Previous Revascularization Research Articles

Outcomes of Endovascular-First Vascular Surgery Bypass-First Approach for Patients With Chronic Limb-Threatening Ischemia Using a Medicare-Linked Database

Chronic limb-threatening ischemia (CLTI) has been increasing in prevalence and remains a significant cause of limb loss and disability and a strong predictor of cardiovascular mortality. Previous studies have demonstrated that endovascular and open repair are similarly effective. These findings led to a significant increase in the adoption of the less-invasive endovascular-first approach. However, it remains unknown whether the two treatment modalities have similar durability in today’s real-world setting. The aim of the present study was to compare the mid-term outcomes of the endovascular-first and bypass-first strategies in patients with CLTI. We identified all patients who had undergone limb revascularization from January 2010 to December 2016 in the Vascular Quality Initiative–Medicare-linked database. Patients with a history of previous revascularization and those who had undergone hybrid or suprainguinal procedures were excluded from the present study. The remaining patients were divided into two groups: endovascular-first (EVF) or bypass-first (BF). The main endpoints were 2-year limb salvage, freedom from reintervention, amputation-free survival (AFS), and freedom from all-cause mortality (ACM). The EVF approach was applied to 12,062 patients (70%) and the BF approach to 5166 patients (30%). The median follow-up was 32 months (interquartile range, 14-48 months). Patients in the EVF group were older and had more comorbidities and tissue loss. At 2 years, the BF group had achieved greater rates of limb salvage (86.4% vs 82.1%; P < .001), freedom from reintervention (72% vs 68%; P < .001), AFS (66.9% vs 56.3%; P < .001), and freedom from ACM (75.7% vs 66.1%; P < .001; Fig). After adjusting for potential confounders, an effect of the treatment strategy on limb salvage (adjusted hazard ratio [aHR], 1.05; 95% confidence interval [CI], 0.96-1.16; P = .25), reintervention (aHR, 0.92; 95% CI, 0.84-1.003; P = .06), AFS (aHR, 0.96; 95% CI, 0.91-1.015; P = .16), and ACM (aHR, 0.94; 95% CI, 0.89-1.004; P = .06) was not observed (Table). The present study is the largest real-word analysis showing the noninferiority of the EVF approach in patients with CLTI, with similar limb salvage, durability, AFS, and ACM compared with the BF approach. However, level 1 evidence on the role of the revascularization strategy in these challenging patients is needed.TableMain outcomes stratified by treatment strategy2-Year outcomeEVF (n = 12,062; 70%)BF (n = 5166; 30%)P valueaHR (95% CI)P valueAmputation-free survival, %56.3066.87<.0010.96 (0.91-1.015).16Limb salvage, %82.1086.40<.0011.05 (0.96-1.16).25Freedom from reintervention, %68.0072.00<.0010.92 (0.840-1.003).06Freedom from all-cause mortality, %75.7066.10<.0010.94 (0.89-1.004).06aHR, Adjusted hazard ratio; BF, bypass first; CI, confidence interval; EVF, endovascular first. Open table in a new tab

Prognostic Value of Quantitative Metrics From Positron Emission Tomography in Ischemic Heart Failure

The aim of this study was to investigate the prognostic and clinical value of quantitative positron emission tomographic (PET) metrics in patients with ischemic heart failure. Although myocardial flow reserve (MFR) is a strong predictor of cardiac risk in patients without heart failure, it is unknown whether quantitative PET metrics improve risk stratification in patients with ischemic heart failure. The study included 254 patients referred for stress and rest myocardial perfusion imaging and viability testing using PET. Major adverse cardiac event(s) (MACE) consisted of death, resuscitated sudden cardiac death, heart transplantation, acute coronary syndrome, hospitalization for heart failure, and late revascularization. MACE occurred in 170 patients (67%) during a median follow-up of 3.3 years. In a multivariate Cox proportional hazards model including multiple quantitative PET metrics, only MFR predicted MACE significantly (p=0.013). Beyond age, symptom severity, diabetes mellitus, previous myocardial infarction or revascularization, 3-vessel disease, renal insufficiency, ejection fraction, as well as presence and burden of ischemia, scar, and hibernating myocardium, MFR was strongly associated with MACE (adjusted hazard ratio per increase in MFR by 1: 0.63; 95% confidence interval: 0.45 to 0.91). Incorporation of MFR into a risk assessment model incrementally improved the prediction of MACE (likelihood ratio chi-square test [16]=48.61 vs. chi-square test [15]=39.20; p=0.002). In this retrospective analysis of a single-center cohort, quantitative PET metrics of myocardial blood flow all improved risk stratification in patients with ischemic heart failure. However, in a hypothesis-generating analysis, MFR appears modestly superior to the other metrics as a prognostic index.

