Left Main Coronary Artery Disease Research Articles

Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience.

Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG. Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30days. Additionally, the composite endpoint of these events was investigated. At 30days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patientssuffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62min vs. 84 ± 29min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint. Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.

Assessment of atherosclerotic plaque morphology using contrast-enhanced ultrasound and its impact on primary cardiovascular events following simultaneous carotid endarterectomy and coronary artery bypass grafting.

The incidence of stroke after on-pump cardiac surgery during the perioperative period can affect up to 2% of patients, and is frequently linked to carotid artery disease. Notably, in patients with significant unilateral carotid artery stenosis of 80%-99%, the risk of stroke reaches 4%. Among individuals undergoing coronary artery bypass grafting (CABG), 3% to 10% exhibit significant carotid artery stenosis. To mitigate the risk of stroke and mortality, patients can undergo either simultaneous or staged carotid endarterectomy and CABG. The aim of this study was to assess whether early postoperative complications, including stroke, following simultaneous CABG/CAE procedures, correlate with morphological attributes of carotid plaque, assessed via contrast-enhanced ultrasound. A single centre retrospective analysis was performed including 62 patients who underwent simultaneous CABG/CEA between 2019 and 2022. Our study excluded patients who underwent staged carotid endarterectomy and CABG procedures, off-pump CABG, or those necessitating urgent CABG. Our analysis focused on patients meeting elective CABG criteria, diagnosed with symptomatic triple-vessel or left main trunk coronary artery disease (CAD), alongside asymptomatic carotid stenosis (a. carotis internae) exceeding 70% or symptomatic ipsilateral carotid stenosis surpassing 50%. The extent of contralateral carotid artery stenosis was not taken into account. Prior to the CEA/CABG procedure, each patient underwent contrast-enhanced ultrasound to assess atherosclerotic lesions, which were classified using Nakamura et al.'s classification. Among the patients, 37.1% exhibited no neovascularisation within the atherosclerotic plaque, 56.5% showed insignificant neovascularisation, and 6.5% displayed notable neovascularization within the plaque. Our study aimed to establish a connection between the degree of plaque vascularisation identified through contrast-enhanced ultrasound and subsequent postoperative complications. Upon evaluating postoperative complications occurring within 30 days after the surgery and the plaque morphology identified through contrast-enhanced ultrasound, a statistically significant correlation was observed between a higher grade of plaque vascularisation and the occurrence of ischaemic stroke (r = 0.329, p = .008). Monte Carlo calculations of the Chi-square test indicated a significant association between a higher grade of plaque vascularisation and the presence of peripheral artery disease (χ2 = 15.175, lls = 2, p = .003). Within 30 days of surgery, a significant correlation exists between the occurrence of ischaemic stroke following carotid endarterectomy subsequent to CABG and the presence of a higher grade plaque vascularisation as identified by contrast-enhanced ultrasound.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main Disease With or Without Diabetes: Findings From a Pooled Analysis of 4 Randomized Clinical Trials.

