Multivessel Revascularization Research Articles

Percutaneous Versus Surgical Revascularization for Acute Myocardial Infarction

IntroductionAcute myocardial infarction (AMI) is a common medical condition in our clinical practice that should be treated with appropriate revascularization in a timely manner. Percutaneous revascularization (PR) has been the first-line treatment option when feasible. Limited data is available comparing PR to surgical revascularization (SR) in the AMI setting. MethodsStudy population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for AMI, PR, SR, and procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay (LOS), stroke, acute kidney injury, bleeding, need for blood transfusion, acute respiratory failure, and total hospital charges. ResultsThe study identified 45,539 discharges with a principal admission diagnosis of AMI (38.7% ST elevation and 61.3% non-ST elevation) who had either PR or SR as a principal procedure (79.1% PR versus 20.9% SR). Single vessel revascularization was performed in 67.8% (93.1% had PR versus 6.9% had SR, p < 0.01). Multivessel revascularization was performed in 32.2% (64.8% had PR versus 35.2% had SR, p < 0.01). 83% of SR was in the setting of non-ST elevation AMI (NSTEMI). In comparison to SR, PR was associated with higher in-hospital all-cause mortality (3.7% versus 2.2%, p < 0.01), shorter LOS (4.3 versus 11.6 days, p < 0.01), and lower incidence of post-procedural stroke (1.0% versus 1.8%, p < 0.01), acute kidney injury (14.9% versus 24.8%, p < 0.01), bleeding (4.3% versus 47.1%, p < 0.01), need for blood transfusion (2.9% versus 18.5%, p < 0.01), acute respiratory failure (10.7% versus 19.8%, p < 0.01), and total hospital charges (120,590$ versus 229,917$, p < 0.01). These results persist after adjustment for baseline characteristics. In a subgroup analysis, SR mortality benefit persisted in patients who had multivessel revascularization (in both ST and non-ST elevation AMI), but not in single vessel revascularization. ConclusionsIn patients presented with AMI, PR was associated with higher in-hospital all-cause mortality but lower morbidity, shorter LOS, and lower total hospital charges than SR. However, the mortality benefit of SR was seen in multivessel revascularization only, and not in single vessel revascularization.

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.

On-pump versus off-pump coronary artery bypass surgery for multi-vessel coronary revascularization.

BackgroundThis study aims to compare the operative and postoperative results of on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass surgery (CABG) for multi-vessel coronary revascularization (≥4 anastomoses).MethodsFrom May 2018 to August 2019, a total of 120 patients (22.5% women, mean age 61.5±8.4 years) received either ONCAB (Group 1, n=60) or OPCAB (Group 2, n=60) for multi-vessel coronary artery disease (CAD). Preoperative left ventricular (LV) ejection fraction (EF) was 53.1%±8.4%. Median EuroSCORE II was 1.59 (interquartile range, 1.01–2.54). The median number of performed coronary anastomoses was 4 (interquartile range, 4–5), with equal distribution in both groups (P=0.4). All procedures were performed by highly experienced surgeons. The primary endpoints were overall survival at 30 days and freedom from severe adverse events (SAE), which included myocardial infarction (MI), coronary artery re-operation, and re-thoracotomy, caused by bleeding and stroke.ResultsThe overall survival in both groups was 100% with no intraoperative OPCAB-to-on-pump conversion. The median procedure time was 169 min (interquartile range, 150–179 min) for Group 1 and 183 min (interquartile range, 169–205 min) for Group 2 (P<0.001). The overall freedom from SAE numbered 93.3% (98.3% vs. 88.3%, P=0.030). Postoperative MI rate was 2.5% (n=3) with no significant difference for either group (0 vs. 5.0%, P=0.100). One MI patient underwent a re-operation, and two other patients received a conservative treatment. A total of 2.5% (n=3) of patients underwent a re-thoracotomy on account of bleeding (0 vs. 5.0%, P=0.100); no anastomosis-related bleeding was detected. Blood transfusion was applied in 31.7% of patients (38.3% vs. 25.0%, P=0.090). A total of 1.7% of patients (1.7% vs. 1.7%, P=0.800) developed a stroke. Ventilation time, intensive care unit stay, and hospital stay were similar in both groups.ConclusionsONCAB showed superior freedom from SAE and shorter procedure times when compared to OPCAB for multi-vessel coronary artery revascularization.

