Previous CABG Research Articles

In patients with recent ACS and uncontrolled dyslipidemia, alirocumab reduced MACE regardless of previous CABG.

Source Citation Goodman SG, Aylward PE, Szarek M, et al. Effects of alirocumab on cardiovascular events after coronary bypass surgery. J Am Coll Cardiol. 2019;74:1177-86. 31466614

Impact of active smoking on the immature platelet fraction and its relationship with the extent of coronary artery disease.

Smoking represents a major cardiovascular risk factor, due to the induction of oxidative stress and low-grade, continuous, inflammation that contribute to promote atherothrombosis. However, the mechanisms leading to increased platelet aggregability associated with smoking are only partially defined. A potential role has been hypothesized for immature platelets, a younger and potentially more reactive fraction, previously associated with the main determinants of coronary artery disease (CAD). Therefore, the aim of our study was to define the impact of smoking on the immature platelet fraction (IPF) and its relationship with prevalence and extent of coronary artery disease. We enrolled a cohort of consecutive patients undergoing coronary angiography in a single centre. Significant CAD was defined as at least 1 vessel stenosis >50%, while severe CAD was defined as left main and/or three-vessel disease. IPF was measured at admission by routine blood cell count (Sysmex XE-2100). We included in our study 2553 patients who were divided according to smoking status (active smokers: 512; nonactive smokers: 2041). Smokers were younger, more frequent males, with lower rate of diabetes mellitus, previous PCI and previous CABG (P<.001, respectively) and were in treatment less often with ARB, BB, nitrates, statins, ASA, clopidogrel, CCB and diuretics (P<.001, respectively) as compared to nonactive smokers. Higher percentage of smokers was observed in patients with higher IPF values, and at multivariate analysis, active smoking resulted as an independent predictor of higher IPF (adjusted OR [95% CI]=1.59[1.03-2.45], P=.035). Among smokers, higher IPF was associated with lower ejection fraction (P=.034), percentage of acute coronary syndrome (P=.002) and platelet count (P<.001) compared to ones with lower IPF. However, the IPF (according to quartiles values) was not associated with the prevalence and extent of CAD (82.5%, 80.4%, 86.1% and 80.9%, from 1st to 4th quartile, respectively, adjusted OR[95% CI]=0.98[0.79-1.23], P=.89) and severe CAD (31%, 31.1%, 39.1% and 35.2%, from 1st to 4th quartile, respectively, adjusted OR[95% CI]=1.03[0.86-1.23], P=.76). The present study shows an independent association between active smoking and the levels of immature platelet fraction in patients undergoing coronary angiography. However, among active smokers, IPF did not result as an independent predictor of CAD or severe CAD.

Complex high-risk and indicated percutaneous coronary intervention for stable angina: Does operator volume influence patient outcome?

Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.

860 Outcomes of First 500 Cases of Transcatheter Aortic Valve Implantation at a High-Volume Australian Private Hospital

Transcatheter aortic valve implantation (TAVI) was first performed in Australia in 2008 and grown to 42 implanting centres nationwide. There is limited published data on outcomes from Australian centres, especially private hospitals. We describe outcomes of the first 500 cases at Queensland’s first TAVI implanting private hospital. From July 2015-March 2020, 500 patients with severe, symptomatic aortic stenosis underwent TAVI at our centre. A multidisciplinary heart-team assessed all patients as suitable. Computed tomography (CT) TAVI assessment was mandatory for procedural planning. Mean age was 85 years old, 57% were male, mean STS score 4.0%, 49% had NYHA Class III/IV, 24% previous CABG, 14% peripheral vascular disease and 4.7% renal impairment. At 30 days mortality was 1.2%, stroke 1.0%, myocardial infarction (MI) 0.2%, major vascular complication 2.5% and new permanent pacemaker (PPM) requirement was 8.4%. Post-procedural paravalvular leak was none or trace in 82.7% mild in 16.8% and ≥moderate in 0.4%. At 1year, mortality was 4.3%, stroke 1.4%, no life-threatening bleeding and PPM 10.1%. Between patients 1-300, 301-400, and 401-500, we observed improvements in major adverse cardiac/cerebrovascular events (4.8%, 4.6%, 2.0%) and post-procedural paravalvular leak of none/trace (80%, 81%, 89%) respectively. Excellent TAVI clinical outcomes can be achieved in the Australian private hospital setting. Expert Heart Team assessment and CT guided procedural planning are key to these outcomes. Cumulative volume experience appears linked to achieving sustained excellent results.