Diabetes may be associated with differential outcomes in patients undergoing left main coronary revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The aim of this study was to investigate outcomes in patients with left main disease with and without diabetes undergoing PCI versus CABG. Individual patient data were pooled from 4 trials (SYNTAX [TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries], PRECOMBAT [Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease], NOBLE [PCI vs. CABG in the Treatment of Unprotected Left Main Stenosis], and EXCEL [Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization]) that randomized patients with left main disease to PCI or CABG. Patients were considered suitable for either approach. Patients were categorized by diabetes status. Kaplan-Meier event rates, Cox model hazard ratios, and interactions were assessed. Among 4393 patients, 1104 (25.1%) had diabetes. Patients with diabetes experienced higher rates of 5-year death (158/1104 [Kaplan-Meier rate, 14.7%] versus 297/3289 [9.3%]; P<0.001), spontaneous myocardial infarction (MI; 67/1104 [6.7%] versus 114/3289 [3.7%]; P<0.001), and repeat revascularization (189/1104 [18.5%] versus 410/3289 [13.2%]; P<0.001). Rates of all-cause mortality did not differ after PCI versus CABG in those with (84/563 [15.3%] versus 74/541 [14.1%]; hazard ratio, 1.11 [95% CI, 0.82-1.52]) or without (155/1634 [9.7%] versus 142/1655 [8.9%]; hazard ratio, 1.08 [95% CI, 0.86-1.36; PintHR=0.87) diabetes. Rates of stroke within 1 year were lower with PCI versus CABG in the entire population, with no heterogeneity based on diabetes status (PintHR=0.51). The 5-year rates of spontaneous MI and repeat coronary revascularization were higher after PCI regardless of diabetes status (spontaneous MI: 45/563 [8.9%] versus 22/541 [4.4%] in diabetes and 82/1634 [5.3%] versus 32/1655 [2.1%] in no diabetes, PintHR=0.47; repeat revascularization: 127/563 [24.5%] versus 62/541 [12.4%] in diabetes and 254/1634 [16.3%] versus 156/1655 [10.1%] in no diabetes, PintHR=0.18). For spontaneous MI and repeat revascularization, there were greater absolute excess risks beyond 1 year in patients with diabetes (4.9% and 9.9%) compared with those without (2.1% and 4.3%; PintARD=0.047 and 0.016). In patients with left main disease considered equally suitable for PCI or CABG and with largely low to intermediate SYNTAX scores, diabetes was associated with higher rates of death and cardiovascular events through 5 years. Compared with CABG, PCI resulted in no difference in the risk of death, a lower risk of early stroke regardless of diabetes status, and a higher risk of spontaneous MI and repeat coronary revascularization, with larger late absolute excess risks in patients with diabetes. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01205776, NCT0146651, NCT00422968, and NCT00114972.

Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial.

The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS). The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; P=0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; P=0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; P=0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; P<0.001). The risk was the highest for residual ostial/proximal LCX lesions. Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.

Annual operator volume and procedural outcomes of chronic total occlusions treated with percutaneous coronary interventions: analysis based on 14,899 patients.

Low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in patients treated with percutaneous coronary interventions (PCI). This study was aimed at evaluating the relationship between operator volume and procedural outcomes of patients treated with PCI for chronic total occlusion (CTO). Data were obtained from the national registry of percutaneous coronary interventions (ORPKI) collected from January 2014 to December 2020. The primary endpoint was a procedural success, defined as restoration of thrombolysis in myocardial infarction (TIMI) II/III flow without in-hospital cardiac death and myocardial infarction, whereas secondary endpoints included periprocedural complications. Data of 14,899 CTO-PCIs were analyzed. The global procedural success was 66.1%. There was a direct relationship between the annual volume of CTO-PCIs per operator and the procedural success (OR: 1.006 [95% CI: 1.003-1.009]; P<0.001). The nonlinear relationships of annualized CTO-PCI volume per operator and adjusted outcome rates revealed that operators performing 40 CTO cases per year had the best procedural outcomes in terms of technical success (TIMI flow II/III after PCI), coronary artery perforation rate and any periprocedural complications rate (P<0.0001). Among the other factors associated with procedural success, the following can be noted: multi-vessel, left main coronary artery disease (as compared to single-vessel disease), the usage of rotablation as well as PCI within bifurcation. High-volume CTO operators achieve greater procedural success with a lower frequency of periprocedural complications. Higher annual caseload might increase the overall quality of CTO-PCI.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BackgroundTo compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).MethodsAmong 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.ResultsAfter adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008).ConclusionsBilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Long Term Outcome of Percutaneous Coronary Intervention in Patients with Unprotected Left Main Disease

