Residual SYNTAX Score Research Articles

Clinical outcome based on functional complete revascularization in patients with three-vessel coronary artery disease: The FAME 3 Trial

Abstract Background Anatomic complete revascularization after angiography-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. The impact of functional complete revascularization (PCI of all fractional flow reserve (FFR) positive lesions) in patients with 3-vessel coronary artery disease (3VD) amenable to PCI or coronary artery bypass grafting (CABG) is unknown. Purpose To investigate the clinical impact of functional complete revascularization after FFR-guided PCI in the FAME 3 trial Methods The FAME 3 trial is a multicenter, international, randomized study comparing FFR-guided PCI with CABG in patients with angiographic 3VD. This pre-specified sub-study evaluated the impact of functional complete revascularization after PCI on the primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. The degree of functional complete revascularization was quantified by calculating the residual functional SYNTAX score (rFSS), defined as the residual anatomic SYNTAX score based on post-PCI angiography minus any FFR-negative deferred lesions. Results Of the 757 patients treated with FFR-guided PCI, the rFSS could be calculated by the core laboratory in 81% (n=601). Among the angiographically significant lesions, PCI was deferred based on FFR in 17% (51 % of patients had deferral of at least one lesion). The patients were divided into two groups according to acceptable functional complete revascularization: rFSS 0-8 (63%) and functional incomplete revascularization: rFSS>8 (37%). The cumulative incidence of death, MI, or stroke at 3 years was significantly lower in patients with rFSS 0-8 (9% vs. 17%, Hazard ratio[HR]:0.5, 95% confidence interval[CI]:0.3-0.8, p=0.006) compared with rFSS>8. In comparison with the CABG arm, the patients with rFSS 0-8 had similar outcome (HR:0.97, 95%CI:0.6-1.5, p=0.87), while in those with rFSS >8 outcome was worse (HR:1.9, 95%CI: 1.3-2.8, p=0.002) (Figure). There was no difference in death, MI or stroke in CABG patients with or without anatomic complete revascularization. In a multivariate-adjusted model, rFSS>8 showed a significant association with death, MI or stroke at three years (adjusted HR: 1.83, 95% CI: 1.09-3.09, p=0.02). Conclusions Acceptable functional complete revascularization with FFR-guided PCI in patients with 3VD is an independent predictor of death, MI or stroke at three years and can be achieved in 63% of patients resulting in similar outcomes compared with CABG.

Clinical prediction model of main adverse cardiovascular and cerebrovascular events for elderly patients with acute coronary syndrome

Abstract Background Age is an independent factor for adverse outcomes in acute coronary syndrome (ACS). With the accelerated aging process, there is an increasing incidence of ACS in the elderly; however, research on this population is underrepresented. Due to the unique presence of multiple diseases and organ changes in the elderly, specialized risk assessment tools are required. Purpose To explore the risk factors for poor prognosis of elderly patients with ACS and establishing a risk stratification tool. Methods The derivation cohort consisted of 1674 elderly ACS patients consecutively enrolled in a single center from January 2013 to December 2013. The validation cohort included 2333 elderly ACS patients consecutively enrolled in nine medical centers from January 2015 to May 2019. All patients were followed up for 2 years, and the study endpoint was defined as major adverse cardiovascular and cerebrovascular events (MACCE). Model selection was performed using Cox regression and the Akaike Information Criterion (AIC) to construct the final risk assessment model. The performance of the predictive model was evaluated in the derivation and validation cohorts using the c-index, receiver operating characteristic (ROC) curves, and calibration curves. Results A total of 1,674 elderly ACS patients (70.97±4.68 years, 23.24% female) were included in the derivation cohort, and 210 cases (12.54%) of MACCE were recorded during the 2-year follow-up period. In the validation cohort, there were 2,333 elderly ACS patients (72.13±5.82 years, 35.83% female), with 364 cases (15.60%) of MACCE documented during the 2-year follow-up. Initially, 25 variables were preliminarily selected based on the results of univariate Cox regression and the clinical importance of these variables. Subsequently, these variables were included in a multivariable Cox model, and model selection was performed based on the AIC, resulting in the final selection of 10 variables (including age, cardiac insufficiency, current smoker, DAPT use, history of PCI or CABG, IABP use, number of lesions, residual SYNTAX score, preoperative HGB, and preoperative PLT). Then we developed and validated a nomogram to predict the 2-year MACCE in elderly ACS patients based on the assessment of 10 clinically easily obtainable variables during hospitalization. In both the derivation and validation cohorts, the nomogram demonstrated good discriminative ability (AUC of 0.723 and 0.699, c-index of 0.727 and 0.661, respectively) and calibration (calibration curves closely approximating the 45-degree diagonal line). The Kaplan-Meier analysis reveals significant differences in MACCE incidence rates between groups stratified by the median predicted probability (p<0.001). Conclusion Our study developed and validated a practical nomogram for predicting the 2-year risk of MACCE in elderly patients with ACS.

