Repeat Revascularization Research Articles

Intravascular imaging-guided coronary drug-eluting stent implantation: an updated network meta-analysis

Previous meta-analyses have shown reduced risks of composite adverse events with intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography guidance alone. However, these studies have been insufficiently powered to show whether all-cause death or all myocardial infarction are reduced with intravascular imaging guidance, and most previous intravascular imaging studies were done with intravascular ultrasound rather than optical coherence tomography (OCT), a newer imaging modality. We aimed to assess the comparative performance of intravascular imaging-guided PCI and angiography-guided PCI with drug-eluting stents. For this systematic review and updated meta-analysis, we searched the MEDLINE, Embase, and Cochrane databases from inception to Aug 30, 2023, for studies that randomly assigned patients undergoing PCI with drug-eluting stents either to intravascular ultrasound or OCT, or both, or to angiography alone to guide the intervention. The searches were done and study-level data were extracted independently by two investigators. The primary endpoint was target lesion failure, defined as the composite of cardiac death, target vessel-myocardial infarction (TV-MI), or target lesion revascularisation, assessed in patients randomly assigned to intravascular imaging guidance (intravascular ultrasound or OCT) versus angiography guidance. We did a standard frequentist meta-analysis to generate direct data, and a network meta-analysis to generate indirect data and overall treatment effects. Outcomes were expressed as relative risks (RRs) with 95% CIs at the longest reported follow-up duration. This study was registered with the international prospective register of systematic reviews (PROSPERO, number CRD42023455662). 22 trials were identified in which 15 964 patients were randomised and followed for a weighted mean duration of 24·7 months (longest duration of follow-up in each study ranging from 6 to 60 months). Compared with angiography-guided PCI, intravascular imaging-guided PCI resulted in a decreased risk of target lesion failure (RR 0·71 [95% CI 0·63-0·80]; p<0·0001), driven by reductions in the risks of cardiac death (RR 0·55 [95% CI 0·41-0·75]; p=0·0001), TV-MI (RR 0·82 [95% CI 0·68-0·98]; p=0·030), and target lesion revascularisation (RR 0·72 [95% CI 0·60-0·86]; p=0·0002). Intravascular imaging guidance also reduced the risks of stent thrombosis (RR 0·52 [95% CI 0·34-0·81]; p=0·0036), all myocardial infarction (RR 0·83 [95% CI 0·71-0·99]; p=0·033), and all-cause death (RR 0·75 [95% CI 0·60-0·93]; p=0·0091). Outcomes were similar for OCT-guided and intravascular ultrasound-guided PCI. Compared with angiography guidance, intravascular imaging guidance of coronary stent implantation with OCT or intravascular ultrasound enhances both the safety and effectiveness of PCI, reducing the risks of death, myocardial infarction, repeat revascularisation, and stent thrombosis. Abbott.

Outcomes following coronary chronic total occlusion revascularization with drug-coated balloons.

Despite the introduction of improved drug eluting stents (DES), the rate of repeat revascularization procedures following percutaneous coronary interventions (PCI) in coronary chronic total occlusions (CTO) remains high. By leaving vessels uncaged and limiting length of stented segments, drug-coated balloons (DCB) represent an appealing alternative to DES for CTO-PCI. Since data supporting the use of DCBs in CTO-PCI is scarce, we compared the outcomes of patients undergoing CTO-PCI involving DCBs vs DES only. From 2 prospective registries, outcomes of patients undergoing CTO-PCI involving DCBs and those undergoing PCI with DES only were compared. Outcomes included major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular death (CV-death). Overall, 157 patients were studied; 112 (71%) underwent CTO-PCI involving DCBs and 45 (29%) were treated with DES only. Mean J-CTO score was 1.84 ± 0.7. Most CTO-lesions involved the right coronary artery, 88 (56%), and 26 (17%) cases were in-stent occlusions. In the DCB group, 46 (41%) lesions were treated with DCBs alone. Mean lengths of the stented segments in the DCB vs DES cohorts were 59 ± 28 mm vs 87 ± 37 mm (P less than .001), respectively. After 12 months, the MACCE rate was higher in the DES only vs DCB group (26% vs 11%, P=.03). Length of the stented segment was an independent predictor for MACCE (HR 1.15 [95% CI, 1.05-1.26] per 10-mm stent length). Revascularization of CTO lesions involving DCBs appears safe and potentially lowers MACCE rates compared to treatment with DES alone. Importantly, using DCBs for CTO treatment may reduce total stent length, which determines PCI outcomes.

