Incomplete Coronary Revascularization Research Articles

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

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

COMPARATIVE ANALYSIS OF OUTCOME AFTER MEDICAL THERAPY ALONE VERSUS INCOMPLETE REVASCULARIZATION ALONG WITH MEDICAL THERAPY IN PATIENTS WITH MULTI-VESSEL CORONARY ARTERY DISEASE

The retrospective study was conducted in the Department of Cardiology, Chaudhry Pervez Elahi Institute of Cardiology, Multan, from 29-Jan-2022 to 28-Jul-2022 to compare the frequency of relief from angina after medical therapy alone versus incomplete revascularization along with medical therapy in local patients with multi-vessel coronary artery disease. A total of 60 patients were enrolled and randomly divided into groups I and II. Group I received standard medical therapy as per the operational definition. Group II underwent incomplete coronary artery re-vascularization – stent placement through PCI in the fluoroscopy suite. Post-IR, these patients also received standard medical therapy. All the patients were called for monthly follow-up. Patients having symptomatic relief from angina were placed in functional class II. Results showed that pain relief from angina was observed in 10 (16.67%) patients and not in 50 (83.33%). A group comparison of symptomatic relief from angina showed that relief was observed in 02 (6.70%) patients in group I and 08 (26.70%) patients in group II. This result was statistically significant, with a p-value of 0.038. Stratification was performed based on age, gender, diabetes, hypertension, smoking, and obesity. There was no association between these variables and angina relief in either group. It can be concluded that in multi-vessel coronary artery disease, incomplete revascularization and medical therapy are superior to medical therapy alone.

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

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

Impact of Incomplete Coronary Revascularization on Late Ischemic and Bleeding Events after Transcatheter Aortic Valve Replacement.

Background: The impact of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing transcatheter aortic valve replacement (TAVR) remain debated. A dismal prognosis in patients undergoing PCI has been associated with elevated baseline SYNTAX score (bSS) and residual SYNTAX score (rSS). The objective was to investigate whether the degree of bSS and rSS impacted ischemic and bleeding events after TAVR. Methods: bSS and rSS were calculated in 311 patients admitted for TAVR. The primary outcome was the occurrence of major adverse cardiac events (MACE), a composite endpoint of myocardial infarction, stroke, cardiovascular death, or rehospitalization for heart failure. The occurrence of late major/life-threatening bleeding complications (MLBCs) and each primary endpoint individually were the secondary endpoints. Results: bSS > 22 was associated with higher occurrence of MACE (p = 0.013). rSS > 8 and bSS > 22 had no impact on overall cardiovascular mortality. rSS > 8 and bSS > 22 were associated with higher rates of myocardial infarction (p = 0.001 and p = 0.004) and late occurrence of MLBCs. Multivariate analysis showed that bSS > 22 (sHR 2.48) and rSS > 8 (sHR 2.35) remained predictors of MLBCs but not of myocardial infarction. Conclusions: Incomplete coronary revascularization and CAD burden did not impact overall and cardiac mortality but constitute predictors of late MLBCs in TAVR patients.

Percutaneous Coronary Interventions in Patients With ST-Elevation Myocardial Infarction: 10-Years Follow-up