Culprit-Vessel-Only vs. Multivessel PCI for Acute MI and Cardiogenic Shock

Although guidelines have recommended complete multivessel revascularization at the time of primary percutaneous coronary intervention (PCI) in patients

Multivessel coronary artery revascularization through left mini-anterior thoracotomy

Multivessel coronary artery revascularization through left mini-anterior thoracotomy

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6months following discharge. Mean age of patients was 52.5 ± 9.8years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Benefit of a staged in-hospital revascularization strategy in hemodynamically stable patients with ST-segment elevation myocardial infarction and multivessel disease: Analyses by risk stratification.

The proper timing and indication of revascularization for a non-culprit artery in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) without cardiogenic shock remains controversial. This multicenter study included patients with STEMI and MVD without cardiogenic shock. Data were analyzed at 3 years according to the percutaneous coronary intervention (PCI) strategy: immediate multivessel revascularization (MVR) (n=351), stepwise MVR (n=510), and culprit-only PCI (n=1,142). The primary outcome was all-cause mortality. The stepwise MVR group had a lower risk of all-cause death. The results were consistent after multivariate regression, propensity-score matching, inverse probability weighting, and Bayesian proportional hazards modeling. In subgroup analyses stratified by the Global Registry of Acute Coronary Events score, stepwise MVR also lowered the risk of all-cause death compared to culprit-only PCI and immediate MVR in high risk patients but not in patients at low to intermediate risk. In patients with STEMI and MVD without cardiogenic shock, in-hospital stepwise MVR was associated with a lower risk of all-cause death than culprit-only PCI or immediate MVR, particularly in the high-risk subgroup.

Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study.

Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF]<30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients. We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI. 214 patients underwent CABG (n [on-pump CABG]=94; n [off-pump CABG]=120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR]=1.86, 95% confidence interval [CI]=1.46-2.42; p<0.001) and off-pump CABG (HR=2.32, 95% CI=1.75-3.15; p<0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ=13.5, 95% CI=3.2-24.5; p=0.012) and off-pump CABG (Δ=16.1, 95% CI=5.9-25.8; p<0.001). Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.

Revascularization Strategies in Patients Presenting With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

The optimal revascularization strategy for residual coronary stenosis following primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) remains controversial. This is a retrospective single-centre study including patients with STEMI and MVD. Based on the revascularization strategy, 3 groups were identified: (1) culprit only (CO), (2) ad hoc multivessel revascularization (MVR), and (3) staged MVR. Clinical outcomes were compared in terms of major adverse cardiac events (MACE), a composite of cardiac death, any myocardial infarction, and any unplanned revascularization at a long-term follow-up. A total of 958 patients were evaluated, 489 in the CO, 254 in the ad hoc, and 215 in the staged group. In the staged group, 65.6% of the patients received planned percutaneous coronary intervention, 9.7% coronary artery bypass grafting, 8.4% no further intervention after lesion reassessment, and in 16.3% an event occurred before the planned procedure. At 1,095 days, MACE was 36.1%, 16.7%, and 31% for CO, ad hoc, and staged groups, respectively. A MVR strategy was associated with lower rate of all-cause death compared with CO (HR 0.50; 95%CI [0.31 to 0.80]; p = 0.004). Complete revascularization reduced the rate of MACE (HR 0.30 [0.21 to 0.43] p < 0.001) compared with incomplete revascularization. Ad hoc MVR had lower rate of MACE compared with staged MVR (HR 0.61 [0.39 to 0.96] p = 0.032) mainly driven by less unplanned revascularizations. In conclusion, in patients with STEMI and MVD, complete revascularization reduced the risk of MACE. Ad hoc MVR appeared a reasonable strategy with lower contrast and stent usage and costs.