Epidemiological Variation of Acute Myocardial Infarction Relevant to In-Hospital Outcomes-Tertiary Center Experience-Saudi Arabia.

BackgroundEpidemiological related differences in patients presenting with ST-elevation myocardial infarction (STEMI) have not yet been fully characterized in the Middle East countries. The aim of this study was to assess gender, ethnic and racial variation in clinical profiles, presentation and treatment strategies with relation to the in-hospital outcomes.MethodThis is a retrospective, single center study reviewing the epidemiological details of STEMI patients who were admitted to our center during the period between October 2015 and August 2019.ResultOut of 3079 patients presented with STEMI, 498 (16%) were women, 2170 (70%) were from Middle Eastern Countries and only 1200 (39%) were non- Arabic speakers. Women were older in age compared to men (60.04 ± 11.2 vs 55.35 ± 11.8; P < 0.001). They showed significantly higher rates of cardiovascular risk factors (P < 0.001 for diabetes mellitus (DM), hypertension (HTN) and obesity) and lower prevalence of smoking and old history of previous revascularization (P < 0.001 and 0.007, respectively). Middle Eastern Countries- STEMI patients were elderly, showed higher prevalence of DM, HTN, smoking and obesity compared to South Asian patients (p = 0.001, 0.057, <0.001, <0.001 respectively). Arabic speaking - STEMI patients showed more prevalence of DM, smoking and obesity compared to non-Arabic speaking patients (p < 0.001). Regarding STEMI localization, post myocardial infarction complications and in-hospital length of stay, there were no detected significant gender, ethnic or racial variation. Women showed higher rates of all in-hospital mortality compared to men (5% vs 3%; p = 0.027) however, no ethnic/racial mortality difference was recorded among STEMI patients. Being elderly, presence of multivessel coronary artery disease and left ventricular systolic dysfunction (LVEF < 30%) are the three independent predictors of mortality among our patients (p = 0.013, 0.048 and <0.0001 respectively).ConclusionOur study demonstrates that there are gender, ethnic/racial-related differences in the demographics and clustered cardiovascular risk factors. However, there were no significant detected variation between both genders and different ethnic groups regarding post MI complications, management provided, and hospital outcomes except for increased the mortality rates among women. Old age, presence of multi-vessel disease and severe left ventricular systolic dysfunction have the greatest effect on in-hospital mortality among STEMI patients.

Low Rate of Invasive Coronary Angiography Following Transcatheter Aortic Valve Implantation: Real-World Prospective Cohort Findings

To evaluate the real need for coronary access after transcatheter aortic valve implantation (TAVI). Prospective observational single-center registry, including 563 consecutive patients who underwent TAVI between April 2008 and November 2018, with both self- and balloon-expandable valves in a tertiary European center. Mean age was 82.4 ± 6.9 years, 53.3% were female, 16% had previous history of coronary artery bypass grafting, 33% of previous percutaneous coronary intervention (PCI), and 16.6% of myocardial infarction (MI). Twenty-four percent of the patients were revascularized within one year before TAVI in preparation for the procedure. Median Society of Thoracic Surgeons score was 4.82 (IQ 2.84). In a median follow-up of 24 months (IQ 21.5), 18 patients (3.2%) were identified as potentially in need for invasive coronary angiography: 9 (1.6%) in the setting of stable coronary artery disease and 9 (1.6%) for an acute coronary syndrome. A total of 11 PCIs were performed in 9 patients, with a complete success rate of 63.6%. Procedures that were unsuccessful or partially unsuccessful were due to the inability to cross the stent or the drug-eluting balloon through the valve struts or misplacement within the coronary artery due to lack of catheter support. In this population, a strategy of previous guideline-directed revascularization before TAVI was associated with a low rate of MI and repeated need of coronary access, with a scattered distribution over time. Assuring future access to coronary arteries in patients at increased risk may depend on the revascularization strategy rather than device selection.