Clinical significance of residual ischemia in acute myocardial infarction complicated by cardiogenic shock undergoing VA-ECMO

Abstract Background Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction of residual ischemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischemia in patients undergoing mechanical circulatory supports. Objectives This study aimed to evaluate the effects of residual ischemia on clinical outcomes in AMI patients undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods AMI patients with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischemia evaluated using the residual SYNTAX score (rSS): rSS=0, 0<rSS≤8, and rSS>8. The primary outcome was 1-year all-cause death. Results A total of 408 patients were classified into the rSS=0 (N=100, 24.5%), 0<rSS≤8 (N=136, 33.3%), and rSS>8 (N=172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9% vs. 55.4% vs. 66.1% for rSS=0, 0<rSS≤8, and rSS>8, respectively, overall P<0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (HRadj 1.03, 95% CI 1.01–1.05, P=0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. Conclusions In AMI patients with refractory CS who underwent VA-ECMO, residual ischemia was associated with an increased risk of 1-year mortality. Therefore, revascularization strategies to minimize residual ischemia should be considered in advanced CS, particularly in cases requiring VA-ECMO.

Comparative characteristics and invasive management in patients with non-ST elevation acute coronary syndromes in two high-volume hospitals from Romania and Germany

Abstract Introduction Cardiovascular disease (CVD) carries the highest mortality burden across Europe, acute coronary syndromes (ACS) being responsible for most CVD-related deaths. However, significant regional differences in ACS management have been reported. Purpose To describe the characteristics and management of patients with higher-risk non-ST elevation ACS (NSTE-ACS) in 2 high-volume hospitals from 2 European countries with different prevalence of CVD and different income (Germany – GER and Romania – RO). Methods All consecutive invasively managed high and very-high risk NSTE-ACS patients admitted in 2022 in two high-volume hospitals from GER and RO were identified. Patient clinical profiles, coronary anatomy, revascularization strategies, and in-hospital outcomes were compared. Results were adjusted for age and gender. Results 707 patients (345 GER, 66.7% male; 362 RO, 71.5% male; p>0.05) were included. RO patients were younger (65.5 vs. 70.1 years), with higher rates of hypertension (88.7% vs. 82.0%), dyslipidemia (95.6% vs. 81.7%), diabetes (46.1% vs. 34.5%), and active smoking (37.3% vs. 23.5%) (all p<0.05); whereas GER patients had higher rates of atrial fibrillation (36.2% vs. 23.2%), chronic respiratory disease (24.6% vs. 10.5%), sleep apnoea (9.0% vs. 1.4%), thyroid disorders (24.1% vs. 6.4%), and prior revascularization by percutaneous coronary interventions (PCI) (36.5% vs. 20.2%) or coronary artery bypass grafting (CABG) (15.7% vs. 3.0%) (all p<0.05). Mean left ventricular ejection fraction (LVEF) was lower in the RO cohort (43.4% vs. 48%, p<0.001). Rates of myocardial infarction diagnosed by high-sensitivity troponin I assays (88.7% GER, 87.6% RO), and median diagnosis-to-cathlab intervals (12.8 hours GER, 15.5 hours RO) were similar (all p>0.05). In the obstructive coronary artery disease (CAD) group (80.3% GER, 84.3% RO), no differences were found in multivessel disease rates (67.1% GER, 69.8% RO) or mean SYNTAX score (18.6 GER, 16.9 RO) (all p>0.05). For type 1 NSTE-ACS (67% GER vs. 79% RO, p<0.001), PCI represented the main revascularization method (88.3% GER vs. 78.3% RO, p<0.05). Excluding patients with prior CABG undergoing PCI, complete revascularization (residual SYNTAX score ≤8), was reported in 77.1% GER and 84.4% RO of the PCI cases (p>0.05). Intravascular imaging was used in 28.4% of PCIs in GER, and in none in RO. In-hospital mortality (7.0% GER, 6.8% RO), and rates of major adverse cardiovascular events, defined as a composite of death, myocardial infarction, and stroke (8.1% GER, 9.1% RO), were similar (all p>0.05). Conclusions Higher-risk NSTE-ACS patient profiles mirror overall country CVD risk patterns. Compared to Germany, patients in Romania are younger, with a higher CVD risk factor burden, lower LVEF, underdiagnosis of major non-CVD comorbidities, and delayed CAD diagnosis. Despite similar guideline-directed management and in-hospital outcomes in both centres, these aspects may influence the long-term prognosis.