505 Influence of Culprit Vessel and Reperfusion Strategy on Clinical Outcomes in ST-Elevation Myocardial Infarction (STEMI)

We postulated that culprit vessel in STEMI may have an interaction with reperfusion strategy (thrombolysis versus primary percutaneous intervention [PPCI]) in determining risk of major adverse cardiovascular events (MACE). A cohort study of consecutive STEMI patients treated at two outer-metropolitan hospitals over a 6-year period (2014- 2019) was performed. Subjects were stratified according to their re-perfusion strategy (thrombolysis or PPCI) and by the location of their culprit coronary artery, confirmed on angiography; (left anterior descending (LAD), left circumflex (LCX), right coronary artery (RCA) and left main (LMCA). Patients with previous CABG or no culprit lesion were excluded from the analysis. A total of 586 patients were analysed of which 394 (67%) were thrombolysed and 192 (33%) underwent PPCI. Females comprised 98 (25%) of the thrombolysed patients and 49 (26%) of the PPCI patients. Of the patients undergoing thrombolysis: the LAD was culprit in 156 patients (45%), LCX in 41 patients (10%), RCA in 188 patients (48%) and LMCA in 9 (2%). Among the PPCI patients: the LAD was culprit in 86 patients (45%), LCX in 20 patients (10%), RCA in 82 (43%) patients and LMCA in 4 (2%). We found no significant difference in the 1-month MACE outcome of patients undergoing thrombolysis or PPCI when stratified according reperfusion strategy or culprit lesion location. MACE at one month following STEMI was similar throughout the study population with no directional trends based on culprit vessel or reperfusion strategy. Our findings indicate time to reperfusion remains the most important factor, rather than reperfusion strategy based on lesion location.

Progression of precerebral atherosclerosis and predictors of ischemic complications in cardiac patients

To identify predictors of progression of precerebral atherosclerosis in long-term period after coronary artery bypass surgery. There were 97 procedures of carotid endarterectomy in patients after previous coronary artery bypass grafting for the period from 2006 to 2017. Inclusion criteria were previous CABG, no significant (over 60%) stenosis of internal carotid arteries at discharge after CABG. The control group included 447 patients without progression of precerebral atherosclerosis in long-term period after CABG. Careful monitoring of progression of precerebral atherosclerosis and therapeutic prevention of ischemic stroke are required in patients with mild-to-moderate ICA stenosis after CABG. The most significant predictors of progression of precerebral atherosclerosis after CABG were AF (OR=1.97, 95% CI 1.04-3.73), previous occlusion of stent (OR=7.89, 95% CI=2.3-27.0), chronic brain ischemia grade II or III (OR=22.45, 95% CI=11.9-42.3), chronic kidney disease (OR=15.8, 95% CI=5.04-49.5). It was revealed that the majority of predictors of adverse ischemic cerebral and myocardial events are indirectly associated with atrial fibrillation.

An Observational Study Assessing Immediate Complete Versus Delayed Complete Revascularisation in Patients with Multi-Vessel Disease Undergoing Primary Percutaneous Coronary Intervention.

Background:More than half of the patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have multi-vessel coronary artery disease. This is associated with worse outcomes compared with single vessel disease. Whilst evidence now exists to support complete revascularisation for bystander disease the optimal timing is still debated. This study aimed to compare clinical outcomes in patients with STEMI and multi-vessel disease who underwent complete revascularisation as inpatients in comparison to patients who had staged PCI as early outpatients.Methods and results:We conducted an observational cohort study consisting of 1522 patients who underwent primary PCI with multi-vessel disease from 2012 to 2019. Exclusions included patients with cardiogenic shock and previous CABG. Patients were split into 2 groups depending on whether they had complete revascularisation performed as inpatients or as staged PCI at later outpatient dates. The primary outcome of this study was major adverse cardiac events (consisting of myocardial infarction, target vessel revascularisation and all-cause mortality).834 (54.8%) patients underwent complete inpatient revascularisation and 688 patients (45.2%) had outpatient PCI (median 43 days post discharge). Of the inpatient group, 652 patients (78.2%) underwent complete revascularisation during the index procedure whilst 182 (21.8%) patients underwent inpatient bystander PCI in a second procedure. Overall, there were no significant differences between the groups with regards to their baseline or procedural characteristics. Over the follow-up period there was no significant difference in MACE between the cohorts (P = .62), which persisted after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]). Furthermore, in propensity-matched analysis there was no significant difference in outcome between the groups (HR: 0.86 95% CI: 0.75-1.25).Conclusions:Our study demonstrated that the timing of bystander PCI after STEMI did not appear to have an effect on cardiovascular outcomes. We suggest that patients with multi-vessel disease can potentially be discharged promptly and undergo early outpatient bystander PCI. This could significantly reduce length of stay in hospital.