Aim To study long-term results and to identify predictors of death in patients with ST-segment elevation acute myocardial infarction (STEMI) who underwent endovascular revascularization.Materials and methods This study included 283 patients registered in the hospital registry of percutaneous coronary interventions (PCI) for STEMI from 2006 through 2009. Analysis of 10-year results included all-cause and cardiovascular death rate, incidence of recurrent myocardial infarction (MI), repeated revascularization, stroke, stent restenosis and thrombosis. Also, a composite endpoint МАССЕ (Major Adverse Cardiovascular and Cerebrovascular Events) was evaluated, which included death, recurrent MI, repeated PCI, stent restenosis and thrombosis, coronary bypass, and stroke.Results Information about the health condition was provided by 204 (72.1 %) patients. Mean follow-up period was 120.1±9.5 months. All-cause mortality was 25.5 % with cardiovascular death determined in 19.1 % of cases. Recurrent MI developed in 21.6 % of patients; in 1.5 % of cases, recurrent MI resulted from thrombosis of previously implanted stents. Repeated PCI was performed for 31.9 % of patients; in 13.7 % of cases, the PCI was performed for stent restenosis. Coronary bypass was performed for 5.4 % of patients. Incidence of stroke was 10.3 %. Major cardiovascular and cerebrovascular complications (МАССЕ) during the follow-up period were determined in 60.3 % patients. According to the Cox proportional hazards regression model, age ≥65 years (odds ratio (OR), 3.75 at 95 % confidence interval (CI) from 1.75 to 8.03; р=0.001) and incomplete coronary revascularization (OR, 3.09 at 95 % CI from 1.52 to 6.30; р=0.002) were independent predictors of death based on data of the 10-year observation.Conclusion Therefore, at 10 years following endovascular revascularization, STEMI patients showed a moderate death rate with a high incidence of major cardiovascular and cerebrovascular complications. The leading causes for fatal outcomes were recurrent cardiovascular complications. The major predictors of death for the coming 10-year period included age ≥65 years and incomplete myocardial revascularization.

Impact of incomplete coronary revascularization on late ischemic and bleeding events after transcatheter aortic-valve Replacement

The respective influences of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing Transcatheter aortic-valve replacement (TAVR) remain highly controversial. The residual SYNTAX Score (rSS) has been developed to assess the impact of residual CAD after PCI. Both baseline SYNTAX Score (bSS) and rSS have been associated with dismal prognosis in patients undergoing PCI. To assess whether the degree of bSS and rSS impact ischemic and bleeding events after TAVR. Three hundred and eleven patients were admitted for TAVR. Severe CAD was defined by bSS > 22. Incomplete revascularization was defined by rSS > 8. The primary outcome was the occurrence of a composite endpoint of either cardiovascular death, myocardial infarction, stroke or rehospitalization for heart failure (MACE). Secondary endpoints included each primary endpoint individually and the occurrence of late major/life threatening bleeding complications (MLBCs). After a median follow-up of 830 days, bSS > 22 was associated with higher occurrence of MACE ( P = 0.013). However, bSS > 22 and rSS > 8 had no impact on overall cardiovascular mortality. By contrast, they were associated with higher rates of periprocedural major bleeding ( P = 0.002), myocardial infarction ( P = 0.001) and late occurrence of MLBCs and transfusion rate ( P = 0.005). Results of multivariate analysis showed that bSS > 22 (HR 2.43 95% CI (1.01–5.85); P = 0.048) and rSS > 8 (HR 2.39 95% CI (1.2–4.7); P = 0.013) remained predictors of MLBCs but not of myocardial infarction ( Table 1 , Fig. 1 ). In unselected TAVR patients, initial CAD burden and incomplete coronary revascularization did not impact overall and cardiac mortality but constitute reliable predictors of late MLBCs.

Technical factors affecting cardiac surgical mortality in Australia.

Aim Examination of potentially avoidable issues in surgical deaths can provide a basis for quality improvement. Perioperative technical factors in cardiac surgery may lead or contribute to patient mortality. Using data from a well-established and comprehensive national surgical mortality audit, we aimed to identify and describe clinical management issues leading to mortality in Australian cardiac surgical patients. Methods Retrospective analysis of a cardiac surgical dataset from the Australian and New Zealand Audit of Surgical Mortality (February 2009 to December 2015) was undertaken. Clinical management issues related to technical factors were analyzed using a thematic analysis approach. Technical clinical management issues were categorized based on the most common themes, followed by qualitative analysis of each theme. Results We identified 256 patients with least one technical management issues (total 270). Injury to structures was the most common theme ( n = 115, 44.9%), followed by unaddressed surgical pathology ( n = 39, 15.2%) and inadequate myocardial protection ( n = 34, 13.2%). More specifically, the most common structural injury involved the right ventricle, with the aorta and femoral vessels also commonly injured. The most common unaddressed surgical pathology was incomplete coronary revascularization, followed by systolic anterior motion of the mitral valve during mitral repair. Graft failure occurred during coronary artery bypass graft surgery, with a poor target vessel being a common issue. Conclusion Technical factors in cardiac surgery resulting in potentially avoidable mortality constitute an important subset of deaths. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Complete revascularization determined by myocardial perfusion imaging could improve the outcomes of patients with stable coronary artery disease, compared with incomplete revascularization and no revascularization