Comparison of the prognosis between complete and incomplete revascularization among moderate to severe chronic kidney disease patients with acute coronary syndrome

Abstract Background Complete revascularization (CR) in acute coronary syndrome patients with multivessel disease (MVD) is recommended in current clinical practice guidelines. However, the benefit of CR in moderate to severe chronic kidney disease (CKD) patients remains controversial. We aimed to compare the clinical outcomes between complete and incomplete revascularization among moderate to severe CKD patients who presented with ACS. Methods Of 1,924 ACS patients who underwent percutaneous coronary intervention (PCI) in our center, 127 patients were CKD. CR was defined as residual SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score ≤ 3. The primary outcome was the patient oriented clinical outcome (POCO) at 1 year, including all-cause death, any myocardial infarction, any revascularization, and heart failure requiring hospitalization. Results The mean age of the patients was 73.89±9.07 years. The median estimated glomerular filtration rate (eGFR) was 32.56±10.68 ml per minute per 1.73 m2. The rate of POCO at 1 year was significantly lower in the CR group (16.3% vs 39.3%; HR 0.36; 95%CI, 0.16-0.81; p=0.014). The primary outcome was mainly driven by 1-year all-cause death which was significantly lower in the CR group (14.0% vs 39.3%; HR 0.32; 95%CI 0.13-0.76; p=0.017). The rate of initiation of renal replacement therapy was comparable (4.7% vs 2.4%; p=0.55). Conclusion CR with a target SYNTAX score ≤ 3 improved 1-year prognosis of POCO and all-cause death in ACS patients with moderate to severe CKD without increasing the rates of renal replacement therapy.1-year POCOPrespecified Subgroup Analysis of POCO

Prognostic value of pan immune-inflammation value in patients undergoing unprotected left main coronary artery stenting.

Aim: This study aimed long-term prognostic factors for percutaneous coronary intervention (PCI) in left main coronary artery (LMCA) disease, focusing on inflammatory parameters like Pan Immune-Inflammation Value (PIV) and Systemic Immune-Inflammation Index (SII).Materials & methods: This retrospective, observational study involved 121 patients receiving unprotected LMCA PCI.The study's primary end point was MACE, including all-cause death, repeat revascularization and myocardial reinfarction.Results: The PIV and SII scores emerged as independent predictors of MACE occurrence in patients undergoing PCI for unprotected LMCA disease (p:0.045,p:0.048;respectively).In addition, age, ejection fraction, creatinine, shock presentation and the residual syntax score were identified as significant independent predictors of MACE in both models.Conclusion: This study showed a significant, independent correlation between PIV, SII and MACE in patients undergoing PCI for LMCA disease, with PIV showing slightly better predictive capability than SII.