A022 In-hospital Outcomes Following Cardiac Catheterisation in New Zealand (NZ): An All NZ Acute Coronary Syndrome Quality Improvement (ANZACS-QI) Analysis

There is limited contemporary short-term outcome data relating to diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. This retrospective analysis aims to determine in-hospital outcomes in patients undergoing DCA and PCI in NZ and identify predictors of poor outcome. This ANZACS-QI Cath/PCI registry-based study included 40870 patients who underwent a total of 46283 procedures over 45169 episodes of care between 01/09/2014 to 24/09/2017. Each episode of care was used to determine the in-hospital outcomes. A stepwise logistic regression was used for multivariate analysis to identify predictors of outcome. Mean age 65 (standard deviation 12) years, male 67%, NZ European 76%, previous CABG 7%. ACS indication 55%. Of the total 46283 procedures performed, 85% were radial access, 28258 were DCA and 18025 were PCI. The table below lists the number of adverse in-hospital outcomes by indication and procedure. Other procedural indications (n=6245) included valvular heart disease, heart failure and ventricular arrhythmia. The independent predictors of death were age (OR 1.55/10y, p<0.0001), STEMI (OR 6.6, p<0.0001), cardiogenic shock (OR 16.9, p<0.0001) and femoral access (OR 3.4, p<0.0001). This study demonstrates low rates of adverse short-term outcomes in NZ patients undergoing DCA and PCI. The rates of death, recurrent MI and stroke compare favourably to international registries, and the independent predictors of death identified are also similar.

Long-term outcomes of percutaneous coronary intervention in grafts and native vessels in coronary artery bypass grafting patients with diabetes mellitus.

Atherosclerosis in diabetic patients progresses fast. Evidence on how to choose target vessels of percutaneous coronary interventions (PCIs) in diabetic patients post-coronary artery bypass graft (post-CABG) is insufficient. One hundred and fifty-seven patients with diabetes and previous CABG, who underwent PCI of either a graft vessel (GV) (n=44) or a native vessel (NV) (n=113) in the National Center for Cardiovascular Disease, China, were studied. In-hospital and long-term clinical outcomes were compared between the groups. Diabetic patients with prior CABG had more PCI to native arteries, but the proportion of grafts PCI increased as time went on. Both groups had similar baseline characteristics. Group GV patients compared with group NV had more totally occluded NVs, less totally occluded grafts and more in-stent restenosis. However, there was no difference in in-hospital mortality and long-term incidence of major adverse cardiac event (MACE), cardiac death, nonfatal myocardial infarction (MI), or revascularization. Multivariate logistic regression analysis showed that PCI success [hazard ratio (HR), 11.488; 95% confidence interval (CI), 1.135-116.303; P<0.05] was independent predictor of MACE. It suggested similar long-term clinical outcomes after PCI in GV or NV in prior CABG patients with diabetes. Thus, the vessel with higher estimated PCI success rate should be prioritized by operators.

Myocardial infarction without obstructive coronary artery disease (MINOCA) - prevalence and prognosis

Introduction: There are conflicting data on the prevalence and prognosis of AMI patients with non-obstructive coronary artery disease (MINOCA). Aim: We studied the prevalence and prognosis of MINOCA patients. Method: In the Hungarian Myocardial Infarction Registry (HUMIR) 45,223 patients (pts) with acute myocardial infarction (AMI) were found who were treated between Jan 1, 2014, and June 30, 2018, and coronary arteriography was performed. ST-elevation myocardial infarction was diagnosed in 22,469 pts (49.7%). Patients without obstructive coronary artery disease who had no previous myocardial infarction, heart failure, PCI and CABG procedure were selected to the MINOCA group (n = 2003). Patients with obstructive coronary artery disease belonged to the MICAD group (n = 43,220). We investigated clinical characteristics of the patients, overall survival and reinfarction. Survival curves were estimated with the Kaplan-Meier method and were modeled with the Cox proportional hazards model. Results: The proportion of MINOCA pts among all myocardial infarction was by 4.4% higher in the STEMI pts compared to the NSTEMI group (2.0% vs. 6.8%). The MINOCA pts were younger (age 64.0 ± 14.4 vs. 65.5 ± 12.2 years), and the proportion of women was higher (55.7% vs. 36.5%). Hypertension, diabetes mellitus and peripheral artery disease were more common in the MICAD group (79.1% vs. 73.7%, 33.0% vs. 21.2%, and 12% vs. 8%). The mortality was higher among the MICAD pts. In the MINOCA group, the mortality of men did not differ between STEMI and NSTEMI, as opposed to women: women with STEMI had higher mortality than women with NSTEMI. The risk of reinfarction was higher in the MICAD group, especially in NSTEMI, the risk in the MINOCA group was lower, and there was no substantial difference between types. Conclusion: In this real word, retrospective, observational study, we found a significant difference in the prevalence of MINOCA pts according to different types of myocardial infarction. In the MINOCA group, the mortality of women with STEMI was substantially higher. Orv Hetil. 2019; 160(45): 1791-1797.

