Multivessel Revascularization In Patients Research Articles

Culprit-only versus immediate multi-vessel revascularization in patients with AMI complicated by advanced cardiogenic shock undergoing VA-ECMO

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by unrestricted grants from the Korean Society of Interventional Cardiology. Aims Despite the benefit of culprit-only percutaneous coronary intervention (PCI) in the CULPRIT-SHOCK trial, the optimal revascularization strategy for a refractory cardiogenic shock (CS) requiring mechanical circulatory support devices remains controversial. This study aimed to compare clinical outcomes between the culprit-only and immediate multi-vessel PCI strategies in patients with acute myocardial infarction (AMI) complicated by CS who underwent venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods and Results This study was patient-pooled data from the RESCUE and SMC-ECMO registries. A total of 408 AMI patients with multi-vessel disease who underwent VA-ECMO due to refractory CS were included in this analysis. The study population was classified into culprit-only versus immediate multi-vessel PCI according to non-culprit lesion (NCL) treatment strategies. The co-primary endpoints were 30-day mortality or renal-replacement therapy and 12-month follow-up mortality. Among the study population, 241 (59.1%) underwent culprit-only PCI and 167 (40.9%) underwent immediate multi-vessel PCI. Compared with culprit-only PCI, immediate multi-vessel PCI was associated with significantly lower risks of 30-day mortality or renal-replacement therapy (66.8% vs. 54.5%, p=0.02) and all-cause mortality during 12 months of follow-up (59.5% vs. 47.8%, hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.53–0.92, p=0.01) in patients with AMI and CS who underwent VA-ECMO. These results were also consistent in the 290 pairs of propensity score-matched population (55.6% vs. 46.1%, HR 0.71; 95% CI 0.51–0.98, p=0.04). Conclusion Among AMI patients with multi-vessel disease complicated by advanced CS, immediate multi-vessel PCI might be associated with improved clinical outcomes in those undergoing VA-ECMO.

Meta-Analysis Comparing Culprit-Only Versus Complete Multivessel Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) in patients with concomitant multivessel coronary artery disease is associated with poor prognosis. We sought to determine the merits of percutaneous coronary intervention of the culprit-only revascularization (COR) compared with multivessel revascularization (MVR) approach. Multiple databases were queried to identify relevant articles. Data were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) and relative risk. A total of 28 studies comprising 26,892 patients, 18,377 in the COR and 8,515 in the MVR group were included. The mean age of patients was 63 years, comprising 72% of male patients. The baseline characteristics of the 2 treatment groups were comparable. On a median follow-up of 1-year, COR was associated with a significantly higher odds of major adverse cardiovascular events (MACE; OR 1.36, 95% confidence interval [CI] 1.10 to 1.70, p = 0.005), angina (OR 2.28, 95% CI 1.83 to 2.85, p ≤ 0.00001) and revascularization (OR 1.76, 95% CI 1.22 to 2.54, p = 0.002) compared with patients undergoing MVR for STEMI. The all-cause mortality (OR 1.18, 95% CI 0.91 to 1.53, p = 0.22), cardiovascular mortality (OR 1.30, 95% CI 0.98 to 1.72, p = 0.07), rate of heart failure (OR 1.17, 95% CI 0.86 to 1.59, p = 0.31), need for coronary artery bypass graft (CABG) (OR 1.47, 95% CI 0.82 to 2.64, p = 0.19), repeat myocardial infarction (MI) events (OR 1.23, 95% CI 0.93 to 1.64, p = 0.15) and risk of stroke (OR 1.27 95% CI 0.68 to 2.34, p = 0.45%) were similar between the two groups. A subgroup analysis based on follow-up duration and study design mostly followed the results of the pooled analysis except that the risk of repeat MI events were significantly lower in the MVR group across RCTs (OR 1.46, 95% CI 1.10 to 1.94, p = 0.009). In contrast to the culprit-only approach, MVR in patients with STEMI is associated with a significant reduction in MACE, angina and need for revascularization.