Natural History After Below-knee Amputation: Analysis of Survival and Prosthetic Fitting Over 2 Decades

Abstract Introduction This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. Methods Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996–2005 and 2006–2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. Results 133 BKA were performed from 1996 to 2005 and 106 from 2006 to 2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. Conclusions In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival was not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.

Initial experience of a MitraClip valve repair program in Spain.

BackgroundThe main objective of this study was to evaluate one-year clinical outcome of patients with symptomatic mitral regurgitation (MR) treated with transcatheter mitral valve repair (TMVR) according to the etiology of MR.MethodsData from a single high-volume center of all consecutive cases with symptomatic MR undergoing TMVR where prospectively included and followed.ResultsBetween October 2015 and October 2019, 81 consecutive patients underwent TMVR and were included in the investigation. The mean age was 75.73±7.81 years, 55 (67.9%) were male. The most frequent mechanism was functional MR (FMR) (59%). The mean EuroSCORE II was 5.7±4.94 [FMR 5.38±3.9, degenerative MR (DMR) 5.72±4.7 and mixed MR (MMR) 6.6±7.5; P=0.7776] and STS score mean was 5.21±3.31 (FMR 4.6±2.3, DMR 6.43±5.2 and MMR 5.7±3.2; P=0.126). Patients with FMR had higher rates of dilated (36 patients, 75.5%) and ischemic (15 patients, 31.3%) cardiomyopathy, as well as worse left ventricular ejection fraction (LVEF). Procedural success was achieved in 72 (88.9%) patients, with a similar distribution between groups. The median of follow-up was 16.3 months. The primary combined endpoint occurred in 19 (23.5%) cases. The number of the combined event regarding the different etiologies were 15 (31.2%) in FMR, 2 (11.8%) in DMR and 5 (31.3%) in MMR (P=0.276). Sixteen patients (20.0%) died during the first year of follow-up and 19 (23.5%) had unplanned heart failure (HF) hospitalization. Previous surgical revascularization (HR =4.94, P=0.004) and a redo TMVR (HR =11.3, P=0.006) predicted the main event.ConclusionsTMVR with the Mitraclip device is safe, with a low incidence of complications and a high rate of procedural success. One-year outcomes show reduction of all cause death and HF admissions. Moreover, most of the patients have sustained MR reduction and an improvement in the functional class at the end of follow-up.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Role of global longitudinal strain diastolic index in assessment of patients with suspected obstructive coronary artery disease and normal or mildly reduced ejection fraction

Objective – To examine the utility of global longitudinal strain imaging diastolic index (SI-DI) in the assessment of patients with suspected obstructive coronary artery disease (CAD). Methods – We performed rest 2D standard echocardiography and strain imaging in 30 healthy subjects and in 148 patients with normal or mildly reduced ejection fraction and indication for coronarography for suspected obstructive CAD. Standard echocardiographic and strain parameters were analysed. Results – Global SI-DI was signifi cantly lower in the selected vs control group (p &lt;0.001). After coronarography patients were divided in three subgroups: 74 patients with more than 50% obstruction in any major artery, 26 patients with previous revascularisation but no significant obstructive lesions at present and 48 patients without obstructive artery disease. Average global SI-DI was significantly lower in the subgroup with obstructive CAD vs the other two subgroups (p&lt;0.05). Global SI-DI lower than 0.5 had a good sensitivity (84%) and a reasonable positive predictive value (52%) for detection of obstructive CAD. Conclusions – Global SI-DI is significantly lower in patients with obstructive CAD and normal or mildly reduced ejection fraction compared with normal subjects. A cut off value lower than 0.5 selects patients with a higher probability of obstructive CAD.