ObjectivesTo compare the outcomes among patients treated by complete coronary revascularization (CCR) or incomplete coronary revascularization (ICR) and no coronary revascularization (NCR) by myocardial perfusion imaging (MPI), as well as to evaluate the impact of severity of ischemia on patients with coronary artery disease (CAD) by different therapy strategies. BackgroundUsing myocardial ischemia severity determined by MPI guiding treatment strategies for CAD patients still lacks strong clinical evidences. MethodsConsecutive patients (N = 286) underwent clinical stress-rest SPECT MPI and were retrospectively followed-up. For assessment of outcome of treatment, all patients were classified into three groups (CCR, ICR, and NCR), and further divided into two subgroups as mild ischemia (< 10% ischemic myocardium) and moderate-severe ischemia (≥ 10% ischemic myocardium). All-cause death was defined as the primary endpoint, and the composite of deaths, nonfatal myocardial infarction, and repeat revascularization (MACE) as the secondary endpoint. ResultsTwo-hundred eighty-six patients were followed-up for 46 ± 21 months. Thirty deaths and 65 MACEs were recorded. Patients treated by revascularization had significantly lower MACE (P < .001) but not mortality (P = .158) than patients treated by NCR. Outcomes of CCR related to mortality rate were greater than ICR and NCR (death: P = .019, MACE: P < .001). In patients with moderate-severe ischemia, CCR showed improved outcomes than ICR and NCR (death: P = .034; and MACE: P < .001). In patients with mild ischemia, the outcomes of CCR, ICR, and NCR had no significant difference (P > .05). Multivariate regression Cox analysis revealed that summed difference score [death: HR 1.09 (1.03, 1.15), P = .004] was an independent risk factor and CCR was an independent negative predictor [death: HR 0.31 (0.12, 0.81), P = .017; MACE: HR 0.30 (0.16, 0.57), P < .001]. ConclusionsOutcomes of patients treated by CCR were most likely more promising in comparison with treatment of ICR and NCR, especially when patients had over 10% ischemic myocardium.

Coronary artery disease and reasonably incomplete coronary revascularization in high-risk patients undergoing transcatheter aortic valve implantation.

To evaluate the long-term impact of coronary artery disease (CAD) and heart team-guided incomplete coronary revascularization in patients undergoing transcatheter aortic valve implantation (TAVI). Revascularization strategy of CAD diagnosed with routine coronary angiography before TAVI is uncertain. Five hundred and forty consecutive TAVI patients were classified as having CAD or normal coronary arteries (no-CAD). Within the CAD group, patients were further classified as those with complete (CR) versus incomplete revascularization (IR). Revascularization strategy was guided by the Heart Team following an algorithm largely based on current guidelines. Main outcome of interest was the incidence of 5-year cardiovascular (CV) death. Prevalence of CAD was 53.9%. CAD patients showed significantly lower left ventricular ejection fraction (LVEF: 55.8 ± 13.4% CAD vs. 61.4% ± 12.1 no-CAD, p < .0001), lower gradients, and larger ventricular volumes in comparison with the no-CAD group. Within the CAD group, 138 patients (47.4%) received CR and 153 (52.6%) IR. In-hospital mortality was 3.9%, without significant difference between groups (4.0% no-CAD vs. 3.8% CAD, p = .88; 2.9% CR vs. 4.6% IR, p = .45). Median follow-up was 57.8 months. Five-year survival free from CV death was 79.6% in the CAD versus 77.9% in the no-CAD group (p = .98), and 84.3% in the CR versus 74.3% in the IR groups (p = .25). These results were confirmed excluding patients with previous revascularization. At multivariable analyses, presentation with acute coronary syndrome (ACS) was significantly associated with 5-year CV death. CAD is frequent in patients undergoing TAVI but portends an adverse prognosis only when presenting with ACS. Heart-team directed complete or reasonably incomplete revascularization was associated with comparable outcomes.

