Previous Previous Percutaneous Coronary Intervention Research Articles

Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction.

The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were classified according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Epicardial blood flow was assessed using the TIMI grading system after reperfusion. A total of 935 patients were included; 85.6% were males and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

Sex-based comparisons of clinical characteristics and outcomes of patients with embolic stroke of undetermined source with implantable loop recorders

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Embolic strokes of undetermined source (ESUS) constitute a significant proportion of all ischemic strokes, but sex-based comparisons of clinical characteristics and outcomes of ESUS patients have not been well explored. As such, we aimed to examine how sex influences outcomes of ESUS patients. Methods Retrospective cohort study performed on consecutive ESUS patients with an implanted ILR between December 2013 to September 2021. We obtained information on the patients’ characteristics, treatments, and outcomes from the electronic medical records. Cox regression was used to investigate whether sex was independently associated with outcomes. Results There were 176 patients included in this study. The mean duration of follow-up was 1254 ± 724 days. Mean age was 60.8 ± 12.0 and 47 (26.7%) of patients were female. On univariable Cox regression analysis for subsequent atrial fibrillation (AF) on implantable loop recorder (ILR), patients with subsequent AF on ILR were more likely to be female (HR 2.19, 95% CI 1.04–4.63, p = 0.040), older (HR 1.07, 95% CI 1.03–1.12, p = 0.001), have a lower glomerular filtration rate (eGFR) (HR 0.98, 95% CI 0.97– 0.99, p = 0.004), and have previous percutaneous coronary intervention (PCI) (HR 2.60, 95% CI 1.05–6.46, p = 0.039). On multivariable Cox regression, after adjustment for age, eGFR and previous PCI status, female sex remained independently associated with the development of subsequent AF on ILR. Female sex was not associated with other outcomes including mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure. Conclusions In this cohort of ESUS patients with ILR implantation, female sex was independently associated with a higher risk of development of AF on ILR. However, female sex was not a predictor of mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure.

Severe Coronary Artery Vasospasm after Mitral Valve Replacement in a Diabetic Patient with Previous Stent Implantation: A Case Report.

Postoperative coronary vasospasm is a well-known cause of angina that may lead to myocardial infarction if not treated promptly. We report a case of a 70-year-old female with severe mitral regurgitation submitted to mitral valve replacement, and a history of diabetes mellitus type II, stroke, idiopathic thrombocytopenic purpura on steroid therapy, and previous percutaneous coronary intervention (PCI) for severe obstruction of the circumflex coronary artery, 4 months prior to surgery. Immediately after intensive care unit admission, the patient developed pulseless electrical activity which required extracorporeal membrane oxygenation for hemodynamic support. The coronary angiography showed diffuse occlusive coronary artery vasospasm, ameliorated after intra-coronary administration of nitroglycerin. The following postoperative evolution was marked by cardiogenic shock and multiple organ dysfunction syndrome. Subsequent echocardiographic findings showed an increase in left ventricular function with an EF of 40%, and extracorporeal membrane oxygenation (ECMO) support was weaned after seven days. However, after a few hours, the patient progressively deteriorated, with cardiac arrest and no response to resuscitation maneuvers. Hemodynamic instability following the surgical procedure in a patient with previous PCI associated with an autoimmune disease and diabetes mellitus should raise the suspicion of a coronary artery vasospasm.

The effectiveness of strict low-density lipoprotein cholesterol management in secondary prevention of Japanese patients

