Primary Revascularization Strategy Research Articles

Clinical outcomes in acute coronary syndrome after presentation of unique electrocardiographic findings

BackgroundUnique electrocardiographic findings are rarely observed in acute coronary syndrome (ACS) with a culprit left anterior coronary artery (LAD). The aim of this study was to assess the epidemiological features and prognostic impact. MethodsThis study was designed as an observational study. A total of 641 patients with a culprit lesion in the left main trunk or LAD were extracted from a cohort of 1776 ACS patients. The primary endpoint was mortality, comparing patients presenting with unique electrocardiogram patterns, specifically the de Winter pattern or Wellens' syndrome (type A or B), upon hospital arrival, with those presenting common electrocardiogram patterns. ResultsA unique electrocardiogram was observed in 7.0% (n = 45; 2 with de Winter pattern, 14 with Wellens' type A and 29 with type B). Compared to patients with a common pattern, cardiogenic shock at hospital arrival were rare in patients with a unique pattern (0% vs. 8.4%, P = 0.04), and percutaneous coronary intervention was primary revascularization strategy in all groups (95.6% vs. 98.2%). The mortality rates were similar between the two groups over a median 565 days of observation period (13.3% vs. 15.7%, P = 0.43), with 0% in Wellens' type A, 13.8% in type B, and both patients with the de Winter pattern died. ConclusionThe de Winter pattern or the Wellens syndrome was found in 7.0% of cases with ACS. They had similar mortality rates compared to those with a common pattern, although the de Winter pattern was identified in only 2 patients.

Vascular effects and benefits through Helical stent implantation vs. conventional stenting: Methodology and initial Results of The MIMICS FLOW investigator-initiated randomized controlled trial

Abstract Aims Endovascular treatment is the primary revascularization strategy for symptomatic peripheral artery disease (PAD), which not only restores tissue perfusion but also affects local lower limb arterial endothelial function. Endothelial dysfunction is the pathophysiologic principle involved in the progression of atherosclerosis and is a prognostically relevant cardiovascular biomarker. A helical stent with a unique 3D helical geometry promotes laminar swirling blood flow elevating wall sheer stress, providing superior hemodynamic advantages and excellent clinical performance as compared to conventional stenting. The potential impact on endothelial homeostasis and the detailed mechanisms following a biomimetic or conventional stent are unknown. To this aim we now determined the effect of the Biomimics or a conventional stent on endothelial and vascular function in symptomatic PAD. Methods The MIMICS-FLOW is an investigator-initiated single-blind, randomized controlled trial (NCT05447052). The influence of novel stent-platforms with improved hemodynamic capabilities with respect to vasomotion of the vessel wall, vascular function and vascular compliance was measured by flow-mediated dilation (FMD) and arterial stiffness indices. Vascular function was determined in 70 PAD patients, Rutherford 2, 3 and 4 randomized to a helical stent and the conventional straight nitinol stent before and after lower limb intervention with a one-month follow-up in the nonstenotic segment of the proximal SFA. Perfusion indices, TLR rate and primary patency were assessed. Results The methodology and initial results regarding endothelial function after 1 month will be presented at ESC. In brief, 70 Patients aged 67 years were 1:1 randomized to each group prior to stent implantation in the SFA. Rutherford and PACSS class and target lesion locations were balanced between groups. One patient in the helical and 2 patients in the Straight group required a reintervention. A higher improvement in SFA FMD was observed in the helical group as compared to conventional stenting (p<0.05). Importantly, this effect was mirrored also by a greater increase in brachial FMD in the helical vs. conventional group (p<0.05). No impact was observed between groups regarding arterial or aortic stiffness. Conclusions Our RCT data provide evidence for an improved vascular function through swirling flow with superior hemodynamics following a helical stent implantation. These findings support the concept for a better mechanistic understanding to enhance endovascular treatment strategies in PAD.

Differences in Comorbidities Explain Black-White Disparities in Outcomes After Femoropopliteal Endovascular Intervention.