Early outcomes of minimally invasive hybrid coronary revascularization

Background: Coronary artery bypass graft (CABG) surgery has been the gold standard for the treatment of coronary artery disease over the years. It is recommended for patients with multi-vessel coronary artery disease, left main disease, diabetics, severe left ventricular dysfunction, unsuitable anatomy for percutaneous coronary intervention (PCI), and failed PCI. The usage of the left internal mammary artery (LIMA) in the CABG to the left anterior descending (LAD) artery has proven to be superior compared to PCI. Minimally invasive hybrid coronary revascularization (MIHCR) is gaining growing interest. Methods: This is a hospital-based prospective observational study with 200 patients followed up for a period of 30 days. This study aims to assess the early outcomes of MIHCR in the Indian population. Results: The 30-day mortality was comparable to other studies, and the number of days in the ICU and hospital stay was shorter than the routine CABG. There was no incidence of a wound infection or stroke. Blood product usage and the need for repeat revascularization and re-exploration were less. The short-term outcomes were promising. Conclusions: MIHCR has excellent short-term results and is safer than conventional OPCABG, as it is less invasive and avoids midline sternotomy. It also reduces the incidence of stroke and lesser usage of blood products, promoting early return of patients to their routine activities.

Impact of body mass index on long-term outcomes in patients undergoing percutaneous coronary intervention stratified by diabetes mellitus: a retrospective cohort study

BackgroundPatients with diabetes mellitus (DM) caused by obesity have increased in recent years. The impact of obesity on long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) with or without DM remains unclear.MethodsWe retrospectively analysed data from 1918 patients who underwent PCI. Patients were categorized into four groups based on body mass index (BMI, normal weight: BMI < 25 kg/m2; overweight and obese: BMI ≥ 25 kg/m2) and DM status (presence or absence). The primary endpoint was the occurrence of major adverse cardiac and cerebrovascular events (MACCE; defined as all-cause death, myocardial infarction, stroke, and unplanned repeat revascularization).ResultsDuring a median follow-up of 7.0 years, no significant differences in MACCE, myocardial infarction, or stroke were observed among the four groups. Overweight and obese individuals exhibited lower all-cause mortality rates compared with normal-weight patients (without DM: hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.37 to 0.78; with DM: HR: 0.57, 95% CI: 0.38 to 0.86). In non-diabetic patients, the overweight and obese group demonstrated a higher risk of unplanned repeat revascularization than the normal-weight group (HR:1.23, 95% CI:1.03 to 1.46). After multivariable adjustment, overweight and obesity were not significantly associated with MACCE, all-cause death, myocardial infarction, stroke, or unplanned repeat revascularization in patients with and without diabetes undergoing PCI.ConclusionOverweight and obesity did not demonstrate a significant protective effect on long-term outcomes in patients with and without diabetes undergoing PCI.

Fractional Flow Reserve and Angiography Guided Complete Revascularization in Primary Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis.

Using a network meta-analysis, this study compared fractional flow reserve (FFR) guided with angiography-guided revascularization of non-culprit lesions in ST elevation myocardial infarction (STEMI). We also assessed if early complete revascularization is superior to delayed revascularization. We conducted a network meta-analysis using Net Meta XL of trials of STEMI patients with multivessel disease and compared revascularization strategies. The primary outcomes of interest were rate of revascularization, myocardial infarction, and all-cause mortality. Ten studies were included in our analysis comprising 7981 patients with 4484 patients undergoing complete revascularization and 3497 patients with culprit-only revascularization. There was no significant reduction in all-cause death, myocardial infarction, or revascularization using FFR guidance. There was significant reduction in repeat revascularization with complete revascularization irrespective of timing of percutaneous coronary intervention (PCI) compared with the culprit-only group. There was an overall trend favoring earlier revascularization. For patients with multivessel disease presenting with ST-elevation MI, complete revascularization significantly reduces repeat revascularization compared with culprit-only treatment. FFR guidance is non-superior to angiography-guided revascularization. Furthermore, there was significant reduction in repeat revascularization irrespective of timing of PCI to non-culprit vessels.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)—356 patients or percutaneous coronary intervention (PCI)—679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Left ventricular recovery after total arterial coronary artery bypass grafting versus conventional coronary artery bypass grafting in patients with multivessel coronary artery disease and reduced left ventricular ejection fraction.