Background: The management of unprotected left main coronary artery disease (LM CAD) poses a significant clinical challenge. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have been extensively compared, with PCI emerging as a viable option for specific patient subsets. Advancements in interventional cardiology, including drug-eluting stents and intravascular ultrasound, have improved PCI outcomes, yet long-term efficacy remains a subject of investigation. Objective: This study aims to evaluate the long-term outcomes of PCI in patients with unprotected LM CAD, focusing on all-cause mortality, cardiac deaths, myocardial infarction, revascularization, and stroke. Methods: A descriptive cross-sectional study was conducted at the Peshawar Institute of Cardiology, KPK, from November 2022 to October 2023. A total of 120 patients aged 55-70 years with LM disease undergoing PCI were included. Long-term outcomes were assessed after five years. Data analysis was performed using SPSS version 23, focusing on frequency and association of outcomes with gender. Results: The study observed all-cause mortality in 15.0% (n=18) of the patients, cardiovascular mortality in 6.7% (n=8), myocardial infarction in 7.5% (n=9), revascularization in 14.2% (n=17), and stroke in 4.2% (n=5). Gender analysis revealed no significant difference in all-cause mortality (P=0.73), with a notable gender disparity in cardiovascular mortality favoring females (P=0.04). Revascularization and stroke rates did not significantly differ by gender. Conclusion: PCI presents a favorable and safe long-term treatment option for patients with unprotected LM CAD, with significant outcomes in terms of mortality, myocardial infarction, revascularization, and stroke. The study supports the continued use of PCI in clinical practice, highlighting the necessity for further comparative research with CABG to optimize patient outcomes.

Intravascular Ultrasound versus Angiography Guided Drug Eluting Stent Implantation in Patients with Left Main Coronary Artery Disease – A Systematic Review and Meta-Analysis

Intravascular Ultrasound versus Angiography Guided Drug Eluting Stent Implantation in Patients with Left Main Coronary Artery Disease – A Systematic Review and Meta-Analysis

Impacts of the SYNTAX score I, II and SYNTAX score II 2020 on left main revascularization

Patients with left main coronary artery disease (LMCAD) with a high SYNTAX score (SS) were excluded from randomized studies that comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). We sought to compare PCI and CABG in the real-world practice and investigate the impact of SS I, SS II, and SS II 2020 on clinical outcomes. In total, 292 Patients with LMCAD (173 PCI, 119 CABG) treated between 2017 and 2021 were enrolled. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, stroke, or myocardial infarction (MI). The mean SS I was high in both groups (PCI vs. CABG: 31.64 ± 11.45 vs. 32.62 ± 11.75, p = 0.660). The primary outcome occurred in 28 patients (16.2%) in the PCI group and in 19 patients (16.0%) in the CABG group without significant difference [adjusted hazard ratio, 95% CI = 0.98 (0.51–1.90), p = 0.97] over the follow-up period (26.9 ± 17.7 months). No significant difference was observed in all-cause mortality (11.6% vs. 11.8%, p = 0.93) or stroke rates (3.5% vs. 5.0%, p = 0.51) between groups. However, PCI was associated with higher MI (4.6% vs. 0.8%, p < 0.05) and revascularization rates (26% vs. 5.9%, p < 0.001). Prognostic value of the SS I, SS II and SS II 2020 on the primary outcome was not relevant in the PCI group. Among patients with LMCAD, PCI and CABG did not significantly differ in the composite endpoint of all-cause death, stroke, and MI. These results support the potential expansion of PCI indications in LMCAD management for whom are ineligible for CABG with complex coronary artery disease.