ST-elevation Myocardial Infarction and Multivessel Coronary Artery Disease - A Critical Review of Current Practice, Evidence and Meta-analyses.

In recent years, practice and guidelines for patients with ST-elevation myocardial infarction (STEMI) have evolved from a 'culprit-only approach' to complete revascularisation; however, several issues remain, particularly regarding assessment of non-culprit lesions and timing of their revascularisation. Complete revascularisation should be performed in patients presenting with STEMI; however, available studies often present contradictory results regarding the optimal timing of non-culprit lesion percutaneous coronary intervention (PCI). The aim of this review is to provide a practical approach for the assessment of patients presenting with STEMI and multivessel coronary artery disease by analysing randomised trials, meta-analyses and our clinical experience. We recommend multivessel revascularisation at the time of primary PCI for simple cases, while we suggest deferring treatment of complex lesions; the optimal timing of staged PCI should be individualised according to clinical judgement.

One-Year Clinical Outcomes between Single- versus Multi-Staged PCI for ST Elevation Myocardial Infarction with Multi-Vessel Coronary Artery Disease: from Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH)

Background and ObjectivesAlthough complete revascularization is known superior to incomplete revascularization in ST elevation myocardial infarction (STEMI) patients with multi-vessel coronary artery disease (MVCD), there are no definite instructions on the optimal timing of non-culprit lesions percutaneous coronary intervention (PCI). We compared 1-year clinical outcomes between 2 different complete multi-vessel revascularization strategies.MethodsFrom the Korea Acute Myocardial Infarction Registry-National Institute of Health, 606 patients with STEMI and MVCD who underwent complete revascularization were enrolled from November 2011 to December 2015. The patients were assigned to multi-vessel single-staged PCI (SS PCI) group (n=254) or multi-vessel multi-staged PCI (MS PCI) group (n=352). Propensity score matched 1-year clinical outcomes were compared between the groups.ResultsAt one year, MS PCI showed a significantly lower rate of all-cause mortality (hazard ratio [HR], 0.42; 95% confidential interval [CI], 0.19–0.92; p=0.030) compared with SS PCI. In subgroup analysis, all-cause mortality increased in SS PCI with cardiogenic shock (HR, 4.60; 95% CI, 1.54–13.77; p=0.006), age ≥65 years (HR, 4.00; 95% CI, 1.67–9.58, p=0.002), Killip class III/IV (HR, 7.32; 95% CI, 1.68–31.87; p=0.008), and creatinine clearance ≤60 mL/min (HR, 2.81; 95% CI, 1.10–7.18; p=0.031). After propensity score-matching, MS PCI showed a significantly lower risk of major adverse cardiovascular event than SS PCI.ConclusionsSS PCI was associated with worse clinical outcomes compared with MS PCI. MS PCI for non-infarct-related artery could be a better option for patients with STEMI and MVCD, especially high-risk patients.

Surgical versus percutaneous multivessel coronary revascularization in patients with chronic kidney disease.

This study compared contemporary outcomes following surgical versus percutaneous coronary revascularization for multivessel coronary artery disease (MVCAD) in patients with chronic kidney disease. Patients with MVCAD and a reduced glomerular filtration rate (<60 ml/min) undergoing coronary bypass surgery (CABG) or percutaneous coronary intervention (PCI) at a single institution between 2010 and 2017 were included. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite outcome of death, stroke, myocardial infarction or repeat revascularization. Multivariable Cox regression models were used for risk-adjustment and propensity matching was also performed. A total of 1853 patients were included in the study (1269 CABG, 584 PCI). CABG was associated with greater 5-year freedom from MACCE (70.1% vs 47.3%, P < 0.0001), a finding that persisted after risk-adjustment. The rates of early and late mortality and readmission were also lower with CABG as were individual rates of myocardial infarction and repeat revascularization. A propensity-matched analysis generated 704 well-matched patients (352 in each arm) with similar results, including greater 5-year freedom from MACCE (72.8% vs 45.8%, P < 0.0001), improved 5-year survival (73.9% vs 52.3%, P < 0.0001), lower readmission (cause-specific hazard ratio 0.68, 95% confidence interval 0.58-0.80; P < 0.0001), lower individual rates of myocardial infarction (2.6% vs 9.7%, P < 0.0001) and repeat revascularization (1.1% vs 7.4%, P < 0.0001). CABG is associated with a lower MACCE rate than that of PCI in patients with MVCAD and chronic kidney disease. Multidisciplinary discussions regarding the optimal revascularization strategy are important in MVCAD, particularly in more complex scenarios such as chronic kidney disease.