P969Predictors of survival after bifurcation stenting (practical insights from COSIBRIA registry)

Abstract Background There is no much information about survival after coronary bifurcation stenting. We explored specifically predictors of death in all-comers registry database. Methods The COSIBRIA registry (COronary SIde Branch Residual IschemiA and COllateralization Assessment Study, Identifier: NCT01268228) collected all coronary bifurcation patients treated with intracoronary ECG (icECG) guidance or angiographically guided PCI. It was designed to explore relation between periprocedural ischemia assessed by means of icECG and post-procedural myonecrosis (troponin rise). Patients with STEMI, distal left main, cardiogenic shock or hemodynamic instability or BVS implantations were excluded. Unipolar icECGs were recorded before, during and after stent placement and at the end of procedure in side branch (SB) and main branch (MB). The coronary wire was placed in all distal vessels with diameter &gt;1.5mm, to “map” the distal zones of ischemia. Provisional T-stenting, with proximal balloon optimization (POT) after stent implantation was default strategy. SB was stented in case of non-normalization of icECG ST-segment elevation after kissing-balloon dilatation or flow compromise and severe dissection (&gt;type C) associated with symptoms. All patients were treated with 3rd and higher generation drug-eluting stents. Results 731 patients were included in the analysis recruited from 01.08.2014 to 31.12.208 – 321 (44%) icECG guided. The mean age of patients was 67±10 years, 68% males, 38% smokers, 94% dyslipidemic, 41% diabetics, 26% had previous MI, 47% previous PCI, previous CABG 3%, renal failure 32%, cerebrovascular and peripheral artery disease – 15% and 10%. At median follow-up of 28 months (IQR 18–45 months), 110 patients died (15%): icECG-guided vs. angio guided (18.1% (58/321) vs. 12.7% (52/410), p=0.043, log-rank p=0.045). Side branches were stented in 27%. On univariate analysis significantly associated with mortality were: age, sex, COPD, renal failure, total cholesterol, atrial fibrillation, cerebrovascular disease, ejection fraction (EF), mitral regurgitation &gt;1st degree, SB stenting, kissing balloon inflation, stent length, lesion location (LAD), SYNTAX score. On Cox-regression analysis an independent predictors of survival were: age (HR=1.033, CI: 1.011–1.055, p&lt;0.001), male sex (HR=1.733, CI: 1.056–2.845, p=0.030), COPD (HR=0.586, CI: 0.349–0.985, p=0.044), EF (HR=0.972, CI: 0.953–0.992, p=0.006), MR&gt;1 (HR=1.617, CI: 1.224–2.136, p=0.001), SB stenting (for non-stent implantation HR=0.497, CI: 0.300–0.824, p=0.007). Conclusions Even with modern treatment of coronary bifurcations the demographic factors and parameters of left ventricular function governs the patient survival. The only technical factor associated with survival was implantation of stent in SB, associated with worse survival. Intracoronary ECG guided PCI was not independently associated with survival.

P2513Offer and participation in different European cardiac rehabilitation programs in the elderly after ACS or coronary revascularization. The EU-CaRE study

Abstract Background Cardiac rehabilitation programs (CRP) are strongly recommended after acute coronary syndrome (ACS) or coronary revascularization (PCI or CABG), but actual offer and participation among elderly patients (age ≥65) have not been well characterised. Purpose To analyse current offer and participation rates in different European CRP in elderly patients. Methods Data from elderly patients recruited for CRP, after ACS, PCI or CABG, in centres from seven European countries participating in the EU-CaRE study (NTR5306), were analysed. Results 3471 patients were screened, of whom 80.9% (n=2806) were offered participation and 68.0% of these (n=1908) agreed to participate in a CRP. Outpatient CRP were offered to 73–92% of screened patients. Among reasons for not offering the program were contraindications and geographical conditions. Patients who were not offered were mainly older, with worse cardiovascular risk profile and comorbidities. In the multivariable analysis main variables related with offering in Copenhagen were age (OR=0.92, CI95% 0.87–0.98), gender (male, OR=2.42, CI95% 1.10–5.31) and previous CABG (OR=0.12, CI95% 0.04–0.36). In Bern, age (OR=0.89, CI95% 0.85–0.93), ACS (OR=1.85, CI95% 1.01–3.54) and smoking status (OR=0.47, CI95% 0.24–0.93). In Zwolle, age (OR=0.89, CI95% 0.91–0.97), CABG (OR=4.34, CI95% 1.37-&gt;10), smoking status (OR=0.23, CI95% 0.06–1.11), diabetes mellitus (OR=0.33, CI95% 0.13–0.91) and comorbidities (i.e. obstructive pulmonary disease). In Santiago, age (OR=0.83, CI95% 0.73–0.91), index event PCI (OR=14.21, CI95% 3.68-&gt;10) and rheumatoid arthritis. The ratio of participation among those who were offered the program varied from 46% to 94% (46% to 67% in outpatients' programs). Main reasons for not participating were patients considered that it was not useful (366, 10.5%), travel distance (205, 5.8%), transport difficulties (134, 3.8%) and exercises on own initiative (70, 2.0%). In a center-specific analysis we performed predictive models of participation. In Copenhagen (AUC=0.69) the main variables predicting participation were age (OR=0.99, CI95% 0.96–1.03), not living alone (OR=1.53, CI95% 0.96–2.42), CABG (OR=2.69, CI95% 1.51–4.80) and comorbidities. In Bern (AUC=0.81), age (OR=0.92, CI95% 0.89–0.95), ACS (OR=3.99, CI95% 2.56–6.20) and peripheral artery disease. In Zwolle (AUC=0.71), age (OR=0.94, CI95% 0.91–0.98), employment status (OR=0.28, CI95% 0.13–0.60), CABG (OR=3.62, CI95% 2.28–5.77) and previous ACS (OR=0.58, CI95% 0.35–0.95). In Santiago (AUC=0.85), age (OR=0.95, CI95% 0.90–0.99), rural habitat (OR=0.58, CI95% 0.32–1.04), valvulopathy (OR=0.33, CI95% 0.14–0.79) and the index intervention PCI. Conclusions Knowing reasons (travel distance, usefulness of the program understood by patient) and variables (age, living alone or in rural area) that determine if CRP is offered and whether or not patients participate will help redesign CRP to better adapt to actual needs of an elderly European population. Acknowledgement/Funding This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement number 634439