Relationship between Earlobe Crease and Anatomical Severity of Coronary Artery Disease in ST-segment Elevation Myocardial Infarction.

Objective Earlobe crease (ELC) is an easily detectable physical sign of cardiovascular risk and coronary artery disease (CAD). However, the relationship between ELC and CAD severity in patients with ST-segment elevation myocardial infarction (STEMI) requiring urgent clinical judgment is unknown. Using the residual synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score, we investigated the relationship between ELC and anatomical severity of CAD. Methods We studied 219 consecutive patients with STEMI (median age, 71 years old) and divided them into 2 groups according to the presence of ELC (ELC group, n=161; non-ELC group, n=58). Results The ELC group had a significantly higher number of diseased vessels than the non-ELC group (≥2 diseased vessels, 79% vs. 46%; ≥3 diseased vessels, 35% vs. 12%; p<0.001). In addition, a higher median residual SYNTAX score was observed after primary percutaneous coronary intervention than the non-ELC group [8 (4-12) vs. 3 (0-8), p<0.001]. Furthermore, a multivariable regression analysis showed that ELC was an independent predictor of the residual SYNTAX score (β=3.620, p<0.001). Conclusions The presence of ELC was significantly associated with the anatomical severity of diseased coronary vessels in patients with STEMI who required emergency clinical judgment and treatment.

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention

Background In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled. Results This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator’s discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE. Conclusions Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

Prognostic value of residual SYNTAX score in patients with coronary artery disease undergoing percutaneous coronary intervention-cohort study

Residual Syntax Score (RSS) is derived from Syntax Score to quantify the burden of residual coronary artery disease after percutaneous coronary intervention (PCI). As data is limited, we report predictive utility of Residual SYNTAX Score in relation to in hospital and 1 year mortality of the patients undergoing percutaneous coronary intervention (PCI).

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy

BackgroundComplete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function. ObjectivesThis study sought to identify the impact of complete revascularization in patients with severe LV dysfunction. MethodsPatients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure. ResultsOf 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome. ConclusionsIn patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048)

Impact of coronary artery disease and revascularization on outcomes of transcatheter aortic valve replacement for severe aortic stenosis

Background/purposeTo evaluate the impact of coronary artery disease (CAD), percutaneous coronary intervention (PCI), and coronary lesion complexity on outcomes of transcatheter aortic valve replacement (TAVR) for aortic stenosis. Methods/materialsThis retrospective study included 1042 patients divided into two groups by the presence or absence of CAD (SYNTAX score 0, no history of revascularization). Propensity score matching was used to compare the two groups. The effect of PCI, SYNTAX score, and residual SYNTAX score was also analyzed. ResultsThe median age of the cohort was 82 years, and 641 patients had CAD. After propensity score matching, 346 pairs were analyzed. During 5 years of follow-up (median: 25, range 0–72 months), the rate of coronary intervention was significantly higher in CAD patients (p = 0.018). However, all-cause mortality, composite of all-cause mortality, stroke, and coronary intervention, and overt bleeding defined by VARC-3 were comparable. After stratification, in patients with creatinine ≥1.5 mg/dl, CAD was associated with a worse composite outcome (p = 0.016). Neither PCI nor SYNTAX score was associated with all-cause mortality in CAD patients. Similarly, residual SYNTAX score showed no association with mortality in patients undergoing PCI (all p values >0.7). PCI did not reach a significant difference in overt bleeding in CAD patients (adjusted p = 0.06). ConclusionsDespite a higher incidence of coronary interventions, major clinical outcomes were similar between patients with and without CAD after TAVR. In patients with chronic kidney disease, CAD may be associated with an adverse composite outcome. Neither PCI nor SYNTAX/residual SYNTAX score influenced all-cause mortality.

Complex percutaneous coronary intervention in patients unable to undergo coronary artery bypass grafting during the COVID-19 pandemic: insights from the UK-ReVasc Registry.