Black adults have a higher incidence of peripheral artery disease and limb amputations than White adults in the United States. Given that peripheral endovascular intervention (PVI) is now the primary revascularization strategy for peripheral artery disease, it is important to understand whether racial differences exist in PVI incidence and outcomes. Data from fee-for-service Medicare beneficiaries ≥66 years of age from 2016 to 2018 were evaluated to determine age- and sex-standardized population-level incidences of femoropopliteal PVI among Black and White adults over the 3-year study period. Patients' first inpatient or outpatient PVIs were identified through claims codes. Age- and sex-standardized risks of the composite outcome of death and major amputation within 1 year of PVI were examined by race. Black adults underwent 928 PVIs per 100 000 Black beneficiaries compared with 530 PVIs per 100 000 White beneficiaries (risk ratio, 1.75 [95% CI, 1.73-1.77]; P<0.01). Black adults who underwent PVI were younger (mean age, 74.5 years versus 76.4 years; P<0.01), were more likely to be female (52.8% versus 42.7%; P<0.01), and had a higher burden of diabetes (70.6% versus 56.0%; P<0.01), chronic kidney disease (67.5% versus 56.6%; P<0.01), and heart failure (47.4% versus 41.7%; P<0.01) than White adults. When analyzed by indication for revascularization, Black adults were more likely to undergo PVI for chronic limb-threatening ischemia than White adults (13 023 per 21 352 [61.0%] versus 59 956 per 120 049 [49.9%]; P<0.01). There was a strong association between Black race and the composite outcome at 1 year (odds ratio, 1.21 [95% CI, 1.16-1.25]). This association persisted after adjustment for socioeconomic status (odds ratio, 1.08 [95% CI, 1.03-1.13]) but was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92-1.01]). Among fee-for-service Medicare beneficiaries, Black adults had substantially higher population-level PVI incidence and were significantly more likely to experience adverse events after PVI than White adults. The association between Black race and adverse outcomes appears to be driven by a higher burden of comorbidities. This analysis emphasizes the critical need for early identification and aggressive management of peripheral artery disease risk factors and comorbidities to reduce Black-White disparities in the development and progression of peripheral artery disease and the risk of adverse events after PVI.

Coronary Artery Revascularization in Heart Transplant Patients: A Systematic Review and Meta-Analysis

Background: Cardiac allograft vasculopathy (CAV) is the primary cause of late mortality after heart transplantation. We look to provide a comprehensive review of contemporary revascularization strategies in CAV. Methods: PubMed and Web of Science were systematically searched by 3 authors. 1,870 articles were initially screened and 24 were included in this review. Results: PCI is the main revascularization technique utilized in CAV. The pooled estimates for restenosis significantly favored DES over BMS (OR 4.26; 95% CI: 2.54–7.13; p < 0.00001; I2 = 4%). There were insufficient data to quantitatively compare mortality following DES versus BMS. There was no difference in short-term mortality between CABG and PCI. In-hospital mortality was 0.0% for CABG and ranged from 0.0 to 8.34% for PCI. One-year mortality was 8.0% for CABG and 5.0–25.0% for PCI. CABG had a potential advantage at 5 years. Five-year mortality was 17.0% for CABG and ranged from 14 to 40.4% following PCI. Select measures of postoperative morbidity trended toward superior outcomes for CABG. Conclusion: In CAV, PCI is the primary revascularization strategy utilized, with DES exhibiting superiority to BMS regarding postoperative morbidity. Further investigation into outcomes following CABG in CAV is required to conclusively elucidate the superior management strategy in CAV.

The impact of percutaneous peripheral interventions on endothelial function.