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015

The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR). The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis. From a total of 211 included patients, those submitted to EVAR were older (74±7 vs. 67±9years; P<0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P=0.004), obesity (28.7% vs. 14.3%, P=0.029), previous cardiac revascularization (30.5% vs. 14.7%, P=0.005), heart failure (17.2% vs. 5.2%, P=0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P=0.002). Patients were followed during a median of 49months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P<0.001), lower 30-day complications (10.6% vs. 22.8%, P=0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P=0.024), the proportion of complications decreased (P=0.014), and the 30-day mortality (P=0.035). Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

Septal Myectomy in patients with previous coronary revascularization - hypertrophic cardiomyopathy masquerading as ischemic heart disease

Patients with obstructive hypertrophic cardiomyopathy (HCM) may have symptoms mimicking ischemic heart disease, including chest pain and shortness of breath. Some patients undergo coronary revascularization which may not lead to symptomatic improvement. This study assesses clinical presentations and outcomes of patients with previous coronary revascularization undergoing septal myectomy. From 08/1996 to 07/2017, 166 adult patients with obstructive HCM underwent septal myectomy at our Clinic with a history of percutaneous coronary intervention (PCI, N=153) or coronary artery bypass grafting (CABG, N=13). We assessed their functional status before and after coronary intervention and outcomes following myectomy. The median (IQR) age was 65 (59-71) years, and 106 (64%) were male. Among 150 patients whose extent of disease was known, single vessel disease was identified in 109 (73%) who had PCI and 1 (9%) who had CABG. Following revascularization, many (59%) reported no improvement in shortness of breath from preoperative status. Myectomy was performed at a median of 3.2 (1.0-6.3) years following coronary revascularization, and 40 (25%) required myectomy within 1year. Patients whose shortness of breath persisted after PCI/CABG (N=90) underwent myectomy earlier than those whose symptoms initially improved (N=63) after coronary revascularization (1.4 [0.6-4.0] years vs. 5.1 [2.8-9.5] years, p<.001). Almost 25% of patient's required septal myectomy within 1year of coronary intervention for continued symptoms originally thought to be due to ischemic heart disease. These findings highlight the overlap of obstruction and ischemic symptoms and the importance of complete evaluation for dynamic obstruction in HCM.

Risk Prediction Tool for Assessing the Probability of Death or Myocardial Infarction in Patients With Stable Coronary Artery Disease

Several risk scores in acute coronary syndromes are available, but few models exist for stable coronary artery disease to guide decision-making and prognosis. A multivariate model was developed using 23 baseline candidate variables from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Therapy EvaluationTrial (n = 2,287 patients). Discrimination of the model was evaluated by the concordance c-index. The procedure was validated using 100 random half samples. We identified 9 independent predictors of death or myocardial infarction (MI) during a 5-year follow-up. The following predictors and points contributing to the risk score were: heart failure (3), number of diseased coronary arteries (1 for each vessel), diabetes (1), age (1 for each 15 years ≥ age 45), previous revascularization (1), current smoking (1), female (1), previous MI (1), and high-density lipoprotein cholesterol (1: 31 to 40 mg/dL; 2: <30 mg/dL). The risk tool had a potential range from 0 to 15, corresponding to 5-year event rates of 5.8% to 56%. C-indices ranged from 0.67 for the full data set to 0.62 for the validating subsamples. Respective observed versus predicted 5-year event rates for 3 predefined risk strata revealed: 30% had a low-risk score of 0 to 3 (9.3% vs 9.3%, or 1.9%/year); 59% had an intermediate-risk score of 4-6 (18.0% vs 18.1%, or 3.6%/year); and 11% had a high-risk score of 7-11 (36% vs 36.5%, or 7.2%/year). This stable coronary artery disease risk score permitted a prognostic assessment of 5-year probability of death or MI with an approximate 4-fold range in event rates from the lowest (9.3%) to the highest (36%) terciles, thus enabling better clinical practice decisions that allow physicians to tailor the intensity of treatment to the level of risk.

1520-P: Developing New Risk Equations to Predict Diabetes-Related Complications and Mortality in U.S. Adults with Type 2 Diabetes