Cardiac surgery for coronary artery disease was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with disease ordinarily treated with coronary artery bypass grafting (CABG) instead underwent percutaneous coronary intervention (PCI). We sought to describe 12-month outcomes following PCI in patients who would typically have undergone CABG. Between March 1 and July 31, 2020, patients who received revascularization with PCI when CABG would have been the primary choice of revascularization were enrolled in the prospective, multicenter UK-ReVasc Registry. We evaluated the following major adverse cardiovascular events at 12 months: all-cause mortality, myocardial infarction, repeat revascularization, stroke, major bleeding, and stent thrombosis. A total of 215 patients were enrolled across 45 PCI centers in the United Kingdom. Twelve-month follow up data were obtained for 97% of the cases. There were 9 deaths (4.3%), 5 myocardial infarctions (2.4%), 12 repeat revascularizations (5.7%), 1 stroke (0.5%), 3 major bleeds (1.4%), and no cases of stent thrombosis. No difference in the primary endpoint was observed between patients who received complete vs incomplete revascularization (residual SYNTAX score £ 8 vs > 8) (P = .22). In patients with patterns of coronary disease in whom CABG would have been the primary therapeutic choice outside of the pandemic, PCI was associated with acceptable outcomes at 12 months of follow-up. Contemporary randomized trials that compare PCI to CABG in such patient cohorts may be warranted.

Progress in the Application of the Residual SYNTAX Score and Its Derived Scores.

The residual SYNTAX score (rSS) is employed for the quantification of residual coronary lesions and to guide revascularization. rSS can be combined with other examinations to evaluate the severity of vascular disease and play an evaluative and guiding role in various scenarios. Furthermore, combining rSS with other indicators, benefits prognosis evaluation, and rSS-derived scores have been increasingly used in clinical practice. This article reviews the progress in the clinical application of rSS and its derived scores for complex coronary arteries and other aspects, based on relevant literature.

Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial.

The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS). The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; P=0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; P=0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; P=0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; P<0.001). The risk was the highest for residual ostial/proximal LCX lesions. Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.

Valor prognóstico do escore SYNTAX residual nos desfechos clínicos intra- hospitalares e de acompanhamento em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos à estratégia farmacoinvasiva

Background Multivessel coronary artery disease is a challenge in clinical practice. An individualized approach should consider not only the patient characteristics, but also a multidisciplinary approach, together with the Heart Team. Multiple angiographic scores have been proposed with the aim of quantifying the risk associated with multivessel coronary artery disease. Residual SYNTAX score has been proposed as a method to systematically characterize and quantify residual coronary disease after percutaneous coronary intervention. There are few data in the literature correlating the residual SYNTAX score in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive strategy. The objective of this study was to evaluate the SYNTAX score and residual SYNTAX score as predictors of in-hospital and medium-term outcomes (180 to 380 days) in patients with multivessel coronary artery disease in the setting of ST-segment elevation myocardial infarction, after successful fibrinolytic therapy. Methods In a cross-sectional, analytical, and prospective study, we evaluated residual SYNTAX score as predictor of in-hospital and medium-term outcomes (6 months to 1 year), in patients with multivessel coronary artery disease, in the setting of ST-segment elevation myocardial infarction after pharmacoinvasive strategy. Results Between August 2019 and December 2020, 108 patients with ST-segment elevation myocardial infarction after fibrinolysis, with reperfusion criteria, were analyzed. The mean SYNTAX score was 13.98 (±4.87) and the mean residual SYNTAX score was 7.56 (±4.47). High residual SYNTAX score was associated with contrast-induced nephropathy and major adverse cardiac event. It was also an independent predictor of major adverse cardiac event with a 9.69-fold increased risk (p=0.0274). Conclusion High residual SYNTAX score confers worse prognosis in patients with ST-segment elevation myocardial infarction after pharmacoinvasive strategy.

Predictors of left ventricular ejection fraction in high-risk percutaneous coronary interventions.