90Risk-adjusted comparison of in-hospital outcomes of transcatheter and surgical aortic valve replacement

Abstract Background Transcatheter aortic valve replacement (TAVR) is recommended for patients suffering from aortic valve stenosis at increased operative risk or age over 75 years. Beyond that patients with different co-morbidities could profit from TAVR. Purpose The present study analyzes in-hospital outcomes of aortic valve replacement procedures in order to identify subgroups of patients in which TAVR might be preferable. Methods For all 33,789 isolated transfemoral TAVR and SAVR procedures performed in Germany in 2014 and 2015, co-morbidities and in-hospital outcomes were identified by ICD- and OPS-codes. Results Patients undergoing TAVR were older with more co-morbidities and at increased estimated risk (logistic EuroSCORE TAVR: 13.9±10.3%; SAVR: 5.3±4.7%; p&lt;0.001). In order to allow comparison of outcomes after TAVR and SAVR, a covariate and propensity-adjusted analysis was performed in different subgroups. The risk of mortality is significantly lower in patients undergoing TAVR with an age over 80 years (TAVR vs. SAVR 80–84: OR 0.55; p=0.002; ≥85 OR 0.42, p=0.006) and at high operative risk (patients with EuroSCORE &gt;9: OR 0.62, p=0.001). No significant difference in in-hospital mortality occurs between TAVR and SAVR in patients under 80 and intermediate or low risk (&lt;75: OR 0.85; p=0.404; 75–79 OR 0.82, p=0.219; EuroSCORE &lt;4: OR 1.44, p=0.308; EuroSCORE 4–9: OR 0.81, p=0.156). In contrast, patients with advanced renal failure and patients in NYHA-class III/IV had better outcomes after TAVR (GFR&lt;30: OR 0.45, p=0.005; NYHA III/IV: OR 0.72, p=0.015). Female sex, previous CABG, peripheral arterial disease, COPD, pulmonary hypertension, and diabetes were not found to be factors which favor a treatment strategy. Patients undergoing TAVR suffered more often from strokes and acute kidney failure. After risk-adjustment TAVR was associated with a lower risk for acute kidney injuries (OR 0.62, p&lt;0.001). Risk for stroke was similar (OR 1.07, p=0.558). Risk of bleeding (OR 0.17, p&lt;0.001) and requiring prolonged mechanical ventilation (&gt;48h, OR 0.21, p&lt;0.001) was decreased in patients undergoing TAVR. As expected, the TAVR procedure is associated with an increased risk for pacemaker implantations (OR 4.61, p&lt;0.001). Conclusions The present study analyzing over 33.000 real-world procedures confirms that TAVR is the safer procedure in clinical practice for patients with severe aortic valve stenosis at increased operative risk, over 80 years, in NYHA-class III/IV, and with renal failure.

P925Risk adjusted comparison of in-hospital outcomes of transapical transcatheter and surgical aortic valve replacement

