK-REVASC Registry

Introduction: The COVID-19 pandemic has restricted availability of ICU resources. Symptomatic patients with coronary artery disease (CAD) normally considered surgical candidates have therefore required alternative revascularization with percutaneous coronary intervention (PCI). The UK-REVASC registry describes the demographics and in-hospital clinical outcomes of this novel patient cohort. Methods: From 1 st March to 31 st May 2020, anonymised data of 171 patients from 38 UK centres were enrolled in a prospective, observational registry. All were on surgical waiting lists or considered for surgery. Results: The demographics, procedural characteristics and outcomes are shown in Tables 1-3. A comparison with routine PCI British Cardiovascular Intervention Society (BCIS) data and UK isolated coronary bypass surgical data are listed, where available and appropriate. The median age was 68 (IQR 60-76) years. There was significantly more previous MI, PCI and CABG in the routine PCI database than in ReVasc Registry patients, perhaps suggesting a more acute presentation with accelerated symptoms in the test group. These were however complex patients with a mean SYNTAX Score (SS) of 27.8 (range 9-65) and >20x the number of LMS plus multi-vessel disease compared to the routine PCI group, which is reflected in a high use of adjunctive imaging. Radial access was very high at 94.1%. PCI success was 97.0%. Complete revascularization was achieved in 52% with the mean residual SS 1.42 (0-20) in these. There were 2 deaths, however the mortality rate was comparable with published surgical data. Furthermore, a 50% reduction in in-patient stay was observed. Conclusion: In this multi-centre UK registry, in-hospital outcomes following PCI for patients with complex coronary disease, who would typically be treated with CABG, compared well with the surgical data. This suggests that the role of PCI could be extended. Future longer term follow-up however is required and planned.

Abstract 14770: Reduction With Evolocumab in Complex Coronary Disease Requiring Revascularization: Insights From the FOURIER Trial

Introduction: Although PCSK9 inhibitors induce plaque regression and reduce the risk of coronary revascularization overall, their ability to specifically reduce the risk of complex coronary atherosclerosis requiring revascularization has not been explored. Methods: FOURIER was a randomized trial of the PCSK9 inhibitor evolocumab vs. placebo in 27,564 patients with ASCVD on statin therapy (median achieved LDL-C 32 mg/dL vs. 89 mg/dL) followed for a median of 2.2 years. The study database was blindly reviewed to assess characteristics of coronary revascularization procedures. Complex revascularization was the composite of complex PCI (per GLOBAL LEADERS criteria, at least one of: multivessel PCI, 3 or more stents implanted, 3 or more lesions treated, bifurcation PCI with 2 or more stents, or total stent length >60 mm) or CABG. PCI complications included no-reflow, side branch loss, thrombus formation, major dissection, or perforation. The effects of evolocumab on types of revascularization and PCI complications were evaluated using Cox proportional hazards models. Results: 1724 patients underwent revascularization procedures during follow-up. Evolocumab reduced the risk of non-complex PCI by 22% (HR 0.78; 95%CI 0.70-0.88; P<0.001) and the risk of complex revascularization by 29% (HR 0.71; 95%CI 0.61-0.84; P<0.001), including complex PCI by 33% (HR 0.67; 95%CI 0.54-0.84; P<0.001) and CABG by 24% (HR 0.76; 95%CI 0.60-0.96; P=0.019; Figure). The incidence of reported PCI complications tended to be lower with evolocumab (HR 0.74; 95% CI 0.49-1.11). Conclusions: Adding evolocumab to statin therapy reduced the risk of developing complex coronary disease requiring revascularization, including complex PCI and CABG individually. Together with prior coronary imaging findings, these data suggest very aggressive LDL-C lowering to <1 mmol/L has beneficial effects on coronary atherosclerosis burden, anatomical complexity, and the need for intervention.