Revascularization completeness after percutaneous coronary intervention (PCI) is associated with improved long-term outcomes. Mechanical circulatory support [intra-aortic balloon pump (IABP) or Impella] is used during high-risk PCI (HR-PCI) to enhance peri-procedural safety and achieve more complete revascularization. The relationship between revascularization completeness [post-PCI residual SYNTAX Score (rSS)] and left ventricular ejection fraction (LVEF) in HR-PCI has not been established. We investigated LVEF predictors at 90 days post-PCI with Impella or IABP support. Individual patient data (IPD) were analyzed from PROTECT II (NCT00562016) in the base case. IPD from PROTECT II and RESTORE-EF (NCT04648306) were naïvely pooled in the sensitivity analysis. Using complete cases only, linear regression was used to explore the predictors of LVEF at 90 days post-PCI. Models were refined using stepwise selection based on Akaike Information Criterion and included: treatment group (Impella, IABP), baseline characteristics [age, gender, race, New York Heart Association Functional Classification, LVEF, SYNTAX Score (SS)], and rSS. Impella treatment and higher baseline LVEF were significant predictors of LVEF improvement at 90 days post-PCI (p ≤ 0.05), and a lower rSS contributed to the model (p = 0.082). In the sensitivity analysis, Impella treatment, higher baseline LVEF, and lower rSS were significant predictors of LVEF improvement at 90 days (p ≤ 0.05), and SS pre-PCI contributed to the model (p = 0.070). Higher baseline LVEF, higher SS pre-PCI, lower rSS (i.e. completeness of revascularization), and Impella treatment were predictors of post-PCI LVEF improvement. The findings suggest potential mechanisms of Impella include improving the extent and quality of revascularization, and intraprocedural ventricular unloading.

Impact of residual coronary lesions on outcomes of myocardial infarction patients with multi-vessel disease

BackgroundThe residual burden of coronary artery disease (CAD) after percutaneous coronary intervention (PCI) drew a growing interest. The residual SYNTAX Score (rSS) was a strong prognostic factor of adverse events and all-cause mortality in patients who underwent PCI. In addition, the SYNTAX Revascularization Index (SRI), a derivative of rSS, was used to figure out the treated proportion of CAD and could be used as a prognostic utility in PCI for patients with multi-vessel disease (MVD).PurposeWe aimed at the assessment of the use of rSS and the SRI as predictors of in-hospital outcomes and up to two-year cumulative follow-up outcomes in patients with MVD who had PCI for the treatment of ST-Elevation Myocardial Infarction (STEMI) or Non-STEMI (NSTEMI).MethodsWe recruited 149 patients who had either STEMI or NSTEMI while having MVD and received treatment with PCI. We divided them into tertiles based on their rSS and SRI values. We calculated baseline SYNTAX Score (bSS) and rSS using the latest version of the calculator on the internet, and we used both scores to calculate SRI. The study end-points were In-hospital composite Major Adverse Cardiovascular Events (MACE) and its components, in-hospital death, and follow-up cumulative MACE up to 2 years.ResultsNeither rSS nor SRI were significant predictors of in-hospital adverse events, while female sex, hypertension, and left ventricular ejection fraction were independent predictors of in-hospital MACE. At the two-year follow-up, Kaplan-Meyer analysis showed a significantly increased incidence of MACE within the third rSS tertile (rSS > 12) compared to other tertiles (log rank p = 0.03). At the same time, there was no significant difference between the three SRI tertiles. Unlike SRI, rSS was a significant predictor of cumulative MACE on univariate Cox regression (HR = 1.037, p < 0.001). On multivariate Cox regression, rSS was a significant independent predictor of two-year cumulative MACE (HR = 1.038, p = 0.0025) along with female sex, hypertension, and left ventricular ejection fraction. We also noted that all patients with complete revascularization survived well throughout the entire follow-up period.ConclusionsNeither rSS nor SRI could be good predictors of in-hospital MACE, while the rSS was a good predictor of MACE at two-year follow-up. Patients with rSS values > 12 had a significantly higher incidence of cumulative MACE after 2 years. The best prognosis was achieved with complete revascularization.