Abstract Background In Japanese guidelines, target value of low-density lipoprotein cholesterol (LDL-C) <100mg/dL is recommended as standard management for secondary prevention of coronary artery disease. On the other hand, the guidelines also state that LDL-C targeting <70mg/dL should be considered in high-risk patients. However, the effectiveness of strict LDL-C management in the prevention of long-term coronary event recurrence in Japanese patients remains unclear. Purpose The purpose of the present study was to evaluate whether the strict management of LDL-C targeting <70 mg/dL was effective to prevent recurrence of acute coronary syndrome (ACS) than standard management in patients with previous percutaneous coronary intervention (PCI). Methods From January 2007 to August 2020, we performed coronary angiography in 359 patients with previous PCI who were suspected of having signs of recurrent cardiac ischemia. Patients were stratified into three groups according to achieved LDL-C value; <70mg/dL (n=57), 70 to <100mg/dL (n=135) and ≥100mg/dL (n=167). In addition, patients who had previous ACS and/or diabetes mellitus were defined as high-risk group, and sub-analysis by their achieved LDL-C values was performed in high-risk group and non-high-risk group. Endpoint was recurrence of ACS. Moreover, risk factors associated with recurrent-ACS were examined in patients with LDL-C <100 mg/dL. Results After follow-up (median 6.1 years), 99 patients (28%) had recurrent-ACS. Recurrent-ACS was significantly lower in patients with LDL-C <70mg/dL than LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p<0.01 and p<0.001, respectively). In sub-analysis, high-risk group with LDL-C <70 mg/dL had lower incidence of recurrent-ACS than LDL-C 70 to <100 mg/dL (p=0.03). Similar tendency was found in non-high-risk group (p=0.08). There was no difference of recurrent-ACS between high-risk group and non-high-risk group in patients with LDL-C <70mg/dL (p=0.41). Moreover, in patients with achieved LDL-C <100mg/dL (n=192), multivariate analysis identified that LDL-C (HR: 1.032, p<0.01) and HbA1c (HR: 1.330, p<0.01) were independent predictors of recurrent-ACS. In these patients, whether or not they were in the high-risk group was not a significant predictor (p=0.61). Conclusions Strict management of LDL-C targeting <70 mg/dL should be considered for a wider range of Japanese patients as well as for Westerners to prevent recurrence of ACS in secondary prevention. Funding Acknowledgement Type of funding sources: None. Probability of freedom from ACS

Release Profile of Cardiac Troponin T and Risk Factors of Postoperative Myocardial Injury in Patients Undergoing CABG.

BackgroundCardiac troponin T (cTnT) is currently one of the important indicators for clinical diagnosis of myocardial injury, which is inevitable in cardiac surgery, especially coronary artery bypass grafting (CABG). Describing the release profile of cTnT and finding out the risk factors of postoperative myocardial injury (PMI) are of great significance. The purposes of this study are to explore the release profile of cTnT in patients undergoing CABG and to search for independent risk factors of PMI.MethodsIn this retrospective study, clinical data of CABG patients were collected. The cTnT was measured at 24 hours before and 6, 12, 24, 48, 72, 96 and 120 hours after operation separately. The release profiles and peak time of cTnT in total cohort and sub-cohorts were observed. Independent risk factors of PMI were explored via univariate and multivariate logistic regression analyses.ResultsIn total, 2084 patients were enrolled, including 998 patients in a cTnT group and 1086 patients in a high-sensitive cTnT (hs-cTnT) group. PMI was recognized in 797 patients. In both groups, cTnT showed a trend of rising first and then falling within 120 hours after operation. The peak cTnT appeared within 12–24 hours after operation, while the peak hs-cTnT occurred mostly within 24–48 hours after operation. Univariate logistic analysis showed that body mass index (BMI), New York Heart Association (NYHA) classification, coronary artery disease (CAD) classification, cerebrovascular disease, left ventricular ejection fraction, number of diseased vessels, valvular disease, intra-aortic balloon pump (IABP) implantation, chronic obstructive pulmonary disease, pulmonary hypertension, previous percutaneous coronary intervention (PCI), BMI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT were related risk factors. Multivariate logistic regression analysis showed that NYHA classification, CAD classification, valvular disease, IABP implantation, pulmonary hypertension, previous PCI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT were independent risk factors of PMI.ConclusionNYHA classification, CAD classification, valvular disease, IABP implantation, pulmonary hypertension, previous PCI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT are independent risk factors of PMI in patients undergoing CABG.

