Revascularization Of Non-culprit Lesions Research Articles

Debate. Revascularization of nonculprit lesions in ACS: physiology or OCT-guided or both? Perspective from imaging

Debate. Revascularization of nonculprit lesions in ACS: physiology or OCT-guided or both? Perspective from imaging

Debate: Revascularization of non-culprit lesions in ACS: physiology, OCT-guided or both? Perspective from physiology

Debate: Revascularization of non-culprit lesions in ACS: physiology, OCT-guided or both? Perspective from physiology

Instantaneous wave-free ratio-guided revascularization of nonculprit lesions in STEMI patients with multivessel coronary disease: The WAVE registry.

Complete revascularization (CR) of nonculprit lesions (NCL) is strongly recommended in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), but no definitive evidence is available regarding which diagnostic strategy should be preferred. Instantaneous wave-free ratio (iFR) has never been investigated in this setting. We aimed to describe clinical outcomes of a cohort of patients undergoing iFR-guided CR. Following primary percutaneous coronary intervention (PCI), consecutive patients with STEMI and intermediate NCL were enrolled and destinated to an iFR-guided CR. NCL with iFR ≤ 0.89 underwent PCI while NCL with iFR > 0.89 were deferred. The primary endpoint was NC target lesion failure (NC-TLF) and the secondary endpoint was major adverse cardiovascular events (MACE), at 1-year follow-up. Overall, 209 patients were enrolled (ischemic iFR = 83; nonischemic iFR = 126). Patients with ischemic iFR showed a higher prevalence of traditional cardiovascular risk factors and angiographically determined three-vesseldisease. In the entire cohort, NC-TLF and MACE occurred in 6.7% and 10.5% of patients, respectively. Compared to the deferred group, patients with ischemic iFR experienced significantly higher rates of both NC-TLF (3.2% vs. 12.1%; p = 0.021) and MACE (7.1% vs. 16.9%; p = 0.041). These results were mostly driven by increased rates of NC-TLF PCI and further revascularizations in this latter group, while no differences were evident in terms of nonfatal myocardial infarction or death. At multivariable analysis, the strongest predictor of MACE was symptom onset to balloon time (HR = 1.17 [95% CI: 1.04-1.31], p = 0.008). In our study enrolling STEMI patients with MVD, iFR assessment was feasible and safe. PCI-deferring according to iFR evaluation of NCL was associated with low rates of adverse events. Further randomized studies are needed to investigate the effectiveness of iFR-guided revascularization compared to current practice in this setting.

Quantitative flow ratio (QFR) identifies functional relevance of non-culprit lesions in coronary angiographies of patients with acute myocardial infarction

IntroductionIn patients with acute myocardial infarction (AMI) and multivessel coronary disease, revascularization of non-culprit lesions guided by proof of ischemia usually requires staged ischemia testing. Quantitative flow ratio (QFR) has been shown to be effective in assessing the hemodynamic relevance of lesions in stable coronary disease. However, its suitability in AMI patients is unknown. In this study, we tested the diagnostic value of QFR based on acute angiograms (aQFR) during AMI to assess the hemodynamic relevance of non-culprit lesions.MethodsWe retrospectively assessed the diagnostic efficiency of aQFR in 280 vessels from 220 patients, comparing it with staged ischemia testing using elective coronary angiography with FFR (n = 47), stress cardiac MRI (n = 200) or SPECT (n = 33).ResultsaQFR showed a very good diagnostic efficiency (AUC = 0.887, 95% CI 0.832–0.943, p < 0.001) in predicting ischemia of non-culprit lesions, significantly superior to coronary lesion’s geometry as assessed by quantitative coronary angiography. The optimal cut-off for aQFR to predict ischemia was 0.80 (sensitivity = 83.7%, specificity = 86.1%). Maintaining a predefined level of 95% sensitivity and specificity, we created a decision model based on aQFR: lesions with aQFR ≤ 0.75 should be treated, lesions with aQFR ≥ 0.92 do not yield any hemodynamic relevance, and lesions in the “grey zone” (aQFR 0.75–0.92) benefit from further ischemia testings. This model would allow to reduce staged ischemia tests by 46.8% without a relevant loss in diagnostic efficiency.ConclusionOur data demonstrate that aQFR allows an effective assessment of hemodynamic relevance of non-culprit lesions in AMI and may guide interventions of non-culprit coronary lesions.Graphic abstract

Complete Revascularization of Stable STEMI Patients Offers a Significant Benefit if Done During the Index PCI, but Not if It's Done as a Staged Procedure.