Jeopardized Myocardium and Survival in Patients Presenting to the Catheterization Laboratory With ST-Elevation Myocardial Infarction and Shock

ObjectiveWe aimed to relate the amount of jeopardized myocardium to mortality in shocked patients presenting to the catheterization laboratory with ST-elevation myocardial infarction (STEMI) and cardiogenic shock. BackgroundIn contrast with historical data and previous professional guidance, contemporary randomized data suggest that multi-vessel revascularization in such patients does not improve survival; mechanistic insight is incomplete. MethodsClinical databases identified cases of STEMI and shock triaged for primary percutaneous coronary intervention (PPCI) in Eastern Denmark from June 2011 to December 2014 (n = 128). British Cardiovascular Intervention Society (BCIS)-1 jeopardy scores were calculated from angiography. The study endpoint was 30-day mortality. ResultsMedian lactate values were 6.0 [2.9–10.7] mmol/L. 30-day mortality was 53.9%. 68% of patients had multi-vessel coronary disease. Median pre-PCI BCIS-1 myocardial jeopardy scores were 8 [6–10]. After multiple logistic regression increasing age (p = 0.008; odds ratio [OR] 1.06), lactate values (p = 0.017; OR 1.02), mechanical ventilation (p = 0.011; OR 1.25) and a systolic blood pressure ≤ 90 mmHg at end-case (p = 0.005; OR 1.26) were predictive of 30-day mortality. Post-PPCI culprit vessel TIMI 3 flow was associated with reduced mortality (p < 0.001; OR 0.66). There was no association between pre-PCI jeopardy scores and the primary endpoint. ConclusionsIn patients with STEMI and shock, myocardial jeopardy scores do not relate to patient outcomes. Jeopardy scores may be applied to existing datasets in order to understand why multi-vessel revascularization does not lead to the anticipated clinical benefits in cardiogenic shock.

Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia

ObjectiveMultivessel tibial revascularization for critical limb ischemia (CLI) remains controversial. The purpose of this study was to evaluate single vs multiple tibial vessel interventions in patients with multivessel tibial disease. We hypothesized that there would be no difference in amputation-free survival between the groups. MethodsUsing the Vascular Quality Initiative registry, we reviewed patients undergoing lower extremity endovascular interventions involving the tibial arteries. Patients with CLI were included only if at least two tibial vessels were diseased and adequate perioperative data and clinical follow-up were available for review. The primary outcome was amputation-free survival. ResultsThere were 10,849 CLI patients with multivessel tibial disease evaluated from 2002 to 2017; 761 limbs had adequate data and follow-up available for review. Mean follow-up was 337 ± 62 days. Of these, 473 (62.1%) underwent successful single-vessel tibial intervention (group SV), whereas 288 (37.9%) underwent successful multivessel (two or more) intervention (group MV). Patients in group MV were younger (69.1 vs 73.2 years; P < .001), with higher tobacco use (29.5% vs 18.2%; P < .001). Group SV more commonly had concurrent femoral or popliteal inflow interventions (83.7% vs 78.1%; P = .05). Multivessel runoff on completion was significantly greater for group MV (99.9% vs 39.9%; P < .001). No differences were observed between group SV and group MV for major amputation (9.0% and 7.6%; P = .6), with similar amputation-free survival at 1 year (90.6% vs 92.9%; P = .372). In a multivariate Cox model, loss of patency was the only significant predictor of major amputation (hazard ratio, 5.36 [2.7-10.6]; P = .01). A subgroup analysis of 355 (46.6%) patients with tissue loss data showed that tissue loss before intervention was not predictive of future major amputation. ConclusionsIn the Vascular Quality Initiative registry, patients with CLI and occlusive disease involving multiple tibial vessels did not appear to have a limb salvage benefit from multiple tibial revascularization compared with single tibial revascularization.