Invited Commentary

Invited Commentary

TCT-176 Staged Versus “One-time” multivessel revascularization in patients with non-ST-segment elevation acute coronary syndromes

To compare the long-term clinical outcomes of staged percutaneous coronary intervention (PCI) and “one-time” PCI in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) and multivessel coronary disease (MVD). From 2009 to 2012, a total of 1414 consecutive NSTE-ACS

Invited Commentary

Invited Commentary

Strategies for multivessel revascularization in patients with diabetes: the FREEDOM trial.

Strategies for multivessel revascularization in patients with diabetes: the FREEDOM trial.

Current Status of Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease.

Primary percutaneous coronary intervention (PCI) is a standard interventional treatment modality for ST-segment elevation myocardial infarction (STEMI). Diagnostic coronary angiogram during PCI reveals multivessel coronary artery disease in about half of patients with STEMI, and it is difficult to make decision on the extent of intervention in these patients. Although revascularization for the infarct-related artery only is still effective for STEMI patients, several studies have reported the efficacy of multivessel revascularization during primary PCI, as well as in a staged PCI procedure. Clinicians should consider clinical aspects such as initial cardiogenic shock and myocardial viability when performing primary multivessel intervention, including the risks and benefits of multivessel revascularization in patients undergoing primary PCI. This review describes the current status of performing multivessel PCI in patients with STEMI and proposes an optimal revascularization strategy based on the previous literature.

Strategies for multivessel revascularization in patients with diabetes

Evaluation of: Farkouh ME, Domanski M, Sleeper LA et al. Strategies for multivessel revascularization in patients with diabetes. N. Engl. J. Med. 367, 2375-2384 (2012). The FREEDOM trial enrolled 1900 patients with diabetes and multivessel coronary disease to percutaneous coronary intervention (PCI) with drug-eluting stents or coronary artery bypass grafting (CABG). In the drug-eluting stents arm, 94% were treated with the first-generation drug-eluting stents. The median duration of follow-up among survivors was 3.8 years. The primary outcome, a composite of death from any cause, nonfatal myocardial infarction or nonfatal stroke, occurred more frequently in the PCI group, with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group, a statistically significant relative-risk reduction of 30%. Stroke rates were significantly higher in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group.

Percutaneous coronary intervention in treatment of multivessel coronary artery disease in patients with non-ST-segment elevation acute coronary syndrome

Among patients with non-ST-elevated acute coronary syndromes (NSTE-ACS) the estimated percentage of single vessel coronary artery disease (SV-CAD) observed during coronarography is about 20-40%, while multivessel coronary artery disease (MV-CAD) is found in about 40-60%. Further treatment in patients with both SV CAD and MV CAD is usually culprit vessel percutaneous coronary intervention (CV-PCI). Nevertheless, in the group of patients with MV-CAD there is still a problematic decision whether the non-infarct related arteries (non-IRA) should be treated with PCI. According to the European Society of Cardiology (ESC) guidelines on myocardial revascularization this decision should be based on the overall clinical and angiographic status of the patient; simultaneously they suggest performing ad hoc CV-PCI. The decision of performing intervention in the rest of the narrowed coronary arteries should be made after consultation with the heart team or according to the protocols adopted in the specific clinic. Furthermore, there is a question of whether the procedure should be performed immediately after culprit vessel revascularization or it should be postponed until the patient is stabilized. Due to the lack of specific recommendations we decided to perform an analysis of existing studies which compared culprit versus multivessel revascularization in patients with MV-CAD and non-ST-elevated acute coronary syndromes.

Strategies for Multivessel Revascularization in Patients with Diabetes

BackgroundIn some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease.MethodsIn this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke.ResultsFrom 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03).ConclusionsFor patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.)