Impact of Target Lesion Revascularization on Long-Term Mortality After Percutaneous Coronary Intervention for Left Main Disease

BackgroundAlthough target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is not rare, its timing of occurrence and prognostic impact on long-term mortality is uncertain. ObjectivesThis study sought to investigate TLR incidence over time and its impact on mortality after PCI with drug-eluting stents (DES) for LMCA disease. MethodsUsing a pooled data from 4 multicenter observational registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents], IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization], MAIN-COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization], and PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease]), we evaluated 1,397 patients with LMCA disease treated with DES and available long-term mortality data. The association between TLR and the 10-year risk of mortality was examined by multivariable Cox proportional hazards regression, with TLR as a time-varying covariate. ResultsDuring maximum follow-up of 10 years (median 6.8 years), TLR occurred in 118 patients and its 10-year cumulative incidence was 10.8%. TLR mostly occurred within 2 years after initial PCI and decreased over time: early-stage TLR (within 2 years) in 73 (61.9%) patients and late-stage TLR (beyond 2 years) in 45 (38.1%) patients. Among all TLR patients, 23 patients underwent coronary artery bypass grafting and 95 underwent repeat PCI. In the time-varying multivariable Cox model, the presence of TLR was not significantly associated with an increased risk of mortality (adjusted HR: 0.90; 95% CI: 0.50-1.63; P = 0.73). ConclusionsAlthough the incidence of ischemia-driven TLR was mostly common within 2 years after left main PCI, TLR occurred steadily during the 10-year follow-up period. However, given that such patients were optimally revascularized, the prognostic impact of TLR on mortality was not substantial. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133; Observational Study for Left Main Disease Treatment [IRIS-MAIN]; NCT01341327; Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN COMPARE]; NCT02791412; Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968)

Evidence-based Management of Left Main Coronary Artery Disease

Left main coronary artery disease (LMCAD) is associated with high morbidity and mortality due to the large myocardial mass at risk. Although medical treatment may be an option in selected low-risk patients, revascularisation is recommended to improve survival in the majority of patients presenting with a significant left main stenosis. In the past decade, multiple randomised clinical trials and meta-analyses have compared coronary artery bypass grafting surgery (CABG) versus percutaneous coronary intervention (PCI), finding controversial results. The strategy for LMCAD revascularisation is still challenging. Coronary anatomy complexity, clinical features and patient preferences are key elements to be considered by the heart team. The current guidelines define CABG as standard therapy, but the continuous improvements in PCI techniques, the use of intracoronary imaging and functional assessment make PCI a feasible alternative in selected patients, particularly in those with comorbidities and contraindications to CABG. This review analyses the most important studies comparing CABG versus PCI in patients with LMCAD.

The Impact of SYNTAX Score with Longterm Outcomes of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: A Systematic Review

The SYNTAX  score was designed to predict the postprocedural risk associated with PCI or surgical revascularization. This study aims to evaluate long term (&gt;5 years) outcome of PCI with CABG by comparing several existing studies. A systematic search was conducted through PubMed/MEDLINE and ScienceDirect databases. This systematic review used all studies in the field of differences in outcome of PCI and CABG intervention in left main coronary artery stenosis. This study used cross sectional study design with a systematic review method based on several cohort studies. The search was conducted until February 10th, 2023. Assessment of the study quality was carried out using the criteria of the Newcastle-Ottawa Scale (NOS). Based on the final assessment, all included studies had a mean NOS score of 8 which could be interpreted as excellent quality. Our search yielded 1675 studies of which we included 5 studies for the final analysis. A total of 5.494 patients were treated with PCI and CABG. In this study, there were differences outcome in low, medium and high syntax scores on long term major adverse cardiac or cerebrovascular events (MACCE) and long term mortality. However, the similar outcome was obtained in long term revascularization, long term stroke and long term Miokard Infark (MI). Left main coronary artery (LMCA) stenosis patients with low to high SS may result various long-term outcomes. CABG is associated with lower incidence of mortality, repeat revascularization, myocardial infarction, and MACCE than PCI. Meanwhile, PCI gives lower incidence of stroke.

Systematic Review of the Efficacy of Orbital Atherectomy in Improving the Outcome of Percutaneous Corornary Intervention in People With Diabetes.