Effect of Evolocumab on Complex Coronary Disease Requiring Revascularization

ObjectivesThis study sought to evaluate the ability of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor evolocumab to reduce the risk of complex coronary atherosclerosis requiring revascularization. BackgroundPCSK9 inhibitors induce plaque regression and reduce the risk of coronary revascularization overall. MethodsFOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) was a randomized trial of the PCSK9 inhibitor evolocumab versus placebo in 27,564 patients with stable atherosclerotic cardiovascular disease on statin therapy followed for a median of 2.2 years. Clinical documentation of revascularization events was blindly reviewed to assess coronary anatomy and procedural characteristics. Complex revascularization was the composite of complex percutaneous coronary intervention (PCI) (as per previous analyses, ≥1 of: multivessel PCI, ≥3 stents, ≥3 lesions treated, bifurcation PCI, or total stent length >60 mm) or coronary artery bypass grafting surgery (CABG). ResultsIn this study, 1,724 patients underwent coronary revascularization, including 1,482 who underwent PCI, 296 who underwent CABG, and 54 who underwent both. Complex revascularization was performed in 632 (37%) patients. Evolocumab reduced the risk of any coronary revascularization by 22% (hazard ratio [HR]: 0.78; 95% CI: 0.71 to 0.86; p < 0.001), simple PCI by 22% (HR: 0.78; 95% CI: 0.70 to 0.88; p < 0.001), complex PCI by 33% (HR: 0.67; 95% CI: 0.54 to 0.84; p < 0.001), CABG by 24% (HR: 0.76; 95% CI: 0.60 to 0.96; p = 0.019), and complex revascularization by 29% (HR: 0.71; 95% CI: 0.61 to 0.84; p < 0.001). The magnitude of the risk reduction with evolocumab in complex revascularization tended to increase over time (20%, 36%, and 41% risk reductions in the first, second, and beyond second years). ConclusionsAdding evolocumab to statin therapy significantly reduced the risk of developing complex coronary disease requiring revascularization, including complex PCI and CABG individually. (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER); NCT01764633.)

NON-ST ELEVATION MYOCARDIAL INFARCTION: CORRELATION OF RED BLOOD CELL DISTRIBUTION WIDTH WITH SYNTAX SCORE

Objective: To determine the correlation between mean RDW values and mean SYNTAX scores in patients of non ST elevation myocardial infarction. Methodology: This descriptive study was conducted at adult Angiography Department of Faisalabad Institute of Cardiology, Faisalabad from September, 2017 to October, 2018. A total of 130 patients were enrolled in this study. Patients were divided into high (n=89) and low (n=41) SYNTAX groups. The high SYNTAX group was defined as patients with value in the third tertile (SYNTAX score, SX score ≥ 33) while the group with low SNTAX score was defined as patients with values in the lower 2 tertiles (SYNTAX score, SX score &lt; 33). The high RDW group was defined as patients with RDW value &gt; 16 % and the low RDW group as those with RDW value &lt; 16 %. Results: The mean RDW value was correlated with mean SYNTAX score in both groups. The RDW levels were significantly high in patients with high SNTAX score than those with low SYNTAX score (16.2± 1.8 vs. 14.2 ± 1.2, p &lt;0.001). Pearson’s coefficient was used to determine the correlation between RDW levels and SYNTAX scores. There was a significant positive correlation between mean RDW value and mean SYNTAX score value (r=0.831, p &lt;0.001). Conclusion: We found a positive and significant correlation between mean RDW values and mean SYNTAX scores in patients of non-ST elevation myocardial infarction. This reflects the utility of RDW being a non-invasive and readily available laboratory test to determine the severity and complexity of coronary disease in these patients.

Cardiac arrest, chronic total occlusion, and occluded stent in a 16-year-old boy with Kawasaki disease: a case report.

BackgroundKawasaki disease is the leading cause of premature coronary artery disease in developed countries. As such, patients may require revascularisation as children. However, there are no randomized data guiding treatment so this must be individualized. This case report describes the decision-making in a young patient requiring revascularization who had already suffered stent occlusion.Case summaryOur patient, a 16-year-old boy with Kawasaki disease, presented with cardiac arrest during exercise. Coronary angiography showed that a proximal left anterior descending artery stent implanted at the age of 8 years had occluded some time ago and his right coronary artery was also chronically occluded. He has discussed in several Heart Team meetings and with international colleagues and a consensus reached to revascularize him surgically.DiscussionIt is vital that young patients with complex coronary disease are discussed in an extensive multidisciplinary setting to determine the most suitable means of treatment. The previously occluded stent was crucial in the individualized decision-making in this patient.