Impact of non-respect of SYNTAX score II recommendation for surgery in patients with left main coronary artery disease treated by percutaneous coronary intervention: an EXCEL substudy.

The SYNTAX score II (SSII) was developed from the SYNTAX trial to predict the 4-year all-cause mortality after left main or multivessel disease revascularization and to facilitate the decision-making process. The SSII provides the following treatment recommendations: (i) coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (equipoise risk), (ii) CABG preferred (excessive risk for PCI) or (iii) PCI preferred (excessive risk for CABG). We sought to externally validate SSII and to investigate the impact of not abiding by the SSII recommendations in the randomized EXCEL trial of PCI versus CABG for left main disease. The calibration plot of predicted versus observed 4-year mortality was constructed from individual values of SSII in EXCEL. To assess overestimation versus underestimation of predicted mortality risk, an optimal fit regression line with slope and intercept was determined. Prospective treatment recommendations based on SSII were compared with actual treatments and all-cause mortality at 4 years. SSII variables were available from EXCEL trial in 1807/1905 (95%) patients. For the entire cohort, discrimination was possibly helpful (C statistic = 0.670). SSII-predicted all-cause mortality at 4 years overestimated the observed mortality, particularly in the highest-risk percentiles, as confirmed by the fit regression line [intercept 2.37 (1.51-3.24), P = 0.003; slope 0.67 (0.61-0.74), P < 0.001]. When the SSII-recommended treatment was CABG, randomized EXCEL patients treated with PCI had a trend towards higher mortality compared with those treated with CABG (14.1% vs 5.3%, P = 0.07) in the as-treat population. In the intention-to-treat population, patients randomized to PCI had higher mortality compared with those randomized to CABG (15.1% vs 4.1%, P = 0.02), when SSII recommended CABG. In the EXCEL trial of patients with left main disease, the SSII-predicted 4-year mortality overestimated the 4-year observed mortality with a possibly helpful discrimination. Non-compliance with SSII CABG treatment recommendations (i.e. randomized to PCI) was associated with higher 4-year all-cause mortality.

P3127Optimal revascularization strategy in non-ST-segment elevation myocardial infarction with multivessel coronary artery disease: staged vs. one-time vs. culprit-only revascularization