The optimal approach to deal with severe coronary artery calcification (CAC) in people with diabetes remains ill-defined. People with diabetes have a significant risk of developing severe vessel calcification and coronary artery disease (CAD). CADis the leading cause of death in people with diabetes. Individuals with diabetes mainly present with severe multivessel stenosis, diffuse coronary calcification, and severe atherosclerosis, which are poor prognostic factors of revascularization procedures. Studies have shown that the revascularization of arteries in people with diabetes often results in worse outcomes than in people without diabetes. Coronary artery bypass grafting (CABG) has been recommended as the standard of care for people with DM and complex anatomic diseases, including left main CAD. However, percutaneous coronary intervention (PCI)is more acceptable to patients in clinical practice because of decreased trauma and rapid recovery. Severe CAC has traditionally been challenging for PCI and a frequent indication for surgical revascularization. This study aims to determine the effectiveness of orbital atherectomy (OA) in improving PCIoutcomes in patients with diabetes and identify possible adverse effects that preclude its use. The study is reported according to PRISMA and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search of EMBASE, Scopus, Web of Science, Cochrane Library, CINAHL, and MEDLINE was conducted for studies that utilized OA before PCI in people with diabetes. A reference list of the eligible articles was also screened. A narrative synthesis was done by representing the data on the effect direction plot, followed by vote counting. Eighteen studies were included in the analysis. Success rate/successful stent delivery was >90%, while freedom from angiographic complication and major adverse cardiovascular and cerebrovascular events (MACCE) were both >80% on the effect direction plot for people with diabetes and those without diabetes. People with diabetes had low event rates similar to those without diabetes. OA appears to be a viable treatment approach for people with diabetes. However, RCTs with a longer duration of follow-up are required to establish the appropriate treatment strategy for severe CAC in people with diabetes.

Effects of peripheral artery disease on long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting in patients with severe coronary artery disease

BackgroundThere is a scarcity of data evaluating the effect of peripheral artery disease (PAD) on long-term mortality after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in patients with severe coronary artery disease in real-world practice. MethodsAmong 14,867 consecutive patients who underwent their first coronary revascularization with PCI or isolated CABG between 2011 and 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, the current study population consisted of 3380 patients with three-vessel coronary artery disease or left main coronary artery disease. Long-term clinical outcomes were compared between PCI and CABG stratified by the presence or absence of PAD. Median clinical follow-up was 5.9 (IQR: 5.1–6.8) years. ResultsThere were 461 patients with PAD (PCI: N = 307, CABG: N = 154), and 2919 patients without PAD (PCI: N = 1823, CABG: N = 1096). The cumulative 5-year mortality after coronary revascularization was 31.2 % in patients with PAD and 16.2 % in those without PAD (p < 0.0001). There was a higher risk of PCI relative to CABG for all-cause death in patients with and without PAD (adjusted HR, 1.59; 95%CI, 0.99–2.53; p = 0.054, and HR, 1.25; 95%CI, 1.01–1.56; p = 0.04) without interaction (p interaction p = 0.48); Nevertheless, there was no excess risk of PCI relative to CABG for cardiovascular death regardless of PAD. ConclusionsThe long-term mortality after coronary revascularization was significantly higher in severe CAD patients with PAD than those without PAD. There was a higher mortality risk of PCI relative to CABG in patients with and without PAD without interaction, which was mainly driven by excess non-cardiovascular deaths.

Acute Occlusion of a “Protected” Left Main Coronary Artery Manifesting as an Acute Coronary Syndrome with Heart Failure: How much Protected it is?

Despite the progress made in technological advancements, the utilization of stenting for both protected and unprotected left main coronary artery (LMCA) disease remains associated with elevated rates of long-term mortality and significant adverse clinical events, sometimes manifesting as cardiogenic shock. A considerable number of individuals retain the opportunity to receive catheter-based interventional therapy as a viable substitute for re-operative coronary artery bypass grafting (CABG). Despite the changed appearance, patients with acute blockage of the protected LMCA still have major adverse cardiac events (MACE) at a similar rate. Acute occlusion of the unprotected LMCA as an acute coronary syndrome (ACS) is uncommon, but that of the protected LMCA is relatively rare. We present a case of a post-CABG patient who developed ACS as a posterior wall myocardial infarction and acute left ventricular failure due to obstruction of a protected LMCA with substantial stenosis across its distal segment extending to the left circumflex (LCx) artery. The pharmaco-invasive management of the protected LMCA thrombotic occlusion with primary percutaneous coronary intervention resulted in significant patient improvement. These lesions are amenable to complex and high-risk coronary intervention with current technology, and the results have been quite encouraging in terms of long-term survival.