We compared total arterial revascularization (TAR) versus conventional revascularization (CR) in terms of left ventricular function recovery in patients with multivessel coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). We conducted a retrospective cohort study of 162 consecutive patients with multivessel CAD and reduced LVEF who underwent isolated coronary artery bypass grafting at our institution between January 2013 and July 2022. We assessed left ventricular function by transthoracic echocardiography at admission, before discharge, and at follow-up of 3, 6, and 12months, using LVEF, global longitudinal peak strain, end-diastolic volume index, and end-systolic volume index. We also evaluated mitral valve regurgitation and graft patency rate at 1 year. The TAR group had a significantly higher increase in LVEF and global longitudinal peak strain, and a significantly lower decrease in end-diastolic volume index and end-systolic volume index than the CR group at 6 and 12months after surgery. The TAR group also had a significantly lower degree of mitral valve regurgitation than the CR group at all-time points within 12months after surgery. The TAR group had a significantly higher graft patency rate than the CR group at 12months. There was no significant difference in hospital mortality or repeat revascularization between the groups. TAR was associated with better recovery of left ventricular function than CR in patients with multivessel CAD and reduced LVEF. Further studies are needed to confirm these findings in this high-risk population.

Dipeptidyl peptidase-4 inhibitors versus sulfonylureas on the top of metformin in patients with diabetes and acute myocardial infarction.

Recent trials have shown that both the extent of glycated hemoglobin reduction and the duration of enhanced glycemic control are major factors that may affect cardiovascular outcome results. We aimed to investigate the impact of metformin (MET) combined with dipeptidyl peptidase-4 (DPP4) inhibitors or sulfonylureas (SU) on long-term clinical outcomes in patients with acute myocardial infarction (AMI) and type 2 diabetes mellitus (DM). This study was a prospective cohort trial. From November 2011 to December 2015, a total of 13,104 AMI patients were consecutively enrolled from the Korea AMI registry-National Institutes of Health. The patients were divided into the MET + DPP4 inhibitors group and the MET + SU group. The primary endpoint, major adverse cardiac events (MACE), was defined as the composite of all-cause death, recurrent myocardial infarction (MI), and any repeat revascularization up to 3-year follow-up. To adjust baseline potential confounders, an inverse probability weighting (IPTW) analysis was performed. Baseline well-matched two groups were generated (the MET + DPP4 inhibitors group, n=468 and the MET + SU group, n=468). During 3-year clinical follow-up, the cumulative incidence of MACE between the two groups was not significantly different after adjustment (16.8% for MET + DPP4 inhibitors group vs. 19.4% for MET + SU group, P=0.302). However, the MET + DPP4 inhibitors group was associated with reduced risk of MI [1.3% vs. 4.9%; hazard ratio (HR): 0.228, 95% confidence interval (CI): 0.090-0.580, P=0.001] than the MET + SU group. In patients with AMI and type 2 DM, the use of MET combined with DPP4 inhibitors was associated with reduced incidence of recurrent MI than MET combined with SU during 3-year follow-up.

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. ClinicalTrials.gov Identifier: NCT02715518.

Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial

There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.

Radial artery vs right internal mammary artery as a second conduit during coronary artery bypass grafting

To compare the clinical outcomes of radial artery (RA) grafts during CABG to those of right internal mammary artery (RIMA) grafts. This was a retrospective, single-institution cohort study of isolated CABG with multiple grafts between 2010-2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:1 match ratio. Long-term postoperative survival was compared among RA and RIMA groups. Similarly, major adverse cardiac and cerebrovascular events (MACCE) were compared among both cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for mortality, while cumulative incidence estimation was utilized for MACCE. A total of 8,774 patients underwent CABG. Of those, 1,674 (19.1%) patients who underwent multiarterial CABG were included in this analysis. 326 (19.5%) patients received RA grafts and 1,348 (80.5%) received RIMA grafts. PSM yielded a cohort of 323 RA patients and 323 RIMA patients. After matching, groups were well-balanced across all baseline variables. No significant differences were observed in immediate postoperative complications or long-term survival, with 5-year survival estimates of 89.5% for the RA group vs 90.1% for the RIMA group. There was a nonsignificant trend toward a higher incidence of MACCE at 5 years in the RA group compared to the RIMA group (31.3% in the RA group vs 24.1% in the RIMA group), especially after 1-year follow-up (21.6% in the RA group vs 15.1% in the RIMA group). Specifically, for RA patients, there were higher rates of repeat revascularization in the 5-year postoperative period (14.7% in the RA group vs 5.3% in the RIMA group), particularly in the territory revascularized by the RA during the index operation (45.7% in the RA group vs 10.3% in the RIMA group). Overall, RA and RIMA secondary conduits for CABG were associated with comparable immediate postoperative complications, 5-year MACCE, and 5-year survival after PSM. RA grafting was associated with significantly higher rates of repeat coronary revascularization at 5 years, specifically in the territory revascularized by the RA during the index operation.

Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature.

Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke. The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%. Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Intermediate and long-term residual cardiovascular risk in patients with established cardiovascular disease treated with statins.

Statins remain the first-line treatment for secondary prevention of cardiovascular (CV) events, with lowering of low-density lipoprotein cholesterol (LDL-C) being their therapeutic target. Although LDL-C reduction significantly lowers CV risk, residual risk persists, even in patients with well-controlled LDL-C; thus, statin add-on agents that target pathways other than LDL-C, such as the omega-3 fatty acid eicosapentaenoic acid, may help to further reduce persistent CV risk in patients with established CV disease. This narrative review examines the contemporary literature assessing intermediate- and long-term event rates in patients with established CV disease treated with statins. CV event rates among patients treated with statins who have established CV disease, including coronary artery disease, cerebrovascular disease, or peripheral arterial disease, accumulate over time, with a cumulative incidence of CV events reaching up to approximately 40% over 10 years. Recurrent stroke occurs in up to 19% of patients seven years after a first cerebrovascular event. Repeat revascularization and CV-related death occurs in up to 38% and 33% of patients with peripheral artery disease after three years, respectively. Additional treatment strategies, such as eicosapentaenoic acid, are needed to reduce persistent CV risk in patients with established CV disease treated with statins.

A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis

BackgroundInvasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. MethodsRelevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. ResultsA total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. ConclusionAn early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes.PROSPERO registration: CRD42023415574.

Need for repeat revascularisation in hybrid coronary revascularisation vs. percutaneous coronary intervention.

Hybrid coronary revascularisation (HCR), being a treatment path combining both coronary artery bypass grafting and percutaneous coronary intervention (PCI) approaches, offers the advantages of both methods in patients with multi-vessel coronary artery disease. Since available literature provides few studies comparing the need for repeat revascularisation (RR) after HCR in comparison to PCI, our review aimed at summarising the latest data on this topic from the last 5 years (2018-2023). The search was conducted within the PubMed and Embase databases, followed by application of inclusion and exclusion criteria and providing a summary of data and characteristics of eligible studies. On the basis of 7 records included in the final analysis, RR and/or follow-up target vessel revascularisation (TVR) were significantly less frequently required in the case of HCR than in PCI in 3 out of 7 records, whereas the remaining four provided no significant differences in analysed rates between the 2 therapeutic pathways. When it comes to lowering the necessity for follow-up TVR and/or RR in a fraction of instances, HCR demonstrates a significant advantage over PCI. The complexity of outcomes associated with these therapies is emphasised by the fact that no statistically significant differences were observed between the 2 methods in the remaining 4 records.

Implications of anemia in patients undergoing PCI with Impella-support: insights from the PROTECT III study.

Anemia is prevalent among patients with cardiovascular disease and is associated with adverse outcomes. However, data regarding the impact of anemia in high-risk percutaneous coronary intervention (HRPCI) are limited. This study aimed to evaluate the impact of anemia in patients undergoing Impella-supported HRPCI in the PROTECT III study. Patients undergoing Impella-supported HRPCI in the multicenter PROTECT III study were assessed for anemia based on baseline hemoglobin levels according to World Health Organization criteria. Patients were stratified into three groups, namely, no anemia, mild anemia, and moderate or severe anemia. Major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 30 and 90 days, and major bleeding events were compared across groups. Of 1,071 patients with baseline hemoglobin data, 37.9% had no anemia, 43.4% had mild anemia, and 18.7% had moderate or severe anemia. Anemic patients were older and more likely to have comorbidities. Anemia was associated with higher MACCE rates at 30 days (moderate to severe, 12.3%; mild, 9.8%; no anemia, 5.4%; p = 0.02) and at 90 days (moderate to severe, 18.7%; mild, 14.6%; none, 8.3%; p = 0.004). These differences persisted after adjustment for potential confounders at 30 and 90 days, and sensitivity analysis excluding dialysis showed similar results. Major bleeding at 30 days was also higher in anemic patients (5.5% vs. 1.2%, p = 0.002). Baseline anemia in Impella-supported HRPCI is common and independently associated with MACCE and major bleeding, emphasizing its significance as a prognostic factor. Specific management strategies to reduce anemia-associated MACCE risk after HRPCI should be examined. Clinical Trial Information Trial Name: The Global cVAD Study (cVAD)ClinicalTrial.gov Identifier: NCT04136392URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. We aimed to analyse clinical outcomes of robotic-assisted CABG. A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). Robotic-assisted CABG and HCR provides good long-term outcomes in patients who are not candidates for conventional CABG.