Background: Treatment of symptomatic peripheral artery disease (PAD) through endovascular interventions is the primary revascularization strategy. Interventions restore perfusion but may cause severe injury to the vascular endothelium, which regulates vascular tone. Endothelial dysfunction is involved in the progression of cardiovascular disease, with higher incidences of vascular events. We aimed to determine the impact of percutaneous interventions on change in endothelial function. Patients and methods: Endothelial function was determined using flow-mediated dilation (FMD) before, the day after lower limb intervention with paclitaxel-coated balloons or stent guided interventions and after a six-month follow-up in the target limb, control limb and the systemic circulation in 42 PAD patients aged 70.2±9 years and 66% men. Additionally, macro- and microvascular function were assessed. Results: In PAD patients aged 70.2±9 years and 66% men, we observed an immediate enhancement of macro-, microvascular and endothelial function after endovascular treatment (FMD of superficial femoral artery (SFA) 3.7±0.2% to 4.1±0.1%, n=42, p=0.02), a sustained long-term improvement after 6-months (FMD SFA 3.7±0.2% to 4.2±0.1%, n=42, p=0.01), and moreover an improved systemic endothelial function (FMD brachial artery 4.3±0.1% to 4.7±0.2, n=42, p=0.01) following peripheral interventions. Subgroup analysis however revealed that following paclitaxel-based percutaneous intervention, the paclitaxel dosage applied was inversely related to the chronic improvement in local endothelial function (r=-0.6, n=22, p=0.005) without evidence for systemic effects (r=-0.25, p=0.27). Conclusions: We demonstrate an improved local and systemic endothelial function after treatment of atherosclerotic peripheral disease with a distinguished response after endovascular intervention with higher dosage of applied paclitaxel restraining the benefits. Further studies have to determine the optimal interventional strategy with respect to different treatment modalities to maintain vessel functions.

Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

BackgroundThe presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA. ObjectivesThe purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry. MethodsAll patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes. ResultsAmong 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p < 0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p < 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64). ConclusionsCCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.

Abstract 13163: Clinical Impact of Contralateral Carotid Occlusion During Carotid Intervention in Contemporary Practice: An Analysis of the National Cardiovascular Data Registry Peripheral Vascular Intervention Registry

Introduction: Contralateral carotid occlusion (CCO) is an established high-risk feature for carotid endarterectomy (CEA) and is a reason to recommend carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA. We investigated the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry. Hypothesis: CCO confers an elevated risk of in-hospital adverse events among patients undergoing CEA, but not CAS. Methods: All patients undergoing CEA or CAS from 2005-2019 in the NCDR CARE and PVI registries were included. The primary exposure was the presence of a CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Analyses were stratified by treatment with CEA or CAS. Multivariable logistic regression models were used to identify factors associated with adverse outcomes. Results: Among 58,423 patients, 4,624 (7.9%) patients had a CCO. Of those, 68.9% (N=3,185) underwent CAS and 31.1% (N=1,439) underwent CEA. The average age of patients with CCO was 69.5±9.7, 32.6% were female, 92.8% were Caucasian, 51.7% had a prior TIA or stroke, and 45.4% had symptomatic disease. Over the study period, there was a 4.3% decline in procedures performed on patients with CCO (p &lt;0.001), but CAS remained the primary revascularization strategy (7.8% CAS vs 3.5% CEA in 2019Q2). Unadjusted rates of the composite outcome were lower after CAS (3.2%) than after CEA (3.9%). Following adjustment, CCO was associated with a 60% increase in odds of an adverse outcome after CEA (95%CI 1.2-2.12, p=0.0013) (Figure). There was no increase in risk for patients treated with CAS (adjusted OR 0.99, 95%CI 0.79-1.22, p=0.89). Conclusions: In this contemporary nationwide registry analysis, CCO remains an important predictor of increased risk in patients undergoing CEA, but not CAS. These data support the continued use of CCO to guide carotid revascularization strategy.

Trends in Utilization and Safety of In-Hospital Coronary Artery Bypass Grafting During a Non-ST-Segment Elevation Myocardial Infarction

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.

One-year limb outcome and mortality in patients undergoing revascularization therapy for acute limb ischemia: short-term results of the Edo registry.