Abstract Background/Introduction Although optimal revascularization strategy in patients with ST-segment elevation myocardial infarction with multivessel coronary artery disease (MVD) was well established, there are few studies which investigated optimal revascularization strategy in non-ST-segment elevation myocardial infarction (NSTEM) with MVD. Purpose We investigated 2-year clinical outcomes according to strategy of revascularization in patients with NSTEMI and MVD. Methods Between November 2011 and October 2015, a total of 2474 patients with NSTEMI and MVD who underwent successful percutaneous coronary intervention were analyzed from the Korea Acute Myocardial Infarction Registry-National Institute of Health (staged 308, one-time 1043 and culprit-only 1123 patients). We did not include patients with left main disease and cardiogenic shock. Primary endpoint was major adverse cardiac events (MACE: the composite of cardiac death, myocardial infarction [MI] or target-vessel revascularization [TVR]) during 2-year follow-up (median 737 days [interquartile range 705–764]). We also analyzed the of all-cause mortality, stroke and non-TVR. Results Baseline characteristics such as age, gender, and prevalence of atherosclerotic risk factors between multivessel revascularization (MVR; staged or one-time revascularization) and CVR were similar. There was also no difference in symptom to balloon time in 2 groups. MACE occurred in 305 patients (12.3%) during 2-year follow-up. MVR could reduce incidence of MACE (10.2% vs. 14.9%; adjusted hazard ratio [HR] 1.50 for CVR, 95% confidence interval [CI] 1.20–1.88, p&lt;0.001), all-cause death (8.4% vs. 12.1%; adjusted HR 1.45 for CVR, 95% CI 1.13–1.87, p=0.003) and non-TVR (1,9% vs. 7.0%; adjusted HR 3.99 for CVR, 95% CI 2.55–6.27, p&lt;0.001). There was no difference in incidence of stroke between MVR and CVR. We also analyzed same analysis between staged and one-time revascularization. Complete revascularization was more achieved in one-time revascularization group compared to staged revascularization group (62.0% vs. 76.1%, p&lt;0.001). In multivariate Cox-regression analysis, staged revascularization was not associated with improved clinical outcomes in terms of MACE (HR 0.74, 95% CI 0.50–1.09, p=0.126), all-cause death (HR 1.07, 95% CI 0.69–1.68, p=0.759), stroke (HR 1.75, 95% CI 0.68–4.52, p=0.245) and non-TVR (HR 2.56, 95% CI 0.75–8.68, p=0.132). Analysis by propensity score matching and inverse probability of treatment weighting did not significantly affect the results. Conclusions MVR reduced 2-year adverse cardiac events in patients with NSTEMI and MVD compared to CVR. However, staged revascularization was not superior to one-time revascularization for reducing MACE among NSTEMI patients with MVD who received MVR.

OPTIMAL CONFIGURATION FOR BYPASS OF THE LAD DURING BILATERAL INTERNAL THORACIC ARTERY GRAFTING

Coronary artery bypass graft (CABG) surgery is considered the most effective and durable approach to multi-vessel coronary revascularization primarily attributed to the excellent patency of the internal thoracic artery (ITA) to left anterior descending (LAD) artery graft. This success has led to the increased use of bilateral ITA (BITA). However, it is not clear whether the left ITA (LITA) or the right ITA (RITA) should be used for the LAD. Therefore, the objective of this study was to compare clinical outcomes between LITA-LAD and RITA-LAD configurations in BITA grafting. The primary outcome was the need for percutaneous or surgical re-intervention of the LAD territory. Secondary outcomes included all-cause mortality and cardiac mortality. Cox proportional hazard models were used with entropy weighting to balance groups. Competing risks were determined using the Fine and Gray model. The studied cohort included 1527 BITA patients with LITA-LAD and 523 with RITA-LAD. The median follow-up was greater in the LITA-LAD group (6.5 years IQR[2.7, 11.3] vs 5.5 years[2.4, 9.2], p < 0.001). Before entropy weighting, RITA-LAD patients were significantly older with more diabetes, peripheral vascular disease and left ventricular dysfunction and more urgent status (all with p < 0.05). Cases with RITA-LAD were also more frequently performed off-pump (p < 0.001). Predicted need for repeat revascularization of the LAD territory at 10 years was 2.8% in the LITA-LAD group and 1.8% in the RITA-LAD group. There was no difference in the need for LAD re-revascularization between groups (Subhazard HR [SHR] 0.686 95% CI [0.296, 1.589], p=0.38). There was no difference in long term all-cause mortality (HR 1.056 95%CI [0.677, 1.647], p=0.81). Adjusted survival at 10 years was 97.2% in the LITA-LAD group and 98.2% in the RITA-LAD group. There was no difference in the risk of cardiac death (SHR 1.062 95%CI [0.502, 2.250], p=0.87). The use of either the LITA or the RITA for LAD grafting during BITA revascularization has no effect on long-term cardiac and all-cause mortality or need for repeat revascularization of the LAD territory. Cardiac surgeons should be confident in using a RITA-LAD bypass in their operative strategy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