Effectiveness of more strict managements after achievement of standard target value of low-density lipoprotein cholesterol in secondary prevention of Japanese patients

Abstract Background In secondary prevention of coronary artery disease, target value of low-density lipoprotein cholesterol (LDL-C) <100 mg/dL is recommended as standard management in Japanese guideline. The guideline also stated that strict management of LDL-C targeting <70 mg/dL is considered in some high risk patients. However, in Japanese patients, effectiveness of more strict management of LDL-C lowering therapy for prevention of long-term cardiovascular events remains unclear. Purpose The purpose of the present study was to evaluate whether the strict management of LDL-C targeting <70 mg/dL was effective to prevent recurrence of long-term coronary events than standard management in patients with previous percutaneous coronary intervention (PCI). Methods We investigated 344 patients with previous PCI who underwent late coronary angiography to examine recurrence of cardiac ischemia beyond the early phase of restenosis from January 2007 to August 2019. Patients were stratified into three groups according to achieved LDL-C value; LDL-C <70mg/dL (n=53), 70 to <100mg/dL (n=130) and ≥100mg/dL (n=161). Endpoints of this study were recurrence of cardiac ischemia presenting as acute coronary syndrome (recurrence-ACS) and any late coronary revascularization. Results During average 7.1 years follow-up, 200 patients (58%) underwent any late coronary revascularization. In 94 of those patients, recurrence-ACS was observed. The incidence of recurrence-ACS was significantly lower in patients with achieved LDL-C <70mg/dL than in those with LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p=0.009 and p=0.001, respectively), however, there was no difference between patients with LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p=0.140). Any late revascularization was significantly lower in patients with achieved LDL-C <70mg/dL and in those with LDL-C 70 to <100mg/dL than in those with LDL-C ≥100mg/dL (p=0.002 and p<0.001, respectively), however, no difference was found between patients with LDL-C <70mg/dL and LDL-C 70 to <100mg/dL (p=0.119). Moreover, in patients with achieved LDL-C <100mg/dL (n=183), multivariate analysis identified that LDL-C (HR 1.035, p=0.007) and HbA1c (HR 1.338, p=0.001) were independent predictors of recurrence-ACS. In contrast, only using statins (HR 0.461, p=0.009) was an independent predictor of recurrence-ACS in patients with achieved LDL-C ≥100mg/dL. Conclusions LDL-C was the important residual risk of recurrence-ACS even after recommended standard LDL-C lowering management had been achieved. More strict management of LDL-C targeting to <70mg/dL should be considered to prevent recurrence-ACS for wider range of Japanese patients in secondary prevention. Incidence of late coronary events Funding Acknowledgement Type of funding source: None

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI): a phase 3, placebo-controlled, randomised trial

Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8-3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74-0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, pinteraction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78-1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75-1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48-2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36-3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74-1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75-0·95, p=0·005, in contrast to patients without PCI where it did not, pinteraction=0·012. Benefit was present irrespective of time from most recent PCI. In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk. AstraZeneca.

The Predictors of Target Lesion Revascularization and Rate of In-Stent Restenosis in the Second-Generation Drug-Eluting Stent Era.