The present study aimed to clarify the current status, therapeutic strategy, and 1-year outcome in acute limb ischemia (ALI) patients in Japan. The EnDOvascular treatment (Edo) registry database includes 324 patients from 10 institutes who were registered between November 2011 and October 2013. A total of 70 ALI patients (mean age 74.0years) from the Edo registry database were enrolled in this study. Of the 70 included patients, 72.9% were male and 35.7% had embolism. Of patients, 38.6%, 42.9%, and 18.6% underwent EVT, surgery, and hybrid thrombectomy, respectively, in primary revascularization strategy. Limb ischemia was categorized into four classes at initial evaluation: SVS/ISCVS class I (n = 13, 18.6%), SVS/ISCVS class IIa (n = 36, 51.4%), SVS/ISCVS class IIb (n = 21, 30%), and SVS/ISCVS class III (n = 0, 0%). Three patients with SVS/ISCVS class IIb limb ischemia developed myonephropathic metabolic syndrome. No catheter-directed thrombolysis was employed as a primary revascularization strategy. The 1-year rates of all-cause death, major amputation, and a composite of perioperative death or major adverse limb event were 28.6%, 5.7%, and 40.0%, respectively. Lower age, male sex, dyslipidemia, high estimated glomerular filtration rate, high albumin level, and low C-reactive protein level were independent positive predictors of all-cause death. In this registry, SVS/ISCVS class IIa ALI was predominant. Approximately 40% of primary revascularization strategy was surgery and EVT, followed by hybrid therapy. All-cause death and major amputation rates at 1 year were less than 30% and 6%, respectively.

Unplanned 30-Day Readmission after Coronary Artery Bypass in Patients with Acute Myocardial Infarction

Background/purposeThe Centers for Medicare and Medicaid services penalizes hospitals with higher than expected readmissions for coronary artery bypass graft surgery (CABG). Little information exists regarding outcomes in patients who sustain an acute myocardial infarction (MI) and undergo CABG as the primary revascularization strategy. Our goal was to determine the unplanned 30-day readmission rate in this high-risk population and predictors of readmission. Materials/methodsAn institutional database was queried to identify patients from 2011 to 2017 who were admitted with an acute MI and underwent CABG within 30 days. Chart review was performed to collect demographics, medical comorbidities and clinical information related to hospital course and readmission status. ResultsA total of 150 patients were included. The 30-day unplanned readmission rate was 23%, and the majority (80%) were non-cardiac related. Predictors of unplanned readmission included female sex (OR 2.61, 95% CI 1.042–6.549, p = 0.041), CABG performed <7 days following MI (OR 2.82, 95% CI 1.21–6.59, p = 0.017), and post-operative atrial fibrillation (OR 3.25, 95% CI 1.07–9.87, p = 0.038). Complications were identified in 32% of clinic visits in patients who did not require readmission. ConclusionsPatients who undergo CABG following MI are a high-risk population with nearly one-quarter readmitted within 30 days. Female sex, <7 days between the index MI and CABG, and post-operative atrial fibrillation are strong predictors for readmission. Early outpatient follow-up may be an effective intervention to reduce hospital readmissions by reassuring patients that non-cardiac symptoms are in line with anticipated post-operative pain and healing.

Focus on STENTYS® Xposition S Self-Apposing® stent: a review of available literature.

Percutaneous coronary interventions are the primary revascularization strategy for the vast majority of patients with coronary artery disease. Nevertheless, challenging settings still limit optimal results, especially in case of significant tapering, bifurcations or primary angioplasty in ST-segment elevation myocardial infarction. Stentys® Self-Apposing® stent was designed to improve strut apposition to the vessel wall and to adapt to difficult targets. The Xposition S is a sirolimus-eluting stent with a novel delivery system, to improve accurate positioning. Several studies compared the device with traditional balloon-expandable stents, showing better results in terms of malapposition reduction and a noninferiority in relation to procedural outcomes. Available data show good clinical results, but a direct comparison with balloon-expandable stents from large randomized trials is still lacking. Thus, the Stentys Xposition S can be an alternative to traditional stents in dedicated scenarios, but strong evidence from large randomized trials is needed to derive stronger recommendations.

An Endovascular-First Approach to the Treatment of Critical Limb Ischemia Results in Superior Limb Salvage Rates