Retrospective Multicenter Analysis of Intravascular Lithotripsy Use During Calcified Left Main Coronary Artery Percutaneous Coronary Interventions

BackgroundIntravascular lithotripsy (IVL) safely and effectively modifies calcified coronary lesions during percutaneous coronary interventions (PCI). Data regarding its utility in modifying calcified left main coronary artery (LMCA) disease are limited. This study aimed to evaluate short-term outcomes of IVL-assisted LMCA PCI. MethodsThis retrospective multicenter all-comers study analyzed patients who underwent intravascular imaging-guided, IVL-assisted PCI for calcified LMCA disease. Clinical and procedural characteristics were obtained, including intravascular imaging measurements. Technical success was defined as successful stent deployment with <30% residual diameter stenosis. Major adverse cardiac events (MACE) was a composite of all-cause death, myocardial infarction, and target vessel revascularization evaluated immediately postprocedure and at 30-day follow-up. ResultsAmong 184 patients treated at 7 centers from 2019-2023, IVL-assisted LMCA PCI achieved 99.4% technical success. Calcium fracture was identified in 136/165 cases (82.4%) on post-IVL imaging. Pretreatment minimal luminal area increased significantly compared to post-PCI minimal stent area (MSA) (4.1 ± 1.3 to 9.3 ± 2.5 mm2, respectively; P < .001). There was a direct correlation between IVL balloon size and the final MSA (P = .002). In-hospital MACE was 4.4% and 30-day MACE was 8.8%. In multivariate logistic regression, presentation with troponin-positive myocardial infarction was the sole predictor of 30-day MACE. ConclusionsIVL-assisted PCI for calcified LMCA lesions was safe and resulted in high technical success rates, confirming its utility as an effective treatment in this challenging lesion subset.

The left main coronary artery (LMCA) physiology study: comprehensive clinical haemodynamic evaluation of physiology and pathophysiology

Abstract Background &amp; Purpose At present, physiological evaluation of left main coronary artery (LMCA) disease is based on the assumption that pressure-based indices are agnostic to the vessel being assessed. We conducted mechanistic studies to determine whether pressure-based indices in the left anterior descending (LAD) and left circumflex (LCx) arteries are different and if so, the basis of this discrepancy, in patients with normal coronary arteries (LMCA Physiology Study) and in those with isolated LMCA disease (LMCA Pathophysiology Study). Methods Patients with exertional angina were prospectively enrolled after baseline investigation of computed tomography or invasive angiography and those with left ventricular impairment were excluded. Eligibility for the Physiology Study required the absence of epicardial disease on angiography and/or fractional flow reserve or significant coronary microvascular disease (LAD coronary flow reserve (CFR) &amp;lt;2.0). Simultaneous intracoronary pressure and Doppler measurements were performed in the LAD and LCx arteries, at rest and adenosine mediated hyperaemia. A subset also underwent 3-Tesla quantitative stress perfusion cardiac magnetic resonance imaging. Eligibility for the Pathophysiology Study required isolated LMCA disease, which was verified physiologically by pressure wire pullback according to predefined criteria of 1) ≥80% of total FFR arising from the left main coronary artery disease and 2) ≤0.05 FFR gradient distal to the left main coronary artery disease in both vessels. A paired 2-tailed test for significance was performed for all analyses. The protocols were approved by the UK National research ethics committee. Results 71 patients were prospectively enrolled, 28 in the Physiology Study and 43 in the Pathophysiology Study (Table 1). In the LMCA Physiology Study, CFR was higher and hyperaemic microvascular resistance (hMR) lower in the LAD compared to the LCx. In the LMCA Pathophysiology Study, the contribution to total FFR of downstream disease was negligible and comparable in both branches. Moreover, hyperaemic, and non-hyperaemic pressure-based indices were all significantly lower in the LAD, compared to the LCx. In addition, CFR was higher and hMR lower in the LAD compared to the LCx. Correlations are outlined in Figure 1. Differences in pressure-derived measurements remained after correction for the influence of hydrostatic pressures. However, when adjusted for subtended myocardial mass, there was no significant difference in invasive hemodynamic indices or quantitative perfusion analysis-derived myocardial perfusion reserve index. Conclusions Commonly used indices of stenosis severity are not agnostic to the vessel assessed due to differences in myocardial mass and microvascular resistances. The need for vessel-specific thresholds has significant implications on LMCA disease assessment and potentially, interpretation of the existing evidence base on physiological assessment of non-LMCA disease.Table 1Figure 1