REASONABLE INCOMPLETE REVASCULARIZATION USING MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING TECHNIQUES

HighlightsIn multivessel coronary artery disease coronary artery bypass grafting under cardiopulmonary bypass using the internal thoracic artery is the accepted standard of revascularization, however, it is characterized by high trauma. Minimally invasive techniques offset this disadvantage but cannot always provide complete revascularization. Determination of feasibility and combined use of incomplete revascularization with minimally invasive techniques of coronary artery bypass may be a worthy alternative to traditional coronary bypass in a certain group of patients. At the same time, literature the data are ambiguous and deficient in the world. Aim. To justify the use of minimally invasive coronary artery bypass technique in incomplete myocardial revascularization in patients with stable ischemic heart disease from the standpoint of efficacy and safety.Methods. The retrospective study focuses on the analysis of minimally invasive coronary artery bypass grafting (minimally invasive direct coronary artery bypass grafting and off-pump coronary artery bypass surgery using sternotomy) and traditional CABG with cardiopulmonary bypass in patients with multivessel coronary artery disease (n = 429) performed in the period from 2013 to 2017. Depending on the CABG technique and the type of revascularization (complete/incomplete), all patients were divided into 3 groups with two comparison subgroups in each. The completeness of revascularization was assessed using the residual SYNTAX score (rSS). The SYNTAX revascularization index (SRI) was calculated using the following formula: SRI = [1 – (rSS/bSS)] × 100. Subsequently, a two-stage (short- and long-term) analysis of the adverse events frequency was carried out.Results. The minimally invasive incomplete revascularization (IR) group and the traditional complete revascularization (CR) group. The rSS in the IR group was 3.0 [2.0; 5.0] compared with the group without traditional CABG, whereas the SRI was 84.31 [75.00; 89.19] % compared with 100.00 [100.00; 100.00] %, respectively (p&lt;0.001). The analysis of in-hospital period did not reveal significant differences in the number of primary and secondary endpoints. Taking into account the additional endpoints, the IR group had a lower level of intraoperative blood loss – 300 [200; 310] mL compared with 500 [400; 500] mL in the CR group (p&lt;0.001). Moreover, the need for blood transfusion was significantly lower – by 4.27 times (95% CI: 0.124–0.441, p&lt;0.001). The length of patients stay with IR in the intensive care unit was 4.12 times shorter (95% CI: 1,954–8,994, p&lt;0.001). The 1-year follow-up visit revealed full comparability between the groups in terms of frequency of both primary and secondary endpoints. There were no differences in freedom from MACCE and mortality.The minimally invasive CR group and the traditional CR group. The in-hospital period and 1-year follow-up visits showed similar outcomes, comparable to the minimally invasive IR and traditional CR groups. The minimally invasive IR group and the minimally invasive CR group. The analysis of in-hospital period and 1-year follow-up visits did not reveal any differences in endpoints. Freedom from MACСE and death was similar as well.Conclusion. The data obtained indicate a similar safety profile and effectiveness of IR. Minimally invasive IR is appropriate with rSS ≤3 and SRI ≥84.3% and can be considered as an alternative approach to myocardial revascularization in patients for whom traditional CABG is undesirable.

No difference on angiographic features between women and men in patients with acute coronary syndrome: insights from the ADDICT-ICCU study