Purpose: To evaluate the effect of a shift to a primary endovascular revascularization (ER) strategy for patients presenting with critical limb ischemia (CLI) after a change in staff at our center in 2008 altered our revascularization strategy. Methods: Between 2004 and 2012, 344 critically ischemic limbs were treated in 279 patients (mean age 74.0±11.4 years; 179 men) during 546 separate hospital admissions. Limbs were analyzed according to (1) their principal revascularization strategy and (2) their date of presentation [early (2004–2008) or late (2008–2012)]. Results: Compared with the open revascularization (OR) and no revascularization (NR) groups, the ER group had an increased freedom from major amputation (92.3% vs 80.0% OR vs 69.3% NR, p<0.001), reduced hospital stay (15.2 vs OR 31.6 vs NR 25.9 days, p<0.001), intensive care unit (ICU) stay (2.3 vs OR 23.7 vs NR 7.2 hours, p=0.033), and operating time for ER vs OR (157.9 vs 316.8 minutes, respectively; p<0.0001). There was also a significant decrease in limbs requiring minor amputations (23.2% vs OR 29.3% vs NR 37.6%, p=0.041) and mean number of admissions/limb compared to OR (1.5 vs OR 1.9 vs NR 1.5, p=0.007). The late era saw the treatment of a larger number of limbs (223 vs 121) compared with the earlier time period. This institutional shift resulted in increased freedom from major amputation (87.4% vs 74.4%, p<0.01), reduced ICU stay (3.45 vs 16.98 hours, p<0.01), and shorter length of stay (20.9 vs 31.5 days, p<0.01) between the 2 eras, respectively. Conclusion: A shift to an endovascular-first treatment strategy is associated with fewer major amputations and shorter length of stay.

SCAI expert consensus statement for renal artery stenting appropriate use.

The pathophysiology of atherosclerotic renal artery stenosis (RAS) includes activation of the renin-angiotensin-aldosterone axis with resultant renovascular hypertension. Renal artery stenting has emerged as the primary revascularization strategy in most patients with hemodynamically significant atherosclerotic RAS. Despite the frequency with which hemodynamically significant RAS is observed and high rates of technical success of renal artery stenting, there remains considerable debate among experts regarding the role of medical therapy versus revascularization for renovascular hypertension. Modern, prospective, multicenter registries continue to demonstrate improvement in systolic and diastolic blood pressure with excellent safety profiles in patients with RAS. Modern randomized, controlled clinical trials of optimal medical therapy versus renal stenting particularly designed to demonstrate preservation in renal function after renal artery stenting have demonstrated limited benefit. However, these trials frequently excluded patients that may benefit from renal artery stenting. This document was developed to guide physicians in the modern practical application of renal stenting, to highlight the current limitations in the peer-reviewed literature, to suggest best-practices in the performance of renal stenting and to identify opportunities to advance the field.

Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: the impact of early coronary revascularization

Methods This retrospective study included 35 consecutive patients rescued by ECMO for AMI -induced cardiopulmonary collapse in a single institution between June 2003 and December 2011. Coronary revascularization was performed soon after ECMO initiation. Percutaneous coronary intervention (PCI) was the primary revascularization strategy. Coronary artery bypass grafting (CABG) was performed if an unsuitable anatomy or unsatisfactory result of PCI. Comparisons were performed in groups with different revascularization strategies and outcomes.

Optimal choice of coronary revascularization and stent type in diabetic patients with coronary artery disease.

Patients with diabetes mellitus (DM) are prone to a diffuse and accelerated form of coronary artery disease (CAD), which in turn is a major cause of cardiac-related morbidity and mortality. Compared with patients without diabetes, patients with diabetes undergoing coronary revascularization are at higher risk of procedural, short-, and long-term cardiovascular events and mortality. Although coronary artery bypass grafting (CABG) has been regarded as the primary revascularization strategy in diabetic patients with complex CAD, percutaneous coronary intervention (PCI) is an effective revascularization alternative, due to remarkable advances in stent devices and adjunctive drug therapies. Outcomes data, from subgroup analyses and small-sized clinical trials and large registries, have suggested that PCI with current stent technology showed comparable long-term risks of mortality and hard endpoints, but higher risk of repeat revascularization for the diabetic population compared to CABG. However, the recent landmark International Future REvascularization Evaluation in patients with diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial provides compelling evidence of the superiority of CABG over PCI in reducing the rates of death, myocardial infarction, at the expense of stroke, in patients with diabetes with advanced CAD. When opting for PCI in patients with diabetes, currently used drug-eluting stents (DES) are more efficient in reducing the risk of repeat revascularization without compromising safety outcomes, compared to bare-metal stents. The selection of a specific type of DES in patients with diabetes is controversial and therefore more data comparing second- and newer-generation DES for patients with diabetes are currently needed. Also, efforts to make more advanced DES platforms suitable for patients with diabetes with complicated angiographic features are still ongoing.

Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: The impact of early coronary revascularization

ObjectivesTo investigate the therapeutic impact of combining extracorporeal membrane oxygenation (ECMO) and early coronary revascularization on acute myocardial infarction (AMI)-induced cardiopulmonary collapse. Materials and methodsThis retrospective study included 35 consecutive patients rescued by ECMO for AMI-induced cardiopulmonary collapse in a single institution between June 2003 and December 2011. Coronary revascularization was performed soon after ECMO initiation. Percutaneous coronary intervention (PCI) was the primary revascularization strategy. Coronary artery bypass grafting (CABG) was performed if an unsuitable anatomy or unsatisfactory result of PCI. Comparisons were performed in groups with different revascularization strategies and outcomes. ResultsAmong the 35 patients, 16 underwent CABG and 1 was bridged to transplant after CABG. Compared to patients receiving PCI only, the CABG group showed similar results in ECMO weaning (58% vs. 69%, p=0.51), hospital discharge (32% vs. 50%, p=0.27), and left ventricular ejection fraction before discharge (45% vs. 49%, p=0.92). Regardless of revascularization strategies, this protocol achieved an ECMO-weaning rate of 63% and a hospital discharge rate of 40%. Dialysis-dependent acute renal failure (OR 5.4, 95% CI: 1.1–27.5) and profound anoxic encephalopathy (OR 5.4, 95% CI: 1.1–27.5) predicted non-weaning of ECMO. Age>60 years (OR 7.3, 95% CI: 1.1–51.0) and profound anoxic encephalopathy (OR 24.6, 95% CI: 2.3–263.0) predicted in-hospital mortality. The major cardiovascular adverse effect (MACE)–free survival was 77% in the first year after discharge. ConclusionEarly revascularization on ECMO is practical to preserve myocardial viability and bridge patients collapsing with AMI to recovery.

Acute and intermediate‐term procedural results using cypher stenting to treat multi‐vessel coronary artery disease

We examined our experience using the sirolimus eluting stents (Cypher) as an alternative to surgical revascularization in carefully selected cohort of patients undergoing multi-vessel percutaneous coronary intervention. Fifty consecutive patients with multi-vessel disease who were good candidates for both surgical and percutaneous revascularization were included in the current analysis. All patients underwent a careful clinical evaluation prior to the intervention, and they were followed for procedural and clinical outcomes for nine months. Mean age was 64+/-11 years (40 males, 30% diabetics) and 10 patients (20%) had three-vessel disease. Angina class was 2.7+/-0.6 at baseline. Overall, 116 lesions were treated using 122 stents (mean 2.4 stents per patient). Total mean stent length was 43+/-12 mm (range: 21-90 mm). Overall, one patient died during follow-up (2%), no patient had stroke or Q wave MI and one patient experienced non-Q myocardial infarction. There was no documented stent thrombosis and two patients (4%) underwent target-vessel revascularization. The hierarchical cumulative major adverse cardiac event rate was 8% and the cardiac event-free survival rate was thus 92%. Multi-vessel stenting using Cypher stents is a viable treatment strategy in selected group of patients with multi-vessel coronary artery disease. It is associated with excellent intermediate-term clinical outcomes and thus it could serve as the primary revascularization strategy of choice in appropriate candidates.

Prognostic value of quantitative troponin T measurements in unstable angina/non-ST-segment elevation acute myocardial infarction treated early and predominantly with percutaneous coronary intervention