Very long-term prognostic value of clinical SYNTAX score in patients undergoing percutaneous coronary intervention for left main coronary artery disease

Abstract Background Recently, long-term prognostic value of SYNTAX score (SS) has been validated in patients with left main coronary artery disease (LMCA). However, the ability of clinical SYNTAX score (CSS) to predict very long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for LMCA has not been fully investigated yet. Purpose We aimed to validate the impact of CSS on very long-term outcomes in patients undergoing PCI for LMCA. Methods Between June 2006 and December 2012, 279 patients underwent unprotected LMCA PCI were analyzed. The SS for each patient was calculated by scoring all coronary lesions using SS algorithm. CSS was calculated by multiplying the SS to an ACEF score (age/left ventricular ejection fraction + 1 if serum creatinine&amp;gt;2mg/dL). Major adverse cardiac events (MACEs) were defined as death, non-fatal myocardial infarction, and revascularizations. Mean follow-up duration was 2,529±1664 days. Results The CSS (26.8±11.9 versus 39.9±26.1, p&amp;lt;0.001) as well as SS (23.2±6.9 versus 25.8±7.9, p=0.003) was significantly higher in patients with MACEs. Area under the curve for MACEs (0.672 versus 0.599, p=0.0023) and mortality (0.744 versus 0.626, p&amp;lt;0.0001) of CSS was significantly higher compared with those of SS (Figure 1). The CSS significantly improved the reclassification and the integrated discrimination of patients compared to SS. Log CSS was an independent predictor for MACEs (hazard ratio [HR] 5.37, 95% confidence interval [CI] 1.98 – 14.61; p = 0.006) and mortality (HR 11.69, 95% CI 3.30 – 41.31; p &amp;lt; 0.001). When patients were categorized into 3 groups according to tertiles of CSS (Low CSS ≤ 22, 22 &amp;lt; Mid CSS ≤ 34, High CSS &amp;gt; 34), patients in the highest CSS tertile had significantly higher rates of MACEs (log-rank p&amp;lt;0.001) and mortality (log-rank p&amp;lt;0.001) compared with those in the lower 2 tertiles (Figure 2). The highest CSS tertile was an independent predictor for MACEs (HR 2.33, 95% CI 1.42 – 3.82; p = 0.001) and mortality (HR 5.66, 95% CI 2.20 – 14.57; p &amp;lt; 0.001). Conclusions The CSS is useful to predict very long-term clinical outcome in patients underwent unprotected LMCA PCI.