Objectives The aim of our study was to investigate the predictors of target lesion revascularization (TLR) and to compare the in-stent restenosis (ISR) progression rates of different 2nd-generation drug-eluting stents (DES). Background The predictors of early and late TLR after 2nd-generation DES implantation have not been fully evaluated. Methods We analyzed 944 stented lesions from 394 patients who had at least two serial follow-up angiograms, using quantitative coronary angiography (QCA) analysis. The study endpoints were TLR and the velocity of diameter stenosis (DS) progression. Results TLR occurred in 58 lesions (6.1%) during the first angiographic follow-up period and 23 de novo lesions (2.4%) during the following second interval. Independent predictors for early TLR were diabetes mellitus (DM) (HR 2.58, 95% CI 1.29–5.15, p=0.007), previous percutaneous coronary intervention (PCI) (HR 2.41, 95% CI 1.03–5.65, p=0.043), and postprocedure DS% (HR 1.08, 95% CI 1.05–1.11, p<0.001, per 1%), while predictors of late TLR were previous PCI (HR 9.43, 95% CI 2.58-34.52, p=0.001) and serum C-reactive protein (CRP) (HR 1.60, 95% CI 1.28-2.00, p<0.001). The ISR progression velocity (by DS%) was 12.1 ±21.0%/year and 3.7 ±10.1%/year during the first and second follow-up periods, respectively, which had no significant difference (p>0.05) between the four types of DESs. Conclusions Our data showed that predictors for TLR may be different at different time intervals. DM, pervious PCI, and postprocedure DS could predict early TLR, while previous PCI and CRP level could predict late TLR. Contemporary DESs had similar rates of ISR progression rates. Trial Registration This study was retrospectively registered and approved by the institutional review board of Seoul National University Hospital (no. 1801–138-918).

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

BackgroundThe perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). MethodsOccurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. ResultsA total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. ConclusionsOBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI.

Previous Percutaneous Coronary Intervention Does Not Increase Adverse Events After Coronary Artery Bypass Surgery

Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous PCI on early outcomes after subsequent CABG by using data from the Japanese national database. This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n= 12,457, 25.9%) were compared with those in patients with no PCI (n= 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis. Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P= 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p= 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.82 to 1.22; p=0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p= 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results. This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure.

Factors Associated with Early Adverse Events after Coronary Artery Bypass Grafting Subsequent to Percutaneous Coronary Intervention.

BackgroundA previous percutaneous coronary intervention (PCI) may affect the outcomes of patients who undergo coronary artery bypass grafting (CABG). The objective of this study was to compare the early in-hospital postoperative outcomes between patients who underwent CABG with or without previous PCI.MethodsThe present study included 160 patients who underwent isolated elective on-pump CABG at the department of cardiothoracic surgery, Minia University Hospital from January 2010 to December 2014. Patients who previously underwent PCI (n=38) were compared to patients who did not (n=122). Preoperative, operative, and early in-hospital postoperative data were analyzed. The end points of the study were in-hospital mortality and postoperative major adverse events.ResultsNon-significant differences were found between the study groups regarding preoperative demographic data, risk factors, left ventricular ejection fraction, New York Heart Association class, EuroSCORE, the presence of left main disease, reoperation for bleeding, postoperative acute myocardial infarction, a neurological deficit, need for renal dialysis, hospital stay, and in-hospital mortality. The average time from PCI to CABG was 13.9±5.4 years. The previous PCI group exhibited a significantly larger proportion of patients who experienced in-hospital major adverse events (15.8% vs. 2.5%, p=0.002). On multivariate analysis, only previous PCI was found to be a significant predictor of major adverse events (odds ratio, 0.16; 95% confidence interval, 0.03 to 0.71; p=0.01).ConclusionPrevious PCI was found to have a significant effect on the incidence of early major adverse events after CABG. Further large-scale and long-term studies are recommended.

Influence of previous percutaneous coronary intervention on clinical outcome of coronary artery bypass grafting: a meta-analysis of comparative studies†.

The prognostic significance of previous percutaneous coronary intervention (PCI) in patients undergoing coronary artery bypass grafting (CABG) is still unclear. Although many studies have reported adverse effects of previous PCI on postoperative mortality in CABG, as yet no meta-analysis has been carried out. We conducted this first meta-analysis to assess whether previous PCI increases postoperative mortality in CABG. MEDLINE and EMBASE were searched for relevant articles up to and including April 2014. Studies published in English satisfying the following criteria were included in the meta-analysis: (i) comparing CABG patients with previous PCI versus without previous PCI; and (ii) reporting hospital mortality. Our search identified 23 comparative studies, including 174 777 patients: 19 179 with previous PCI and 155 598 without previous PCI. Pooled analysis demonstrated that previous PCI had an adverse effect on hospital mortality: odds ratio (OR) 1.187, 95% confidence interval (CI) 1.075-1.312. Furthermore, subgroup analysis stratified by the proportion of multiple previous PCI (i.e. number of patients with multiple previous PCI/number of patients with single or multiple previous PCI) was performed. In the subgroup of studies with the proportion <40%, the adverse effect was not significant: OR 0.897 (95% CI 0.723-1.113); however, in the subgroup of studies with the proportion ≥ 40%, the adverse effect of previous PCI was significant: OR 1.987 (95% CI 1.563-2.526). A meta-regression coefficient was significantly positive for the proportion of patients with a history of multiple PCI (coefficient 0.841; 95% CI 0.457-1.226; P < 0.001). This meta-analysis would argue that as the proportion of patients with multiple previous PCI in the CABG cohort increases, postoperative mortality also increases. This result re-emphasizes the importance of the heart team approach to coronary revascularization.