Abstract Background Transfemoral transcatheter aortic valve replacement (TF-TAVR) is the standard therapy for patients with severe aortic valve stenosis at high operative risk. If the transfemoral access is not possible, a transapical access is an alternative. However, it is known from randomized trials and large registries that outcomes after transapical TAVR (TA-TAVR) are inferior to TF-TAVR. Purpose We compared in-hospital outcomes of patients undergoing TA-TAVR or SAVR in a nationwide data-set, in order to identify patients' groups, who benefit from SAVR or TA-TAVR. Methods We identified all 13,151 isolated SAVR and 4,625 TA-TAVR performed in Germany 2014 and 2015 on the basis of ICD- and OPS codes. In order to compare outcomes, we adjusted for risk factors using a covariate adjusted analysis. Results Patients undergoing TA-TAVR were older (68 vs. 80 years), had more co-morbidities, and accordingly an increased logistic EuroSCORE (LogES 5.3 vs 16.7%). However, stroke, acute kidney injuries, relevant bleedings, and prolonged mechanical ventilation occurred less frequently in patients undergoing TA-TAVR (OR TA-TAVR vs SAVR: stroke 0.66, p=0.017; acute kidney injury 0.72, p=0.002; relevant bleeding: 0.38, p&lt;0.001; prolonged mechanical ventilation &gt;48h: 0.5, p≤0.001). The risk for a new permanent pacemaker was higher after TA-TAVR (OR 2.44, p≤0.001). Without adjustment in-hospital mortality was higher after TA-TAVR (2.0% vs. 5.9%). After covariate adjustment, the difference disappeared (OR TA-TAVR vs. SAVR 1.2, p=0.136). In order to identify subgroups, which may benefit from TA-TAVR or SAVR, we compared mortality in different subgroups after risk adjustment. Patients under 75 years (OR TA-TAVR vs. SAVR: 1.86, p=0.01) and female (OR 1.48, p=0.043) patients had a lower risk for in-hospital mortality after SAVR. In all other groups (age 75–79, 80–84, &gt;85, log. EuroScore &lt;4, 4–9,&gt;9, NYHA III/IV, previous CABG, COPD, pulmonary hypertension, chronic renal failure, Diabetes) none of both treatment strategies was superior. Conclusion TA-TAVR is with regard to in-hospital mortality not superior to SAVR in clinical practice. Younger patients under 75 years and female patients benefit from SAVR. However, complications such as bleeding, stroke, or prolonged ventilation were less frequently in patients undergoing TA-TAVR.

P3737Predictors, feasibility and outcomes of coronary interventions up to 3 years after TAVI with a balloon-expandable valve. Results from a large European multicenter registry

Abstract Background/Introduction Coronary artery disease (CAD) and aortic stenosis often coexist. Transcatheter aortic valve implantation (TAVI) is emerging as a favorable treatment for younger and lower surgical risk patients. The need for coronary angiography (CA) and percutaneous coronary intervention (PCI) after TAVI will thus increase. Purpose We retrospectively evaluated the outcome of PCI performed after TAVI with the balloon-expandable SAPIEN 3 transcatheter heart valve in the SOURCE 3 European registry. Methods Cardiovascular (CV) mortality was computed at 3 years for patients with PCI and for those without. Univariate and Cox multivariate models were developed to assess the potential impact of PCI on CV mortality. Results Out of 1939 TAVI patients, 44 (2.3%) underwent PCI within 3 years after TAVI (mean interval from TAVI: 428±341 days). Patients with PCI were 80.9 years old and 63.6% were male. They had higher baseline logistic EuroSCORE (22.6% vs. 18.3%, p=0.007), higher rate of prior CAD diagnosis (72.7% vs. 51.0%, p=0.005), prior PCI (45.5% vs. 33.6%, p=0.108) and previous CABG (25.0% vs. 11.0%, p=0.013) than other patients of the cohort. Coronary access (ability to cannulate selectively the coronaries) was feasible in 100% of patients; PCI was successful in all but one case. The univariate model showed that CV mortality was slightly higher in patients undergoing PCI compared with those without PCI (Hazard Ratio: 1.86 [0.96–3.59], p=0.07); CV mortality rate was even lower with the multivariate model (HR: 1.39, p=0.52). Conclusions Interventions of CA and PCI after TAVI with a balloon-expandable valve was feasible and successful in all but one case in this large European registry. There was a trend towards a worse CV mortality at 3 years in patients needing PCI, which did not reach statistical significance likely because of the low incidence of PCI in our TAVI population. Acknowledgement/Funding The SOURCE 3 registry is sponsored by Edwards Lifesciences

P878Prevalence and prognosis of patients with myocardial infarction with nonobstructive coronary arteries: a nationwide registry based study