Strategies for Multivessel Revascularization in Patients with Diabetes

Strategies for Multivessel Revascularization in Patients with Diabetes

TCT-469: Comparison of Clinical Outcomes between Infarct-Related Artery Revascularization only and Multivessel revascularization in Patients with Acute Myocardial Infarction and Cardiogenic Shock

TCT-469: Comparison of Clinical Outcomes between Infarct-Related Artery Revascularization only and Multivessel revascularization in Patients with Acute Myocardial Infarction and Cardiogenic Shock

Off-pump multi-vessel revascularization in patients with poor left ventricular function*

BACKGROUND: The subset of patients that benefit most from off-pump CABG remains controversial. This study randomly compared off- with on-pump CABG in patients with poor EF. METHODS: Fifty-one patients were included in this study and randomized to undergo off- (n = 26) or on-pump (n = 25) CABG. Inclusion criteria were EF < 35% and multi-vessel disease. The primary end-points were the time to extubation, a composite end-point and mortality. RESULTS: EF, Euro-score, the number of grafts and inotropic support were similar between groups. In contrast time to extubation was 11.2 ± 3.8 hours in the off-pump versus 16.4 ± 2.7 hours in the on-pump group (p < 0.05). There were no hospital deaths in both groups. However, 2 off-pump (8%) compared to 5 on-pump (20%) patients presented a composite end-point. CONCLUSIONS: In this high-risk cohort off-pump CABG reduces time to extubation and in-hospital morbidity.

Coronary Intervention in Patients With Acute Coronary Syndrome: Does Every Culprit Lesion Require Revascularization?

In patients presenting with acute coronary syndromes, 30-60% of patients have multiple significant coronary lesions. Patients presenting with acute coronary syndrome and multivessel disease have a significant increase in the incidence of major cardiovascular morbidity and mortality when compared with patients who have single-vessel disease. Although great progress has been made to reduce the extent of infarction through effective and rapid reperfusion due to faster time to reperfusion, potent antiplatelets, and antithrombotics, there is not much consensus as to how best to treat multivessel disease in patients presenting with acute coronary syndromes. We present a review of the current body of evidence for safety and efficacy of multivessel revascularization in patients presenting with acute coronary syndromes.

Culprit-only or multivessel revascularization in patients with acute coronary syndromes: An American College of Cardiology National Cardiovascular Database Registry report

Multivessel (MV) coronary artery disease (CAD) frequently exists in patients presenting with non-ST-elevation (NSTE) acute coronary syndromes (ACSs). Although an early invasive strategy improves outcome in these patients, there are limited data on culprit-only, single-vessel (SV) percutaneous coronary intervention (PCI) or MV PCI in the NSTE ACS setting. To identify the predictors of SV versus MV PCI in patients with ACS and compare their outcomes up to hospital discharge, we analyzed the records of 105,866 patients undergoing PCI with ACS and MV CAD from 402 centers reported to the American College of Cardiology National Cardiovascular Database Registry between 2000 and 2004. Demographic, clinical, and angiographic characteristics of the patients were used to create a propensity score for SV versus MV PCI. Single-vessel PCI was performed in 68% (72,048 patients), whereas the remaining 32% (33,818 patients) had MV PCI. Factors independently associated with the performance of SV versus MV PCI were presentation with NSTE infarction (vs unstable angina), adjusted odds ratio (OR) of 1.29 (95% CI 1.24-1.34); being older, adjusted OR of 1.09 (95% CI 1.08-1.11) per decade; and presence of total occlusion, adjusted OR of 1.25 (95% CI 1.16-1.36). The c-statistic for the model was 0.70. Procedural success was achieved in 91% of SV PCI and 88% of MV PCI (P < .001). Inhospital mortality was 1.3% and 1.2%, respectively (P = .09; adjusted OR 1.11 [95% CI 0.97-1.27], P = .13). Rates of morbidity, such as bleeding, development of renal failure, or nonfatal cardiogenic shock, were similar for both groups. In patients with MV CAD, presenting with ACS and selected for PCI, performance of MV PCI appears to be associated with at least as successful an inhospital outcome as SV PCI.