Procedure and Effectiveness of Extracorporeal Membrane Oxygenation in Percutaneous Coronary Intervention for High-risk Complex Coronary Disease

Objective: It has been demonstrated that performing percutaneous coronary intervention (PCI) in the absence of mechanical circulation support (MCS) for patients with complex high-risk coronary artery disease bears a high risk. Alternatively, to figure out the procedure effectiveness and the mid-term prognosis of PCI for complex high-risk coronary artery disease, we accomplished the whole process by the assistance of extracorporeal membrane oxygenation (ECMO). Methods: Between July 2016 and October 2017, 6 consecutive complex and high-risk coronary disease patients underwent routine ECMO-supported PCI. Results: The average age of the patients was 70.5±11.98, and half of them (50%) were male. The mean creatinine (Cr) was 188.67±151.68 µmol/L. The average scores for SYNTAX, SYNTAX II, and LVEF pre the procedure was 41.33±12.14, 47.87±9.45 / 31.55±8.82, and 44.40±12.58%, respectively. The mean supporting duration of ECMO was 10.50±7.79 h. Regarding the postoperative complication, one case observed lower limp venous thrombosis and another reported infection at the access site. Two patients (33.3%) died for refractory heart failure during the follow-up course of 17.00±9.51 months, and the average net improvement index (NII) was 28.30±25.11% for this period. Conclusion: With the support of ECMO, the prognosis of complex high-risk coronary disease has shown to be improved by intervention in our study.

Cardiovascular outcomes after percutaneous coronary intervention on bifurcation lesions with moderate to severe coronary calcium: A single-center registry study.

Both target vessel calcification and target vessel bifurcation are associated with worse outcomes following percutaneous coronary intervention (PCI). Whether these entities in combination interact to influence outcomes after PCI of complex coronary disease is not known. This study evaluated the association of target vessel bifurcation and target vessel calcification, alone and in combination, with adverse events following PCI. Registry data from 21,165 patients who underwent PCI with drug-eluting stents (DES) between January 2009 and December 2017 were analyzed. Patients were divided into four groups according to the presence or absence of target vessel bifurcation and presence of none/mild or moderate/severe target vessel calcification on angiography. Associations between lesion groups and 1 year major adverse cardiac events (MACE) were examined using Cox regression analysis. At 1 year, unadjusted rates of MACE, death, myocardial infarction (MI), as well as stent thrombosis were highest in the group with both bifurcation lesion and moderate/severe calcification. After adjusting for confounders such as age, renal disease, and smoking, hazard ratios for MACE were 1.14 (95%CI 0.99-1.33) for bifurcation with none/mild calcification, 1.21 (95%CI 1.06-1.38) for no bifurcation and moderate/severe calcification, and 1.37 (95%CI 1.14-1.64) for bifurcation and moderate severe calcification, compared to patients with no bifurcation and none/mild calcification. The presence of a bifurcating target vessel with moderate/severe calcification is associated with a higher risk of adverse outcomes than either attribute alone. New approaches are needed to improve outcomes in this subset of patients with complex coronary artery disease.

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5-year follow-up randomized controlled trials.

A 5-year survival of patients with unprotected left main (ULM) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined. Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE [a composite endpoint of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization] along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to the use of first- vs. last-generation coronary stents. Subgroup comparisons were performed according to SYNTAX score (below or above 33) and to age (using cut-offs of each trial's subgroup analysis). Four RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation, and 1540 with last-generation stents. At 5-year rates of all-cause death did not differ [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.71-1.21], as those of CV death and stroke. Coronary artery bypass graft reduced rates of MACCE (OR 0.69, 95% CI 0.60-0.79), mainly driven by MI (OR 0.48, 95% CI 0.36-0.65) and revascularization (OR 0.53, 95% CI 0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of SYNTAX score (OR 0.76, 95% CI 0.59-0.97 for values < 32 and OR 0.63, 95% CI 0.47-0.84 for values ≥ 33) while was not evident for 'younger' patients (OR 0.83, 95% CI 0.65-1.07 vs. OR 0.65, 95% CI 0.51-0.84 for 'older' patients). For patients with ULM disease followed-up for 5 years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. Coronary artery bypass graft reduced risk of MI, revascularization, and MACCE especially in older patients and in those with complex coronary disease and a high SYNTAX score.

A CHIP FELLOW'S TRANSITION INTO PRACTICE: BUILDING A COMPLEX CORONARY THERAPEUTICS PROGRAM

Both the prevalence and complexity of CAD are on the rise, leading to a resurgence in novel techniques and equipment utilized to treat complex coronary disease. However, declining PCI volumes and lack of formal post-graduate education opportunities have created a gap in treatment delivery. Several