Abstract Background There are conflicting data about the proportion and prognosis of patients (pts) with acute myocardial infarction (AMI) with nonobstructive coronary arteries (MINOCA). Purpose To define the incidence and prognosis of MINOCA pts in different types of AMI. Methods The Hungarian Myocardial Infarction Registry (HUMIR) is a nationwide, mandatory database in which the clinical and demographic informations of patients with AMI are recorded. Between January 1, 2014 and June 30, 2018, a total of 45,223 AMI (ST-elevation myocardial infarction (STEMI) n=22,469) pts were registered. After excluding pts with previous AMI, PCI, CABG, and congestive heart failure, 2003 MINOCA pts were found (MINOCA group), while 43,220 AMI pts had obstructive coronary artery disease (MI-CAD group). Results The proportion of pts with MINOCA disease was 4.4% among the total pts with AMI. The prevalence was higher in the non ST-elevation myocardial infarction (NSTEMI) group (n=1546, 6.8%) than in the STEMI (n=457, 2.0%) group. The pts with MINOCA disease were slightly younger compared to the pts with MI-CAD (mean age 64.0±14.4 vs. 65.5±12.2 years respectively). The proportion of women was higher in the MINOCA group than in the MI-CAD group (55.7% vs. 36.5%). At discharge, pts with MINOCA disease were less likely to be prescribed certain drugs compared to the pts with MI-CAD. These include aspirin (85.4% vs. 95.6%), RAAS blockers (83.8% vs. 90.4%), statins (86.2% vs. 94.7%), β-blockers (86.8% vs. 89.8%) for the MINOCA and MI-CAD groups respetively. At the 1-year follow-up, the incidence of new AMI events was 1.6% in the MINOCA group compared with 5.0% in the MI-CAD group (HR=2.79). All-cause mortality was higher among the pts with MI-CAD compared to the pts with MINOCA disease. In the MINOCA group, among the pts with NSTEMI, men and women had similar outcomes at 30 days, but men had somewhat higher mortality at one and two years. In contrast, in the STEMI group, women had higher mortality compared to men at all time points during the study (Table 1). Mortality among MINOCA and MI-CAD pts Mortality MINOCA (n=2003) MI-CAD (n=43,220) MINOCA – STEMI MINOCA – NSTEMI Men (n=218) Women (n=239) Men (n=669) Womenr (n=877) 30-day 5.9% [4.9–7.0] 8.4% [8.1–8.7] 8.7% [4.9–12.4] 13.4% [9–17.6] 4.3% [2.8–5.9] 4.4% [3.1–5.8] 1-year 12.5% [11.0–14.0] 15.6% [15.3–16.0] 12.1% [7.6–16.4] 20.3% [15–25.2] 12.2% [9.6–14.7] 10.8% [8.7–12.8] 2-year 16.7% [14.9–18.5] 19.9% [19.5–20.3] 18.2% [12.4–23.6] 23.6% [17.8–29] 16.9% [13.8–20] 14.3% [11.7–16.7] 95% confidence interval in brackets. Conclusion The population-level incidence of MINOCA disease was 4.4% in AMI; the incidence was higher in the NSTEMI group compared to the STEMI group (6.8% vs. 2.0%). Despite the benign anatomy, the long-term prognosis is poor, especially in women after STEMI: 1 out of 4 pts died at the two-year follow up. Acknowledgement/Funding None

Repeat Coronary Bypass Surgery or Percutaneous Coronary Intervention After Previous Surgical Revascularization

ObjectiveTo assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG. MethodsFrom January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used. ResultsIn multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65). ConclusionRCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

Vitamin D levels and platelet reactivity in diabetic patients receiving dual antiplatelet therapy

BackgroundHypovitaminosis D represents an emerging cardiovascular risk factor, and especially among higher-risk subsets of patients, such as in those with diabetes mellitus. The anti-inflammatory and anti-thrombotic properties of vitamin D, in fact, could be even more beneficial among diabetics, where platelet hyperreactivity and suboptimal response to antiplatelet drugs has been associated with poorer outcomes. However, no study has so far evaluated the impact of vitamin D levels on platelet reactivity and high-on treatment platelet reactivity (HRPR) among diabetic patients receiving dial antiplatelet therapy (DAPT). MethodsOur population is represented by a consecutive cohort ofdiabetic patients treated with DAPT (ASA + clopidogrel or ticagrelor or dose-adjusted prasugrel) for an acute coronary syndrome or elective PCI, undergoing platelet reactivity assessment at 30–90 days post-discharge. Aggregation was assessed by multiple-electrode aggregometry. HRPR was defined for values above the lower limit of normality (in non-treated patients). ResultsWe included 440 patients, that were divided according to quartiles values of vitamin D (< 9.4; 9.4–15.59; 15.6–21.64; ≥ 21.65 ng/ml). Among them, 31 were excluded as chronically treated with vitamin D supplementation. Lower vitamin D quartiles were associated with more advanced age (p = 0.01), female gender (p = 0.04), renal failure (p = 0.005), history of previous MI (p = 0.01), CABG and use of diuretics (p = 0.003), severe coronary disease (p = 0.002), but lower ejection fraction (p = 0.001), treatment with statins (p = 0.04) and new ADP-antagonists (p = 0.002). Vitamin D levels related with higher HbA1c (p = 0.001), cholesterol (p = 0.02) and creatinine (p = 0.004) and lower hemoglobin (p = 0.004).The prevalence of HRPR with ASA was low and not related to vitamin D quartiles (3.4% vs 2.7% vs 1.8% vs 2.1%, p = 0.44; adjusted OR[95%CI] = 1.16[0.60–2.26], p = 0.67).The prevalence of HRPR for ADP antagonists was associated to hypovitaminosis D (40.2% vs 29.1% vs 29.4% vs 25.5%, p = 0.03; (adjusted OR[95%CI] = 1.76[1.04–2.98], p = 0.036for I vs II-IV quartile). The impact of vitamin D quartiles, was significant only in patients on new ADP antagonists (n = 225, of whom 81 on prasugrel 5 mg; p = 0.03; adjusted OR[95%CI] = 3.12[1.34–7.49], p = 0.009) but not with clopidogrel (p = 0.85, adjusted OR[95%CI] = 1.05[0.49–2.24], p = 0.89). ConclusionsAmong diabetic patients receiving dual antiplatelet therapy for an acute coronary syndrome or elective percutaneous coronary intervention, severe vitamin D deficiency is associated with a higher ADP-mediated platelet reactivity and rate of HRPR, and especially for new ADP-antagonists over clopidogrel.