The effect of completeness of revascularization during CABG with single versus multiple arterial grafts.

Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.

P6358Comparison of residual added index with residual sYNTAX score in the risk stratification of patients with incomplete coronary percutaneous revascularization after ST-elevation myocardial infarction

P6358Comparison of residual added index with residual sYNTAX score in the risk stratification of patients with incomplete coronary percutaneous revascularization after ST-elevation myocardial infarction

TCTAP A-098 Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug-eluting Stent Era

Chronic kidney disease (CKD) is a significant prognostic factor after percutaneous coronary intervention (PCI) even in the drug-eluting stent (DES) era. However, there has been limited data regarding prognostic impact of angiographic complete revascularization (CR) using DES in this population. We

Impact of chronic obstructive pulmonary disease and frailty on long-term outcomes and quality of life after transcatheter aortic valve implantation

BackgroundAssociation between chronic obstructive pulmonary disease (COPD) and long-term mortality as well as the quality of life (QoL) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is still unclear.AimWe sought to evaluate the impact of COPD on mortality and QoL of patients with AS undergoing TAVI.MethodsA total of 148 consecutive patients who underwent TAVI were enrolled and stratified by history of COPD.ResultsOf 148 patients enrolled, 19 (12.8%) patients had a history of COPD. Patients with COPD were high-risk patients with higher prevalence of incomplete revascularization and frailty features. At follow-up of 15.8 months, all-cause mortality in patients with COPD was over four times higher than in patients without COPD [17.8% vs. 52.6%; p = 0.002—age/gender-adjusted OR (95% CI) 4.73 (1.69–13.24)]. On the other hand, in Cox regression model, the only independent predictors of all-cause death at long-term follow-up were: incomplete coronary revascularization [HR (95% CI) 5.45 (2.38–12.52); p = 0.001], estimated glomerular filtration rate [per 1 ml/min/1.73 m2 increase: 0.96 (0.94–0.98); p = 0.001], and previous stroke/transient ischemic attack [2.86 (1.17–7.00); p = 0.021]. Also, the difference in mortality between patients with and without COPD was not significant after adjustment for the most of frailty indices. Importantly, groups were comparable in terms of QoL at baseline and 12 months.ConclusionCOPD may pose an important factor affecting long-term outcomes of patients with severe AS undergoing TAVI. However, its effects might be partially related to coexisting comorbidities and frailty.

НЕПОЛНАЯ КОРОНАРНАЯ РЕВАСКУЛЯРИЗАЦИЯ КАК НЕЗАВИСИМЫЙ ФАКТОР РИСКА УХУДШЕНИЯ ПРОГНОЗА КОРОНАРНОГО ШУНТИРОВАНИЯ БЕЗ ИСКУССТВЕННОГО КРОВООБРАЩЕНИЯ У БОЛЬНЫХ ИШЕМИЧЕСКОЙ БОЛЕЗНЬЮ СЕРДЦА

Currently, most researchers define the term complete coronary revascularization (CCR) as coronary arterial bypass graft (CABG) of at least one branch of each of the three affected coronary basins: left anterior descending artery (LAD) left circumflex artery (LCA) and right coronary artery RCA. The rejection of bypass of one or more diseased coronary basin is estimated as an incomplete coronary revascularization (ICR). Material and methods. This retrospective study included patients, underwent isolated coronary bypass operations from 2001 to 2014 in the Irkutsk Regional Hospital. 1418 patients underwent isolated off-pump bypass operations. ICR occurred in 469 patients, the CCR - in 949. All patients were divided into 2 groups: ICR group and CCR group. These groups were compared by the late survival and by the frequency of the major cardiac events (MACE). The results of study were assessed after 1, 5 and 10 years from the date of CABG. Results. Survival of patients of ICR group after 1,5,10 years after surgery was 98.5 %, 75.4 % and 75.4 % respectively, of CCR group of patients - 98.7 %, 88.7 % and 81.3 % (p = 0.006). In ICR group "free" from MACE after 1, 5 and 10 years after surgery were respectively 98.2 %, 70.8 % and 61.0 % of patients, while in CCR group those made 98.3 %, 84.6 % and 72,6 % (p = 0,007). We can conclude that incomplete revascularization can be defined as a prediction factor of worst long-term outcome results of CABG.