Risk equations to predict diabetes-related complications and mortality in most type 2 diabetes simulation models were based on data from the UK Prospective Diabetes Study. Two recently completed U.S. diabetes trials, the Action to Control Cardiovascular Risk in Diabetes and the Action for Health in Diabetes and their follow-up studies with &amp;gt;15,000 participants and &amp;gt;7 years follow-up, provide a unique source for developing new risk equations. We estimated parametric hazard models for cardiovascular, neuropathy, nephropathy, vision, and hypoglycemia complications and mortality in persons with type 2 diabetes using longitudinal data from the trials. We included demographic variables, time-varying risk factors, and histories of complications. Variable selection was based on backwards stepwise regression and expert opinion. We estimated 17 complication and 3 mortality equations. HbA1c was selected in all but one complication/mortality equation, with hazard ratios ranging from 1.09 for stage 3 chronic kidney disease to 1.85 for amputation per 1% increase. Other risk factors were selected less frequently. For mortality, smoking was the risk factor with the largest hazard ratio. At least one lagged complication was selected for every complication/mortality equation. Previous congestive heart failure was associated with increased risk for 13 complications, with hazard ratios as high as 2.6 for amputation. Other lagged complications selected for over half of the complications included microalbuminuria, previous revascularization, macroalbuminuria, and previous stroke. Congestive heart failure, myocardial infarction, and stroke increased mortality in persons with current or previous cardiovascular disease. Kidney-related complications also increased mortality. Our equations can be used in type 2 diabetes simulation models to estimate costs, outcomes, and cost-effectiveness of interventions for type 2 diabetes, particularly in U.S.-based models. Disclosure T.J. Hoerger: Research Support; Self; Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services. M. Kaufmann: None. S. Neuwahl: None. H. Shao: None. H. Chen: None. M. Laxy: None. Y.J. Cheng: None. S.R. Benoit: None. A.M. Anderson: None. T. Craven: None. P. Zhang: None. Funding Centers for Disease Control and Prevention (200-2016-92270)

Coronary revascularization after surgical aortic valve replacement.

ObjectiveIt remains unclear how often coronary revascularization is necessary after aortic valve interventions, either by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement. However, these data are relevant for treatment and prosthesis choice. The authors sought to analyze the incidence and characteristics of coronary revascularization after SAVR during follow-up.MethodsOf 2256 patients undergoing isolated SAVR between 1987 and 2015, 420 patients (mean age 56.9 ± 15.5 years, 66.9% male) were followed at the Erasmus Medical Center. Incidence, predictors, and characteristics of coronary revascularization were analyzed. Cumulative incidence of revascularization was assessed using a competing risk approach.ResultsMean follow-up after SAVR was 17.2 years (total of 4541 patient-years). A total of 24 patients underwent 28 procedures of revascularization. The cumulative incidence of revascularization after SAVR was 0.5%, 2.2%, 4.1%, and 6.9% at 1, 5, 10, and 20 years, respectively. The linearized rate of revascularization was 6.2 per 1000 patient-years. Percutaneous coronary intervention was the most common revascularization method (64%; N = 18/28). Revascularization before SAVR (N = 36/420; of whom 27 percutaneous coronary intervention) was an independent predictor of revascularization during follow-up (hazard ratio, 6.6; 95% confidence interval, 2.6-17.1; P < .001).ConclusionsAfter SAVR, the rate of coronary revascularization was 6.9% (N = 24/420) at 20-year follow-up. Patients were at particular risk if they had undergone previous revascularization before SAVR. These data may furthermore be relevant to the transcatheter aortic valve replacement population.

Intra-Arterial Administration of Iloprost in Patients Undergoing Endovascular or Hybrid Revascularization Procedures for Peripheral Arterial Disease

The aim of this study was to find out if intra-arterial intraoperative iloprost administration, in selected patients undergoing endovascular revascularization procedures, could lead to better results compared with a control group of patients with similar clinical background and risk factors. We prospectively collected data of consecutive patients undergoing endovascular or hybrid revascularization in the period from June 2017 to August 2019, which were then retrospectively analyzed. Those patients were divided into 2 groups: iloprost and control groups. Inclusion criteria were as follows: the presence of an arteriography that included the foot; Rutherford class 4-6; and Rutherford class 3 with at least 2 cardiovascular risk factors or previous revascularization procedures on the same limb. The intraoperative intra-arterial administration of iloprost was the inclusion criterion for the iloprost group. Patients with a compromised cardiological condition were excluded, as this was a contraindication for iloprost administration. Patients from the 2 groups were matched using the propensity score matching (PSM) methodology of Rosenbaum and Rubin. The primary outcome was freedom from target lesion revascularization (TLR). The secondary outcomes were limb salvage and overall survival. During the mentioned period, we treated 190 consecutive limbs. The mean follow-up was 11.73months (median, 10; interquartile range, 5-19). After PSM, the freedom from TLR was significantly better in the iloprost group (78±7%, 74±8%, and 63±9% vs. 67±8%, 50±9%, and 38±10% at 3, 6, and 12months, respectively; P=0.043). No significant difference was found in terms of limb salvage (92±5%, 88±6%, and 88±6% vs. 92±4%, 85±6%, and 81±7% at 3, 6, and 12months, respectively; P=0.52) and survival (95±3%, 95±3%, and 95±3% vs. 95±4%, 92±5%, and 71±9% at 3, 6, and 12months, respectively; P=0.14) between the 2 groups. These results seem to encourage considering intraoperative use of this adjunct, at least in endovascular revascularization procedures, to improve distal outflow.