Predictors of Readmission after Inpatient Plastic Surgery

BackgroundUnderstanding risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following inpatient plastic surgery.MethodsThe 2011 National Surgical Quality Improvement Program dataset was reviewed for patients with both "Plastics" as their recorded surgical specialty and inpatient status. Readmission was tracked through the "Unplanned Readmission" variable. Patient characteristics and outcomes were compared using chi-squared analysis and Student's t-tests for categorical and continuous variables, respectively. Multivariate regression analysis was used for identifying predictors of readmission.ResultsA total of 3,671 inpatient plastic surgery patients were included. The unplanned readmission rate was 7.11%. Multivariate regression analysis revealed a history of chronic obstructive pulmonary disease (COPD) (odds ratio [OR], 2.01; confidence interval [CI], 1.12-3.60; P=0.020), previous percutaneous coronary intervention (PCI) (OR, 2.69; CI, 1.21-5.97; P=0.015), hypertension requiring medication (OR, 1.65; CI, 1.22-2.24; P<0.001), bleeding disorders (OR, 1.70; CI, 1.01-2.87; P=0.046), American Society of Anesthesiologists (ASA) class 3 or 4 (OR, 1.57; CI, 1.15-2.15; P=0.004), and obesity (body mass index ≥30) (OR, 1.43; CI, 1.09-1.88, P=0.011) to be significant predictors of readmission.ConclusionsInpatient plastic surgery has an associated 7.11% unplanned readmission rate. History of COPD, previous PCI, hypertension, ASA class 3 or 4, bleeding disorders, and obesity all proved to be significant risk factors for readmission. These findings will help to benchmark inpatient readmission rates and manage patient and hospital system expectations.

Improvement of doppler derived coronary flow reserve in asymptomatic patients with previous percutaneous coronary intervention on left anterior descending coronary artery: effects of ranolazine

Background: Ranolazine reduces the Na-dependent calcium overload via inhibition of the late sodium current, improving diastolic tone and oxygen handling. In patients with previous percutaneous coronary intervention (PCI), microvascular coronary dysfunction can be still present. Transthoracic Doppler-derived coronary flow reserve (CFR) is an index of coronary arterial reactivity and decreases under the condition with microvascular dysfunction as well as coronary artery stenosis. The aim of this study was to assess the effect of ranolazine on CFR in this patient group. Methods: 48 asymptomatic patients (33 M, 15 F; mean age 66±11 years) with previous PCI on left anterior descending coronary artery (LAD) and no other significant coronary stenosis, was enrolled in the study. Within six weeks after PCI, they underwent baseline CFR assessment. Then they were randomly assigned to placebo or Ranolazine for 12 weeks (up-titrated from 350 to 750 mg twice, with increases every 4 weeks). CFR assessment was performed again at the end of treatment period. Coronary flow was assessed in the left anterior descending coronary artery (LAD), and was identified as the color signal directed from the base to the apex of the left ventricle, containing the characteristic biphasic pulsed-Doppler flow signals. CFR were determined as the ratio of hyperemic, induced by intravenous dypiridamole administration, to baseline diastolic coronary flow velocity. Results: There were no significant differences in baseline characteristics between Ranolazine and placebo group. CFR was successfully performed in all patients. Baseline CFR was not significantly different in Ranolazine and placebo group (2.23±0.59 vs. 2.19±0.55 - p = ns). After 12 weeks CFR significantly increased in Ranolazine group (2.65±0.64 vs. 2.23±0.59 - p < 0.01) but not in placebo group (2.24±0.58 vs. 2.19±0.55 - p = ns). No patient dropped out during 12 weeks therapy. Side effects were sinilar in both groups. Conclusions: In asymptomatic patients with previous PCI on LAD coronary artery Ranolazine is able to improve CFR. This is probably due to improvement in microvascular coronary dysfunction. Larger studies will be able to confirm these data.