TCT-239 Impact of Nonrespect of SYNTAX Score II Recommendations for Surgery in Patients With Complex Coronary Artery Disease Treated by PCI: A Pooled Analysis of 3,280 Randomized Patients: SYNTAX, BEST, and PRECOMBAT Trials

The SYNTAX Score II (SSII) was developed to predict 4-year all-cause mortality after left main (LM) or multivessel disease revascularization and to facilitate the decision-making process by providing the following treatment recommendations: 1) coronary artery bypass grafting (CABG) or percutaneous

Meta-analysis Comparing Multivessel Versus Culprit Coronary Arterial Revascularization for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes

We present a systematic review and meta-analysis comparing efficacy and safety outcomes between single procedure multivessel revascularization (MVR) and culprit vessel only revascularization in patients presenting with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS is the most common form of acute coronary syndrome (ACS), and multivessel disease is common. There is no consensus on the most efficacious single procedure revascularization strategy for patients undergoing percutaneous coronary intervention not meeting coronary artery bypass grafting criteria. Studies in PubMed and EMBASE databases were systematically reviewed, and 15 studies met criteria for inclusion in the meta-analysis. Baseline characteristics between the groups were similar. A random effects model was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity of studies was assessed using Cochrane's Q and Higgins I2 tests. For short-term outcomes, patients who underwent MVR had higher rates of major adverse cardiac events (OR 1.14; 95% CI 1.01 to 1.29; p = 0.03); and stroke (OR 1.94; 95% CI 1.01 to 3.72; p = 0.05), but lower rates of urgent or emergent coronary artery bypass grafting (OR 0.35; 95% CI 0.29 to 0.43; p <0.00001). In the long-term, MVR patients had less frequent major adverse cardiac events (OR 0.76; 95% CI 0.61-0.93; p = 0.009), all-cause death (OR 0.83; 95% CI 0.71 to 0.97; p = 0.03), and repeat revascularization, (OR 0.62; 95% CI 0.42 to 0.90; p = 0.01). MVR following NSTE-ACS was associated with higher short-term risk, but long-term benefit. In conclusion, these results support the use of single procedure multivessel revascularization for NSTE-ACS patients who are suitable candidates at the time of percutaneous coronary intervention.

Five-year results of the complete versus culprit vessel percutaneous coronary intervention in multivessel disease using drug-eluting stentsII (CORRECTII) study: aprospective, randomised controlled trial.

Objectives/backgroundIn patients with multivessel coronary artery disease (MVD) the decision whether to treat a single culprit vessel or to perform multivessel revascularisation may be challenging. The purpose of this study was to evaluate the long-term outcome of multivessel percutaneous coronary intervention (MV-PCI) versus culprit vessel only (CV-PCI) in patients with stable coronary artery disease or non-ST elevation acute coronary syndrome.MethodsIn this dual-centre, prospective, randomised study a total 215 patients with MVD were randomly assigned to MV-PCI or CV-PCI. The primary endpoint was the occurrence of major adverse cardiac events (MACE) including death, myocardial infarction (MI), and repeat revascularisation. Secondary endpoints were the combined endpoint of death or MI, the individual components of the primary endpoint, and the occurrence of stent thrombosis. Patients were followed up to 5 years after enrolment.ResultsThe occurrence of the primary endpoint was similar at 28% versus 31% in the MV-PCI and CV-PCI group, respectively (hazard ratio [HR] 0.87, 95% confidence interval [CI]: 0.53–1.44, p = 0.59). The rate of repeat revascularisation was 15% versus 24% (HR 0.59, 95% CI 0.32 to 1.11, p = 0.11), whereas definite or probable stent thrombosis occurred in 2% versus 0% (p = 0.44).ConclusionsIn this randomised study comparing the strategies for MV-PCI and CV-PCI in patients with MVD, no difference was found in the occurrence of MACE after 5 years. We observed a numerically higher rate of death or MI and a lower rate of repeat revascularisation after MV-PCI, although these findings were not statistically significant.