To evaluate the effect of baseline cardiac troponin T measurements on in-hospital and long-term outcomes in patients with unstable angina/non-ST-segment elevation myocardial infarction who are treated with an early invasive strategy. We conducted a prospective cohort study involving 1024 consecutive patients with unstable angina/non-ST-segment elevation myocardial infarction. Patients were stratified according to quantitative troponin T measurements on admission, and underwent coronary angiography and subsequent coronary stenting of the culprit lesion as the primary revascularization strategy within 24 hours. The primary endpoint was all-cause mortality. The risk of in-hospital and long-term mortality increased with absolute levels of troponin T. In-hospital mortality was 0.7% (3/449) in patients with levels <0.010 microg/L, 2.0% (4/197) in those with levels from 0.010 to 0.035 microg/L, 3.2% (6/186) in those with levels from 0.035 to 0.229 microg/L, and 4.7% (9/192) in patients with levels >0.229 microg/L. Cumulative 2-year mortality rates were 2.8%, 8.0%, 10.5%, and 14.8% from the lowest to highest troponin T groups (P <0.001). In contrast, the risk of nonfatal myocardial infarction assumed an inverted U-shaped curve and was lower in the lowest and highest troponin T groups. Troponin T remains a strong predictor of mortality, even at low levels, in patients with unstable angina/non-ST-segment elevation myocardial infarction who are treated with early revascularization. The risk associated with elevated levels is linear for death but not for myocardial infarction.

Women do have an improved long-term outcome after non–ST-elevation acute coronary syndromes treated very early and predominantly with percutaneous coronary intervention

This study sought to assess gender-based differences in long-term outcome after very early aggressive revascularization for non-ST-elevation acute coronary syndromes (NSTACS). The Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC) II study suggested that women have less to gain from an early invasive strategy. We conducted a prospective cohort study in 1,450 consecutive patients with NSTACS undergoing coronary angiography and subsequent coronary stenting of the culprit lesion as the primary revascularization strategy within 24 h of admission. The combined primary end point was defined as death or nonfatal myocardial infarction (MI) and recorded for a mean of 20 months. Percutaneous coronary intervention was performed in more than 50% of patients in women and men and accompanied with stenting in 80%. The percutaneous coronary intervention:coronary artery bypass grafting ratio was 4:1 in men and 5:1 in women. The primary end point occurred in 29 (7.0%) women as compared with 108 (10.5%) men (hazard ratio for women, 0.65; 95% confidence interval [CI] 0.42 to 0.99; p = 0.045). Backward-stepwise multivariate Cox regression analysis identified female gender as an independent predictor of death or MI (hazard ratio for female gender, 0.51; 95% CI, 0.28 to 0.92; p = 0.024). Kaplan-Meier analysis showed that women had consistently lower event rates during the entire follow-up period (p = 0.037 by log-rank for death or MI). Women treated with very early aggressive revascularization with coronary stenting of the culprit lesion as the primary revascularization strategy have a better long-term outcome as compared with men.

Inflammation and long-term mortality after non-ST elevation acute coronary syndrome treated with a very early invasive strategy in 1042 consecutive patients.

This study sought to evaluate the predictive value of C-reactive protein (CRP) on long-term mortality in non-ST-elevation acute coronary syndromes (NSTACS) that were treated with a very early aggressive revascularization strategy. We conducted a prospective cohort study in 1042 consecutive patients with NSTACS who were undergoing coronary angiography and subsequent coronary stenting of the culprit lesion as the primary revascularization strategy within 24 hours. Levels of CRP were determined on admission. The patients were followed for a mean of 20 months. In-hospital mortality was significantly higher in patients with a CRP>10 mg/L (3.7% versus 1.2% with CRP<3 mg/L and versus 0.8% with CRP of 3 to 10 mg/L; relative risk for CRP>10 mg/L compared with CRP< or =10 mg/L was 4.2, 95% confidence interval [CI] was 1.6 to 11.0; P=0.004). The increase in mortality in patients with CRP>10 mg/L persisted during follow-up. Long-term mortality was 3.4% with CRP<3 mg/L, 4.4% with CRP between 3 and 10 mg/L, and 12.7% with CRP>10 mg/L (relative risk for CRP>10 mg/L compared with CRP< or =10 mg/L, 0.8; 95% CI, 2.3 to 6.2; P<0.001). In addition, Kaplan-Meier survival analysis demonstrated a significantly reduced survival at 4 years in patients with a CRP>10 mg/L (78% versus 88% for a CRP of 3 to 10 mg/L and versus 92% for CRP<3 mg/L; P<0.001 by log-rank). In a multivariate analysis, CRP was an independent predictor of long-term mortality. Patients with a CRP>10 mg/L had >4 times the risk of death (odds ratio, 4.1; 95% CI, 2.3 to 7.2). CRP is a strong independent predictor of short and long-term mortality after NSTACS that are treated with very early revascularization.