Invited Commentary

There is accumulating evidence that coronary artery bypass grafting (CABG) after previous percutaneous coronary intervention (PCI) is associated with higher early mortality and major adverse cardiac event (MACE) rates. Several possible explanations are addressed. Dysfunctional and denuded coronary endothelia after PCI initiate an inflammatory response with accumulation of platelets and neutrophils, resulting in microvascular thrombotic obstruction and distal microembolization. Coronary side branch obstruction resulting from stenting may lead to compromised collateral blood flow and focal infarctions. In addition, late structural changes may affect both the stented area and coronary artery territory distal to the stent, which would be the target area of a subsequent bypass graft anastomosis. The coronary artery distal to the stent may have inadequate runoff, and a bypass graft will have decreased patency. Preoperative use of antiplatelet medication such as clopidogrel may cause excess postoperative bleeding, and perioperative discontinuation of antiplatelet medication may cause in-stent thrombosis and adversely influence the results. The CABG patients with previous PCI may have an increased risk of repeated coronary revascularization during follow-up, because the rate of restenosis remains high even in the era of drug-eluting stents. As a result, impaired long-term outcome and decreased quality of life in the CABG patients with previous PCI also are anticipated. Mannacio and colleagues [1Mannacio V. Di Tommaso L. de Amicis V. et al.Previous percutaneous coronary interventions increase mortality and morbidity after coronary surgery.Ann Thorac Surg. 2012; 93: 1956-1963Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] provide early and late clinical outcomes after CABG in patients with previous PCI, compared with outcomes in CABG patients without previous PCI. History of PCI is identified as a risk factor for hospital mortality and MACEs among patients undergoing CABG. The authors also demonstrate that previous PCI is a risk factor for decreased survival at 5-year follow-up. The authors enrolled a large patient cohort (n = 7,855) and performed propensity-score matching with excellent discriminating power (c-statistic of 0.94). However, further data analysis is needed to draw a conclusion that previous PCI affects midterm outcomes after later CABG. Reevaluation, including late occurrence of cardiac death, nonfatal myocardial infarction, and reintervention-free survival, will strengthen the authors' hypothesis. In addition, operative strategy data, such as use of the left internal thoracic artery and saphenous vein grafts and completeness of revascularization, are lacking. Moreover, their survival curve is questionable. The authors indicate that hospital mortalities, which must be included, are not included in their analysis. Both survival curves of the two groups, however, start below 1.0, indicating that hospital mortalities are included in their survival analysis. Survival differences at 5-year follow-up appear to be due to the high hospital mortality in the PCI group patients, rather than late occurrence of events during follow-up. Despite several limitations in this article, I agree with the authors' conclusion and suggestion that all previous PCIs should be treated as a risk factor for subsequent CABG. Although the authors′ findings are not new, I hope this study will strengthen the current evidence for the harmful effects of previous PCI on our CABG patients. Previous Percutaneous Coronary Interventions Increase Mortality and Morbidity After Coronary SurgeryThe Annals of Thoracic SurgeryVol. 93Issue 6PreviewThis multicenter study investigated the impact of previous percutaneous coronary interventions (PCI) on postoperative outcome and 5-year survival of subsequent coronary artery bypass grafting. Full-Text PDF