Impact of repeat revascularization within 5 years on 10-year mortality after percutaneous or surgical revascularization

Abstract Background The SYNTAX trial demonstrated negative impact of repeat revascularization (RR) on 5-year outcomes following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with three-vessel (3VD) and/or left main coronary artery disease (LMCAD). We aimed to investigate the impact of RR within 5 years, on 10-year mortality in patients with 3VD and/or LMCAD after PCI or CABG. Methods The SYNTAXES study evaluated the vital status out to 10 years of patients with 3VD and/or LMCAD. Patients were stratified by RR within 5 years and randomized treatment. The association between RR within 5 years and 10-year mortality was assessed. Results A total of 330 (220 RR after initial PCI and 110 RR after initial CABG) out of 1800 patients (18.3%) underwent RR within 5 years from initial revascularization. RR occurred more frequently after initial PCI than after initial CABG (25.9% vs 13.7%, p&amp;lt;0.001). Overall, 10-year mortality was comparable between patients undergoing RR and those not (28.2% vs 26.1%, adjusted HR: 1.17, 95% CI: 0.93-1.48, p=0.187). Among patients requiring RR, those who underwent PCI as initial revascularization had a higher risk of 10-year mortality compared to initial CABG (33.5% vs 17.6%, adjusted HR: 2.09, 95% CI: 1.21-3.61, p=0.008). Conclusions In the SYNTAXES study, RR within 5 years had no impact on 10-year all-cause death in the population overall. Among patients requiring any repeat procedures, 10-year mortality was higher after initial treatment with PCI than after CABG. These exploratory findings should be investigated with larger populations in future studies.Graphic Abstract

Gamma-Glutamyl Transferase as a prognostic risk factor in complex coronary disease: a serendipitous (re)discovery of machine learning in the SYNTAXES?

Abstract Background/Introduction Over the last decade, epidemiology and pathology studies have suggested that gamma-glutamyl transferase (GGT) has an independent role in the pathogenesis and clinical evolution of cardiovascular diseases associated with atherosclerosis. Recently, machine learning (ML) algorithms have identified pre-procedural GGT as a significant predictor of long-term mortality after coronary revascularization in the SYNTAX trial. Purpose The aim of this study is to investigate the impact of pre-procedural GGT on 10-year all-cause mortality in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) following revascularization. Methods The SYNTAX trial was a randomized trial comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in 1,800 patients with complex CAD. The present report is a post-hoc sub-analysis of the SYNTAXES study, an investigator-driven extended 10-year follow-up of the SYNTAX trial. Before revascularization, blood samples were taken for GGT as well as other biological markers and analyzed by an independent central chemistry laboratory. The primary endpoint was all-cause mortality at 10-years. The changes in hazard for all-cause mortality in GGT over time were modelled using restricted cubic spline functions in a Cox regression model adjusted by age and sex. Subsequently, we compared survival in four groups defined by gender specific GGT thresholds of &amp;lt;32 IU and ≥32 IU for females and &amp;lt;64 IU and ≥64 IU for males, in accordance with prior studies. Results Out of 1,800 patients enrolled in the SYNTAX study, 167 (9.3%) did not have a GGT available at baseline and 1,633 (90.7%) patients were included in the present study. The mean values of GGT for males and females were 43.5±48.5 and 36.4±46.1 U/L, respectively. In the overall population a 10 U/L increase in GGT was significantly associated with 10-year all-cause death (adjusted hazard ratio [HR] 95% confidence interval [CI]: 1.03 [1.02–1.04], p &amp;lt;0.001, Figure A). For Kaplan–Meier analysis, patients were stratified into four groups according to previously reported sex related GGT thresholds. Ten-year mortality was numerically higher in males (adjusted HR 1.31, 95% CI: 0.90–1.91), and significantly higher in females (adjusted HR 1.88, 95% CI: 1.16–3.05) among patients with higher versus lower GGT (Figure B). Furthermore, GGT was significantly associated with CRP, a surrogate-marker of inflammation, as well as established cardiovascular risk biomarkers such as TG, total cholesterol, and glucose. Conclusions Preprocedural GGT is an independent predictor of 10-year mortality following coronary revascularization in patients with 3VD and/or LMCAD. This long-term association has been identified using ML algorithms and should be corroborated using data from large biobanks.Figure AFigure B