Treatment of Carotid Restenosis Using Transcarotid Revascularization.

Transcarotid artery revascularization (TCAR) using the ENROUTE Neuroprotection System (Silk Road Medical) is a United States Food and Drug Administration-approved treatment modality for stroke risk reduction in the setting of carotid artery stenosis. The goal of this investigation was to define the real-world outcomes associated with the application of this technique to patients presenting with restenosis after previous carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TF-CAS). Retrospective review of prospectively maintained institutional databases capturing all nontrial TCARs performed between August 2013 and July 2018 using the ENROUTE Neuroprotection System was completed at 3 unaffiliated hospital systems and unified for descriptive outcomes analysis. During the study period, 237 combined TCARs were performed at our respective institutions. Of these procedures, 55 stents were implanted for the indication of restenosis after previous carotid revascularization (47 CEA, 8 TF-CAS). Within the 30-day perioperative period, we observed no ipsilateral strokes or deaths; one patient experienced perioperative myocardial infarction (MI; 1.8%). We noted a 4.8% incidence of postoperative hematoma, but none of these events were clinically significant as no reinterventions were performed in any of the 55 patients. Additionally, we did not observe any cases of stent thrombosis or pulmonary embolus. Mean length of stay was 2.2 ± 2.8 days. Our mean follow-up duration was 15.0 ± 9.2 months. Throughout the follow-up period, we did not observe any additional stroke or MI events. Additionally, there were no cases of in-stent restenosis, thrombosis, or reinterventions. Transcarotid artery revascularization can be performed in patients with restenotic carotid arteries with acceptable rates of ipsilateral stroke, MI, and death as demonstrated in this small multi-institutional series.

Abstract 258: Mortality Comparison of Right Bundle Branch Block and Left Bundle Branch Block in US Veterans Undergoing Left Heart Catheterization - A Long Term Follow-up Study

Background: The prognostic importance of right bundle branch block (RBBB) has been debated. It has been described as a benign variant, especially when compared to left bundle branch block (LBBB). We studied the presence of bundle branch blocks in a high-risk U.S. Veteran cohort. Methods: Retrospective electrocardiogram (ECG) analysis for presence of RBBB or LBBB was conducted in 1,535 consecutive patients presenting for left heart catheterization. Evaluated risk factors were gender, age, BMI, hypertension, hyperlipidemia, diabetes, smoking history, chronic kidney disease, reduced ejection fraction and history of previous revascularization. Mean follow up time was 112 ± 66 months. Results: Analysis of 1,535 ECGs revealed 113 patients with RBBB and 65 patients with LBBB. Risk factor burden between the two groups appeared similar with exception of higher incidence of reduced ejection fraction and previous revascularization in the LBBB group. Mortality of RBBB group was 92.0% compared to 96.9% of LBBB group. Mean time to death for RBBB group was 74.1 months compared to 61.0 months for LBBB group. Hazard ratio (HR) for RBBB with Cox regression controlling for aforementioned risk factors was 1.41, 95% CI = 1.14-1.74; p =.002. HR for LBBB controlling for the same risk factors was 1.84, 95% CI = 1.42-2.40; p =&lt;.001. Conclusion: In a high-risk cohort of US Veterans, both LBBB and RBBB are independent risk factors for mortality. While LBBB is a known adverse risk factor, presence of RBBB portends a poor prognosis and warrants further research.

A real-life correlation between clinical SYNTAX score II and carotid intima-media thickness in patients with stable coronary artery disease.