Previous percutaneous coronary intervention increases morbidity after coronary artery bypass grafting

We hypothesized that the incidence of previous percutaneous coronary intervention (PCI) is increasing and that prior PCI influences patient morbidity and mortality after coronary artery bypass grafting (CABG). A total of 34,316 patients underwent isolated CABG operations at 16 different statewide, institutions from 2001 to 2008. Patients were stratified into prior PCI (n = 4346; 12.7%) and no prior PCI (n = 29,970). Patient risk factors, intraoperative variables, and outcomes were compared by univariate and multivariate analyses. The incidence of prior PCI in CABG has risen from <1% to 22.0% from 2001 to 2008 (P<.001). Prior PCI patients were younger (P < .001) and more commonly had previous myocardial infarction (P < .001), but less commonly had heart failure (P < .001). The operative mortality was similar between groups (2.3% vs 1.9%; P = .13). Prior PCI patients had more major complications (15.0% vs 12.0%; P < .001), longer hospitalization (P = .01), and higher readmission rates (P=.01). Importantly, by multivariate analyses, prior PCI was not associated with mortality, but was an independent predictor of major complications after CABG (odds ratio, 1.15; P = .01). The incidence of prior PCI in patients undergoing CABG is increasing. Previous PCI is associated with a higher risk of major complications, greater hospital length of stay, and higher readmission rates after CABG.

Changing Pattern of Reoperative Coronary Artery Bypass Grafting: A 20-Year Study

Fewer patients are undergoing reoperative coronary artery bypass grafting (CABG). We investigated the prevalence of redo vs primary CABG and previous percutaneous coronary intervention (PCI), changing trends in preoperative risk profiles, and independent predictors of operative death. Data on demographic characteristics, preoperative risk factors, and hospital outcomes were collected prospectively for patients undergoing isolated reoperative CABG from January 1, 1990, to December 31, 2009. To examine the effect of time on the prevalence of redo CABG cases and previous PCI, we divided patients into four groups: 1990 through 1994, 470; 1995 through 1999, 415; 2000 through 2004, 240; and 2005 through 2009, 79. To examine risk profiles and outcomes, we created two groups: 1990 through 1999, 885; 2000 through 2009, 319. Redo CABG decreased from 7.2% (1990 through 1994) to 2.2% (2005 through 2009). PCI before redo CABG significantly increased from 14.5% (1990 through 1994) to 26.6% (2005 through 2009). Patients with diabetes, dyslipidemia, hypertension, peripheral vascular disease, and left main disease increased. In-hospital mortality did not change significantly, but postoperative low cardiac output syndrome dropped. Age (odds ratio [OR], 1.04), peripheral vascular disease (OR, 2), congestive heart failure (OR, 5.8), and preoperative shock (OR. 9.7) independently predicted higher operative mortality. Reoperative CABG has significantly decreased. The increased prevalence of PCI before redo CABG is one of the reasons. Despite an increasing risk profile, hospital outcomes have remained largely the same. Preoperative shock and congestive heart failure are the most important predictors of operative mortality.

Does Prior Percutaneous Coronary Intervention Adversely Affect Early and Mid-Term Survival After Coronary Artery Surgery?

To determine the association between previous percutaneous coronary intervention (PCI) and results after coronary artery bypass graft surgery (CABG). Increasing numbers of patients undergoing CABG have previously undergone PCI. We analyzed consecutive first-time isolated CABG procedures within the Australasian Society of Cardiac and Thoracic Surgeons Database from June 2001 to May 2008. Logistic regression and propensity score analyses were used to assess the risk-adjusted impact of prior PCI on in-hospital mortality and major adverse cardiac events. Cox regression model was used to assess the effect of prior PCI on mid-term survival. Of 13,184 patients who underwent CABG, 11,727 had no prior PCI and 1,457 had prior PCI. Mean follow-up was 3.3 +/- 2.1 years. Patients without prior PCI had a higher EuroSCORE value (4.4 +/- 3.3 vs. 3.6 +/- 3.0, p < 0.001), were older, and more likely to have left main stem stenosis and recent myocardial infarction. There was no difference in unadjusted in-hospital mortality (1.65% vs. 1.55%, p = 0.78) or major adverse cardiac events (3.0% vs. 3.0%, p = 0.99) between patients with or without prior PCI. After adjustment, prior PCI was not a predictor of in-hospital (odds ratio: 1.22, 95% confidence interval [CI]: 0.76 to 2.0, p = 0.41) or mid-term mortality at 6-year follow-up (hazard ratio: 0.94, 95% CI: 0.75 to 1.18, p = 0.62). In this large registry study, prior PCI was not associated with increased short- or mid-term mortality after CABG. Good outcomes can be obtained in the group of patients undergoing CABG who have had previous PCI.