Abstract Background Previous studies have observed poorer outcomes in women with acute coronary syndrome (ACS). Angiographic features and angioplasty techniques to explain this difference between women and men have rarely been analyzed in recent studies. Purpose To analyze by a core laboratory angiographic finding, coronary artery disease (CAD) complexity and percutaneous intervention outcomes in women and men in patients with ACS. Methods From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1575 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for ACS (n=379) with an independent angiographic core laboratory evaluation. The prevalence, location, and severity of CAD (lesion≥50%), the Syntax score, the residual Syntax score and the characteristics of percutaneous coronary intervention (PCI) were compared between women and men. The primary endpoint was Major Adverse Cardiac Events (MACE) defined by death, resuscitated cardiac arrest, or cardiogenic shock. Results Among the 379 patients with ACS (mean age: 63±13 years), 23% were women (n= 86) and 77% were men (n=286). Cardiovascular risk factors and CAD history were well balanced between women and men except for active smoking with less smokers in women (59% vs 81%, p&amp;lt;0.001). Regarding location of CAD (stenosis ≥50%), there was no significant difference between women and men: left anterior descending artery (56% vs 57%; p=0.90), circumflex (28% vs 39%; p=0.12) and right coronary artery (50% vs 48%; p=0.81). No difference was found for baseline Syntax score (7.98 vs 9.64; p=0.13). Women and men have a similar rate of multivessels disease (44% vs 50%; p=0.46) and 3 vessels disease (16% vs 20%; p=0.57). Concerning PCI, Syntax score of the culprit lesion was significantly lower in women (4.5 vs 5.5, p=0.02). Women and men received a similar number of stents (2.3 vs 2.4; p=0.33). Stent length (28.9 vs. 30.3, p=0.43) or stent diameter (3.1 vs 3.2; p= 0.11) were not significantly different. Final TIMI 3 flow was found in 92.9% of women and 88.1% of men (p=0.23). The rate of procedural complications was low in both groups. At the end of the procedure, the residual Syntax score was similar in women and men (4.4 vs 5.4; p= 0.34). The rate of in-hospital MACE was not different between women and men (4.7% vs 4.4%; p=0.91). Conclusion In this study with an independent angiographic core laboratory analysis of ACS patients, no difference between women and men regarding CAD severity or PCI outcomes was observed. Other reasons should be considered if a difference in prognosis exists between women and men.Angiographic features in Women and menAngiographic analysis by Core Laboratory

Impacts of illicit drug use on coronary angiographic findings in a multicenter registry of patients with acute coronary syndrome

Abstract Background Although illicit drug use may induce acute coronary syndrome (ACS), its impacts on coronary angiographic characteristics and the coronary artery disease (CAD) burden are a matter of debate. Purpose To assess the association between illicit drugs use and coronary angiographic findings in a multicenter patients with ACS. Methods From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1,499 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for ACS with an angiography analysed by an independent Angiographic Core Laboratory. Patients with history of coronary artery bypass graft surgery were excluded. We compared coronary angiographic findings between illicit drugs users and others for the following parameters: the prevalence, location, type, and severity of CAD obstruction (stenosis≥50%), SYNTAX score, residual SYNTAX score, and the characteristics of percutaneous coronary intervention (PCI). Results Among the 283 patients with ACS (62±13 years, 77% men), 38 (13.4%) had a positive test for illicit drugs (cannabis: 12%, cocaine: 1.1%, MDMA: 0.7%). Drug users were younger than other patients (51±12 vs 64±12 years, p&amp;lt;0.001), but there were no significant difference in sex ratio (89.5% vs 75.5%, p=0.088). There was no significant difference in the rate of STEMI (52.6% vs 45.7%, p=0.535) and NTSEMI (47.4% vs 54.3%, p=0.535) between drug users and others. Regarding the CAD burden, drug users had significantly less obstructive coronary lesions (1.6±1.1 vs 2.2±1.4, p=0.012), less multivessel obstructive CAD (31% vs 61%, p=0.001), and a trend for a lower initial SYNTAX score (8.3±7.8 vs 10.8±8.4; p=0.084) compared to others. Concerning culprit lesion, drug users had less bifurcation lesions (p=0.008), a trend for more left anterior descending (LAD) artery lesions (p=0.091), a higher thrombus burden score (p=0.057), and less lesions above 20 mm (p=0.183). Conclusion In patients with ACS, recent illicit drug use is associated with less number of significant lesions and less multivessel CAD. Concerning culprit lesions, illicit drugs use is associated with less bifurcation lesions, with a trend for more LAD lesions and a higher thrombus burden score.ACS analysed with Core LaboratoryAngiographic findings according to drug