BackgroundSYNTAX score II (SSII) is an update of the established SYNTAX score (SS) that uses clinical variables such as age, sex, creatinine clearance, left ventricular ejection fraction, chronic obstructive pulmonary disease, and peripheral arterial disease. Furthermore, SSII has been proven to be a more powerful predictive tool than SS in patients with complex coronary artery disease (CAD). Carotid õntima-media thickness (CIMT) is a widely used noninvasive evidence for subclinical or early atherosclerosis, and it was proved to be an independent predictor for cardiovascular events. Most of the previously published articles studied the association between the CIMT with old cardiovascular scoring systems such as SSI and Gensini score with debatable data about their correlation.AimTo study the correlation between SSII and CIMT in stable CAD patients undergoing elective coronary angiography (CA).Method and patientsA prospective study including 155 patients undergoing elective CA for stable CAD excluding patients with history of acute coronary syndrome, previous coronary revascularization either by percutaneous coronary intervention or coronary artery bypass grafting, and previous cerebrovascular stroke.ResultsThe mean age of patients was 58.25 ± 16.46 years, and 79 patients (50.96%) were men. The mean SSII score was 10.23 ± 11.36 and mean CIMT was 0.85 ± 0.24. The correlation between SSII and CIMT using Spearman correlation showed a strong correlation between SSII score and CIMT with correlation coefficient r = 0.752.ConclusionThe study showed a strong positive correlation between SSII and CIMT in stable CAD patients undergoing elective CA.

Prognostic significance of previous myocardial infarction and previous revascularization in patients undergoing SPECT MPI

Accurate risk stratification in patients with known coronary artery disease (CAD) is critical for patient management. Prior myocardial infarction (MI) or revascularization without MI are often equated as known CAD. We compared the prognostic significance of prior MI and previous revascularization in patients undergoing single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Consecutive patients undergoing SPECT MPI at Cedars-Sinai Medical Center between 1992 and 2012 were included. Medical history, including history of MI or revascularization, was collected prospectively. Association with all-cause mortality was assessed with multivariable Cox analysis, adjusted for patient demographics, medical history, medications, and SPECT MPI results. In total, 50,121 patients were identified including 7428 (14.8%) with a history of previous MI and 3608 (7.2%) with a history of revascularization without prior MI. During a median follow-up of 8.0 years, 19,696 (39.3%) patients died including 4467 (60.1%) with a history of MI and 1880 (52.1%) with a history of revascularization. Prior MI (adjusted HR 1.12, p=0.001) and prior revascularization without MI (adjusted HR 1.15, p<0.001) were independently associated with increased all-cause mortality. Previous MI (adjusted HR 1.27, p<0.001) and previous revascularization without MI (adjusted HR 1.21, p<0.001) were significantly associated with increased all-cause mortality only in patients without ischemia. In this large cohort of patients undergoing SPECT MPI, previous MI and previous revascularization without MI were independent predictors of all-cause mortality, with no significant difference in associated risk. History of CAD may be particularly important for risk stratification in patients without ischemia.

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Profile and treatment of chronic coronary syndromes in European Society of Cardiology member countries: The ESC EORP CICD-LT registry.

International guidelines recommend pharmacotherapy combinations for chronic coronary syndromes (CCSs) but medical management remains suboptimal. The CICD-LT registry is investigating short- and long-term outcomes and management in patients in European Society of Cardiology (ESC) member countries, in a longitudinal ESC EURObservational Research Programme aimed at improving CCS management. Between 1 May 2015 and 31 July 2018, 9174 patients with previous ST-elevation myocardial infarction (STEMI), non-STEMI or coronary revascularisation, or other CCS, were recruited during a routine ambulatory visit or elective revascularisation procedure. Baseline clinical data were recorded and prescribed medications analysed at initial contact and discharge, and according to patient gender and age (<75 vs. ≥75 years). Poorly controlled cardiovascular risk factors, including current smoking (18.5%), obesity (33.9%), diabetes (25.8%), raised low-density lipoprotein cholesterol (73.3%) and persistent hypertension (24.7%), were common across all cohorts. At ambulatory visit or admission, the guidelines-recommended combination of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aspirin, statin and any antiplatelet agent was prescribed to 57.8% of patients with STEMI/NSTEMI. Differences in prescribing rates, including for combination therapies, were observed based on age and gender and persisted after adjustment for demographic factors. Cardiovascular risk factors were common in contemporary CCS patients and secondary prevention prescribing was suboptimal. Patients aged ≥75 years and, to some extent, female patients were less likely to receive guidelines-recommended drug combinations than younger and male patients. One- and two-year follow-up will study prescribing changes and associations between baseline characteristics/prescribing and subsequent clinical outcomes.