TIMI frame count as a predictor of major adverse cardiovascular events during the first month after primary PCI.

This study evaluated the correlation between corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (CTFC) and major adverse cardiovascular events (MACE) within the first month following primary percutaneous coronary intervention (PPCI). Eighty patients who underwent PPCI at Ayatollah Rouhani teaching Hospital in Babol Eighty patients who underwent PPCI at Ayatollah Rouhani teaching Hospital in Babol were included. CTFC, a measure of coronary blood flow, was assessed. Demographic and clinical data, were collected. ST segment resolution, a criterion for successful PPCI, was evaluated. MACE, including cardiac deaths, need for repeat revascularization of culprit vessels, and recurrent non-fatal myocardial infarction, and CVA (cerebrovascular accident) were recorded. Statistical analyses were performed to assess the association between CTFC and demographic/clinical variables, as well as ST resolution and MACE. The majority of patients were (78.8%) men and (81.2%) nonsmokers. No significant association was found between CTFC and demographic/clinical variables. The left anterior descending (LAD) artery was the most commonly involved vessel (48.8%). ST segment resolution of more than 50% was observed in 51.2% of patients. During the one-month follow-up, 13.7% of patients experienced MACE, including 7 cardiac deaths. However, there was no significant association between CTFC and MACE. (P=0.30). This study concludes that CTFC is not a reliable predictor of MACE within the first month after PPCI. Furthermore, ST segment resolution of more than 50% was associated with a lower prevalence of cardiovascular events.

Left main coronary artery disease: percutaneous coronary intervention or coronary artery bypass grafting? A critical review of current knowledge and contemporary debates.

Significant unprotected left main (ULM) disease is the highest-risk coronary artery lesion, carries high morbidity and mortality related to a large amount of myocardium supplied, and should undergo prompt revascularization. Among recent randomized controlled trials (RCTs), NOBLE failed to demonstrate non-inferiority of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). However, all the other RCTs have shown comparable outcomes. While CABG is associated with higher stroke rates at 30 days and 1 year, PCI is associated with increased spontaneous myocardial infarction (MI) events and the need for repeat revascularization. Furthermore, the benefit of CABG is more evident with the increased complexity of coronary artery disease. In current European and American guidelines, CABG is the standard of care for ULM disease. PCI is considered a reasonable alternative in selected patients (2a B-NR). There is still a great need for carefully designed RCTs with longer follow-up times to validate the role of recent technological and pharmacological regimens.

Percutaneous Coronary Intervention in a Saphenous Vein Graft Failure: A Case Report

Abstract: Recent published data from the Society of Thoracic Surgery (STS) national database displayed that among patients aged &gt;65 years old who survived following an initial coronary artery bypass graft (CABG) operation, rates of repeat revascularization at 1, 5, 10, and 18 years were 2%, 8%, 16%, and 25%, respectively. The most preferred mode of revascularization was percutaneous coronary intervention (PCI). While remain the most frequently used conduits beside left internal mammary artery (LIMA), saphenous vein grafts (SVGs) have high failure rates. Percutaneous coronary intervention in SVGs is associated with an increased risk of distal coronary embolization, commonly resulting in periprocedural MI. We reported a 79-year-old male patient admitted due to progressive symptoms of chronic coronary syndrome. The patient had a history of hypertension and a CABG surgery in 2012. Electrocardiogram showed ischemia and old myocardial infarction (OMI) in inferior leads as well as poor R wave progression in the precordial leads. Transthoracic echocardiogram displayed a normal ejection fraction but impaired left ventricular (LV) diastolic relaxation. Diagnostic coronary angiography revealed a 70% tubular stenosis in proximal part of SVG supplying posterior descending artery, patent LIMA graft to left anterior descending artery, and complex lesion on native vessel (chronic total occlusion in mid right coronary artery). Implantation of drug eluting stent in SVG-posterior descending artery was performed. Direct-stenting PCI technique using undersized-stent was done to prevent any complications. In conclusion, despite the high risk of complications, vein graft intervention was successfully performed without any complications. Since the high rates of in-stent restenosis following PCI in SVGs, long-term dual antiplatelet therapy should be commenced in this patient. Keywords: saphenous vein graft; vein graft intervention; percutaneous coronary intervention