Gender-related differences in long-term outcome among high-risk patients with myocardial infarction treated invasively.

IntroductionTreating acute myocardial infarction (AMI) with percutaneous coronary intervention (PCI) has an impact on improving long-term outcome. However, patients with other comorbidities are challenging, and are considered as a high-risk population.AimTo assess gender-related differences in long-term prognosis after AMI among high-risk patients.Material and methodsThe single-center registry encompassed 4375 AMI patients treated with PCI. The following high-risk groups were selected: age > 70 group (n = 1081), glomerular filtration rate (GFR ) < 60 group (n = 848), diabetes mellitus (DM) group (n = 782), low ejection fraction (EF) group (n = 560) defined as EF < 35%, and incomplete coronary revascularization (ICR) group (n = 2008). Within each group, comparative analysis of long-term mortality with respect to gender and age was performed.ResultsThere were no significant differences in long-term mortality with respect to gender among groups with age > 70 (29.0% vs. 30.3%) and GFR < 60 (37.2% vs. 42.3%) (both p = NS respectively for men vs. women). In the DM group (24.8% vs. 30.8%; p = 0.06) and EF < 35% group (36.3% vs. 44.5%; p = 0.07) there was a trend towards significance. The ICR group showed a higher mortality rate with respect to gender (19.7% vs. 27.3%; p < 0.001). Differences in survival assessed by the log-rank test were significant among ICR and EF < 35% groups.ConclusionsFemale gender is related to higher long-term mortality among high-risk groups, but a statistically significant difference was observed only in patients with ICR and those with EF < 35%. Female gender may be associated with worse prognosis in diabetic patients, but it needs evaluation. However, worse prognosis in women was not independent and was associated mainly with other comorbidities and worse clinical characteristics.

Association Between Blood Transfusions and 12-Month Mortality After Transcatheter Aortic Valve Implantation.

Blood transfusions are considered as an important predictor of adverse outcome in patients with severe aortic (AS) undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the association between blood transfusions and mortality after TAVI. We enrolled 101 consecutive patients with severe AS undergoing TAVI. Patients who required transfusion were defined as patients in whom at least one unit of packed red blood cells (PRBCs) was transfused in the perioperative period. Twelve-month outcomes were assessed based on Valve Academic Research Consortium definitions. A total of 28 (27.7%) patients required blood transfusion after TAVI. Baseline characteristics of the patients with and without a transfusion were similar. Median amount of PRBCs was 2 (interquartile range, 2-4). Twelvemonth all-cause mortality was higher in patients with than without a blood transfusion (39.3% versus 9.6%; P = 0.001). Importantly, the need for a blood transfusion after TAVI was an independent predictor of higher mortality rates after 12 months (hazard ratio (HR) 2.84 95%CI (1.06-7.63); P = 0.039; (HR for incomplete coronary revascularization 10.86, 95%CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95%CI 1.39-11.07; P < 0.001). The duration of inhospital stay was longer in patients requiring transfusion (16.0 (14.0-22.0) versus 7.0 (7.0-11.5) days; P = 0.014). In conclusion, blood transfusions after TAVI were associated with higher mortality rates after 12 months, longer in-hospital stay, and were identified as an independent predictor of impaired clinical outcome.

Impact of Coronary Artery Disease Burden on 12‐Month Mortality of Patients After Transcatheter Aortic Valve Implantation

The aim of the study was to compare 12-month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI). There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI. One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12-month all-cause mortality. Twelve-month all-cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39-11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06-7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO. Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all-cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long-term mortality after TAVI.

The incremental impact of residual SYNTAX score on long-term clinical outcomes in patients with multivessel coronary artery disease treated by percutaneous coronary interventions.