Plasma homocysteine level is unrelated to long-term cardiovascular events in patients with previous percutaneous coronary intervention

It is unclear whether plasma homocysteine (Hcy) level affects long-term outcomes in patients with previous percutaneous coronary intervention (PCI). Accordingly, we investigated the association of plasma Hcy level with long-term major adverse cardiovascular events (MACEs), especially with recurrence of angina pectoris (AP) or new myocardial infarction (MI) in patients with previous PCI. A total of 231 patients with previous (>12 months) PCI were followed up for a median period of 49 months. The primary end point was recurrence of AP or new MI. The secondary end points were MACEs (cardiovascular death, recurrence of AP, new MI, revascularization therapy, hospitalization for heart failure, or stroke). During the follow-up period, 35 patients (15.2%) had a primary end point, and 58 (25.1%) had a secondary end point. A univariate analysis by a Cox proportional hazards regression model showed that plasma Hcy level was not associated with the primary (hazard ratio [HR] 1.13, 95% confidence interval [CI] 0.41-3.08, p=0.82) and secondary (HR 1.60, 95% CI 0.75-3.42, p=0.23) end points. The adjustment for other clinical variables did not alter the results. Plasma Hcy level appears to be unrelated to recurrent AP, new MI, and long-term MACE within coronary artery disease patients with previous PCI.

Comparison of Effectiveness of Atorvastatin 10 mg Versus 80 mg in Reducing Major Cardiovascular Events and Repeat Revascularization in Patients With Previous Percutaneous Coronary Intervention (Post Hoc Analysis of the Treating to New Targets [TNT] Study)

The Treating to New Targets (TNT) study demonstrated that intensive atorvastatin therapy to achieve low-density lipoprotein cholesterol concentrations well below recommended target levels provides an incremental clinical benefit in patients with stable coronary artery disease. This post hoc analysis of the TNT study was conducted to investigate whether this benefit extends to patients with previous percutaneous coronary intervention (PCI). A total of 10,001 patients with clinically evident coronary artery disease, including 5,407 patients with previous PCI, were randomized to atorvastatin 10 or 80 mg/day and followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event. Revascularization, a component of a secondary end point, was also examined. In patients with previous PCI, mean low-density lipoprotein cholesterol levels at study end were 79.5 mg/dl in the 80-mg arm and 100.8 mg/dl in the 10-mg arm. First major cardiovascular events occurred in 230 patients (8.6%) receiving high-dose atorvastatin and 289 patients (10.6%) receiving low-dose atorvastatin (hazard ratio 0.79, 95% confidence interval 0.67 to 0.94, p = 0.008). Repeat revascularization during follow-up (PCI or coronary artery bypass grafting) was performed in 466 patients (17.3%) in the 80-mg arm and 624 patients (22.9%) in the 10-mg arm (hazard ratio 0.73, 95% confidence interval 0.65 to 0.82, p <0.0001). In conclusion, intensive lipid lowering to a mean low-density lipoprotein cholesterol level of 79.5 mg/dl (2.1 mmol/L) with atorvastatin 80 mg/day in patients with previous PCI reduces major cardiovascular events by 21% and repeat revascularizations by 27% compared with a less intensive lipid-lowering regimen.