Non-specific chest pain and subsequent serious cardiovascular readmissions

BackgroundThe rates of readmission for serious cardiovascular events among patients admitted with a diagnosis of non-specific chest pain are unknown. MethodsA national retrospective cohort study in the United States was undertaken to evaluate the rates, trends and predictors of readmission for serious cardiovascular events (acute coronary syndrome (ACS), pulmonary embolism (PE) and aortic dissection (AD)) after an inpatient episode with a primary diagnosis of non-specific chest pain. ResultsAmong 1,172,430 patients with an index diagnosis of non-specific chest pain between 2010 and 2014, 2.4% were readmitted with an ACS, 0.4% with a PE and 0.06% with an AD within 6 months of discharge. Predictors of ACS readmissions were diabetes (OR 1.49 95% CI 1.17–1.32), coronary artery disease (OR 2.29 95% CI 2.15–2.44), previous percutaneous coronary intervention (OR 1.65 95% CI 1.56–1.75), previous CABG (OR 1.52 95% CI 1.43–1.61) and discharge against medical advice (OR 1.94 95% CI 1.78–2.12). Female patients (OR 0.82 95% CI 0.78–0.86) and patients in whom a coronary angiogram was undertaken (OR 0.48 95% CI 0.45–0.52) were less likely to be readmitted for ACS. For PE, predictors of readmission were pulmonary circulatory disorder (OR 2.20 95% CI 1.09–4.43), anemia (OR 1.62 95% CI 1.40–1.86) and cancer (OR 4.15 95% CI 3.43–5.02). Peripheral vascular disease (OR 8.63 95% CI 5.47–13.60), renal failure (OR 2.08 95% CI 1.34–3.24) were predictors of AD. ConclusionsNon-specific chest pain may not be a benign condition as readmissions for serious cardiovascular events occur in 3% of patients within 180 days. Research is needed to define measures that may mitigate readmissions among these patients.

Abstract 223: Adherence to Warfarin and Oral Anticoagulants: Outcomes of 12 Months Follow-up in Patients With Non-valvular Atrial Fibrillation

Adherence to direct oral anticoagulants (DOACs) or vitamin K antagonists (warfarin) is an essential element of anticoagulation effectiveness and can be related to the outcomes of long-term therapy. Multiple studies have proved that patients with atrial fibrillation (AF) can be effectively treated with oral anticoagulants, achieving reduced morbidity and mortality which is mostly associated with stroke due to thromboembolism. However, despite these DOACs offering some potential advantages over vitamin K antagonists, their usage in the US has been slow to increase, and information on adherence and clinical outcomes based on real-world data is still limited. The goal of this retrospective study was to identify any distinct characteristics of patients with atrial fibrillation who received initial anticoagulation therapy with warfarin versus those who received DOACs. In addition, follow-up for at least the first 12 months of anticoagulation therapy was assessed for adherence to the prescribed anticoagulant or the reasons for change. Methods: This IRB approved study was conducted at Hartford Hospital using data from the Cardiology/Cardiac Arrhythmia clinic database to identify patients with non-valvular atrial fibrillation. Out of more than 4,000 encounters during 2014-2016, 100 patients on anticoagulation therapy with full records of follow-up for at least 12 months were randomly identified (35 on warfarin and 65 on DOACs). Patients’ CHA 2 DS 2 -VASc scores and clinical baseline clinical characteristics were recorded at the onset of anticoagulation treatment. Patients were followed for at least 12 months in order to assess the outcomes and reasons for changes in anticoagulation therapy. Results: The patients initially started on warfarin had a higher mean CHA 2 DS 2 -VASc score (4.54 vs. 3.69) and higher mean age (76.63 vs 72.73 years) than the composite DOACs group. At the time of initial prescription, the warfarin group tended to have a higher percentage of co-morbidities than patients on DOACs, such as previous MI - 17.14% vs 7.69%, previous CVA - 22.85% vs 15.38%, diabetes - 40.0% vs 26.15 %, CAD - 42.85% vs 29.23%, previous CABG - 22.85% vs 9.23%, and CHF - 22.85% vs 16.93 %. The 12 month follow-up showed that 22.9% of the patients on warfarin were switched to a DOAC versus only 6.2% of patients on DOACs being switched to warfarin. The most common reasons for patients on warfarin being switched to DOACs were individual patient preference or difficulties with INR monitoring. DOACs were most commonly changed to warfarin due to cost. Conclusions: Patients placed on warfarin may initially have more severe co-morbidities and higher CHA 2 DS 2 -VASc scores. The change in anticoagulation treatment from warfarin to DOACs may suggest greater patient or provider satisfaction with this new class of anticoagulants, but patient preference and cost are also important factors.