To broaden the data supporting the use of the residual SYNTAX score (rSS) to define "reasonable" incomplete coronary revascularization (ICR) in order to improve the allocation of patients with severe coronary artery disease (CAD) to surgical/percutaneous revascularization and long-term clinical outcomes. ICR is associated with a worse prognosis in patients with severe CAD, yet no consensus exists regarding its definition. We studied 148 consecutive patients with triple vessel/left main (3VD/LM) CVD treated by percutaneous coronary interventions (PCI). Clinical outcomes at 3 years were collected; the SS and rSS were calculated. We used various definitions of "reasonable" ICR:no post-PCI total occlusion, single vs. mutivessel residual post-PCI disease, and the rSS at a cutoff value determined according to ROC curve fitted for 3 years major adverse cardiovascular and cerebrovascular adverse events (MACCE) in order to determine which definition has the strongest correlation with long-term outcomes. rSS ≤ 8 was associated with significant reductions in 3 year MACCE (19.4 vs. 51.1%, HR = 3.62, P = 0.014) Death/MI/CVA (13.7 vs. 28.8%, HR = 6.01, P = 0.030) and repeat revascularization (8.6 vs. 28.9%, HR = 3.44, P = 0.033) using a Cox proportional hazard ratio model adjusted to baseline characteristics, whereas single vessel residual disease and absence of total occlusion were not. "Reasonable" ICR as determined by rSS carries better long-term prognosis in terms of clinical outcomes vs. more extensive residual coronary disease in patients with 3VD/LM coronary artery disease treated by PCI. The rSS may improve the allocation of coronary patients to the optimal mode of revascularization.

Complete versus incomplete coronary revascularization of patients with multivessel coronary artery disease.

The treatment of patients with multivessel coronary artery disease in need of a revascularization procedure is influenced by the clinical situation (stable vs. unstable), comorbid conditions (diabetes mellitus), and anatomical variables (proximal left anterior artery stenosis, left ventricular dysfunction). Given the invasive nature of coronary artery bypass graft (CABG) operations, surgeons have embraced the concept of complete anatomical revascularization in one procedural stage since the inception of CABG surgery. However, achieving complete coronary revascularization has been more challenging with percutaneous coronary intervention (PCI), and as a result, incomplete procedures are far more common than complete ones. Data continue to emerge on the potential benefits of complete revascularization on clinical outcomes and suggest that complete revascularization should be the goal of therapy whenever possible. The heart team should carefully review the degree to which each revascularization modality can achieve this goal during procedural planning.

Usefulness of the Ankle-Brachial Index to Predict High Coronary SYNTAX Scores, Myocardium at Risk, and Incomplete Coronary Revascularization

Peripheral artery disease (PAD) is strongly associated with coronary artery disease and poor outcomes after coronary revascularization. The aim of this study was to test the hypothesis that patients with PAD diagnosed by a low ankle-brachial index (ABI; ≤0.90) have more complex coronary artery disease and more myocardium at risk than patients with normal ABIs (1.00 to 1.40) and that subsequent coronary revascularization is less complete. Adults referred for coronary angiography underwent ABI measurement using a standard Doppler ultrasound technique. Blinded reviewers calculated SYNTAX scores and Duke jeopardy scores at baseline and 3 months after angiography. Of 814 patients, 8% had PAD (ABI ≤0.90), 9% had borderline PAD (ABI 0.91 to 0.99), 77% were normal (ABI 1.00 to 1.40), and 7% had vascular calcification artifact (ABI >1.40). Patients with PAD were more likely to have high SYNTAX scores (≥33), with an odds ratio of 4.3 (95% confidence interval 1.2 to 14.9), compared with those with normal ABIs after adjustment for traditional cardiovascular risk factors. Similarly, there was a positive association between baseline high Duke jeopardy score (≥8) and PAD (adjusted odds ratio 3.5, 95% confidence interval 1.7 to 7.1). Postrevascularization high Duke jeopardy scores (≥5) were also positively associated with PAD (adjusted odds ratio 3.0, 95% confidence interval 1.1 to 8.8). In conclusion, PAD is associated with higher SYNTAX scores, more myocardium at risk, and less complete coronary revascularization than in patients with normal ABIs. More complex coronary artery disease and incomplete revascularization may contribute to worse cardiovascular outcomes in patients with PAD.