BackgroundComplete revascularization (CR) of hemodynamically stable STEMI improves outcomes when compared to culprit-only PCI. However, the optimal timing for CR (CR during index PCI [iCR] versus staged PCI [sCR]) is unknown. sCR is defined as revascularization of non-culprit lesions not done during the index procedure (mean 31.5±24.6 days after STEMI). Our goal was to determine whether iCR was the superior strategy when compared to sCR.MethodsA systematic review of Medline, Cochrane, and Embase was performed for RCTs reporting outcomes of stable STEMI patients who had undergone CR. Only RCTs with a clearly defined timing of CR, for the classification into iCR and sCR, and a follow-up of at least 12 months were included. Seven RCTs comprising 6647 patients (mean age:62.9±1.4 years, male sex:79.4%) met these criteria and were included.ResultsAfter a mean follow-up of 25.1±9.4 months, iCR was associated with a significant reduction in cardiovascular mortality (risk ratio [RR] 0.48, 95% confidence interval [CI] 0.26–0.90, p=0.02, relative risk reduction [RRR] 52%) and non-fatal reinfarctions (RR 0.42, 95% CI 0.25–0.70, p=0.001, RRR: 58%). sCR showed a significant reduction in non-fatal reinfarctions only (RR 0.68, 95% CI 0.54–0.85, p=0.0008, RRR: 32%). There was no difference in the safety outcome of contrast-induced nephropathy between groups.ConclusioniCR of stable STEMI patients is associated with a significant reduction in cardiovascular death and a trend towards reduction in all-cause mortality. These benefits are not seen in sCR. Both strategies are associated with a reduction in non-fatal reinfarctions.

Complete revascularization in STEMI with multivessel disease: how late is too late?

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent research has shown that in patients (pts) with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease, revascularization of non-culprit lesions soon after primary percutaneous coronary intervention (PCI) reduces the risk of death and myocardial infarction (MI) compared with culprit-lesion-only PCI. However, in real-world practice, centres often cannot perform PCI of non-culprit lesions as early after hospital discharge as reported in these studies. Purpose To analyse current treatment of STEMI with multivessel disease in a district hospital and determine if there is still benefit in doing complete revascularization (CR) even when non-culprit lesion PCI is done late after hospital discharge. Methods We conducted a retrospective pilot study including all consecutive pts with STEMI submitted to primary PCI in a district hospital in 2018 who presented angiographically significant multivessel disease amenable to PCI. We compared outcomes between pts who underwent CR after hospital discharge (study group), those who did it during hospitalization and the group who only underwent culprit-lesion PCI. Exclusion criteria included history of coronary bypass graft, cardiogenic shock at admission, a chronic total occlusion as single non-culprit lesion and death before treatment strategy was defined. Results Of the 302 pts treated for STEMI in 2018, 125 had multivessel disease. Of these, 27 met exclusion criteria, resulting in a sample of 98 pts with a mean age of 66 years. Median time from symptom onset to PCI was 5 hours, with 8% of pts presenting in Killip class II-III. Most pts (61%) underwent CR during index hospital stay. 15% underwent PCI of non-culprit lesions after hospital discharge, with a median time from primary to non-culprit PCI of 86 days. Finally, 18% underwent no further revascularization. An additional 5 pts had non-culprit lesions treated surgically after a median of 364 days. At a median follow-up of 2.4 years, death had occurred in none of the pts of the study group, which did not significantly differ from the 7 pts (12%) in the group revascularized at index hospitalization (log-rank test: p = 0.185) but was significantly inferior to the 5 (29%) in the culprit-only PCI group (p = 0.037). There was no significant difference in a composite outcome of death, MI and stroke. The secondary outcome of ischaemia-driven revascularization occurred more often in the study group compared with those revascularized during hospitalization (HR 6.68; 95% CI 1.09-41.01; p = 0.040). Conclusions This study suggests that complete revascularization in STEMI with multivessel disease even late after hospital discharge is still superior to culprit-lesion only PCI in reducing risk of death. On the other hand, this late revascularization seems to be associated with higher rates of ischaemia-induced revascularization. Further research with a larger sample will be required to confirm the results of this pilot study.

Instantaneous wave-free ratio-guided revascularization of non-culprit lesion in patients with ST-segment elevation myocardial infarction and multivessel coronary disease: design and rationale of the WAVE registry.

Background The optimal management of patients with ST-elevation acute coronary syndromes and multivessel coronary artery disease is challenging. There is a growing body of evidence supporting invasive functional evaluation of multivessel disease with FFR or iFR has been added to the literature. In this regard, the WAVE study recently demonstrated the diagnostic accuracy of iFR functional assessment of non-culprit lesions in multivessel patients with STEMI. However, no studies have still verified the long-term clinical impact of an iFR-guided revascularization in this setting of patients. Methods Patients undergoing primary PCI for STEMI and presenting multivessel disease will be enrolled. After the treatment of the culprit lesion, an iFR-guided functional assessment of non-culprit lesions will be done: if iFR ≤ 0.89 PCI will be performed during the index procedure or staged. Conversely, iFR> 0.89 will be direct the patient towards a conservative approach. Results The study start date was May 1, 2018. The enrollement phase was completed on March 30, 2020. The primary endpoint is the occurrence of Target Lesion Failure (TLF), a composite of cardiovascular death, non-fatal myocardial infarction, and ischemia-driven revascularization of the vessel previously assessed with iFR. Secondary end points include MACE (Cardiovascular death, non-fatal MI, any revascularization). Conclusions The aim of the present study is to evaluate the long-term clinical impact of an iFR-guided revascularization of the non-culprit lesions in STEMI patients with multivessel coronary artery disease.

Revascularization Deferral of Nonculprit Stenoses on the Basis of Fractional Flow Reserve: 1-Year Outcomes of 8,579 Patients

BackgroundIntracoronary physiology is increasingly used in nonculprit stenoses of patients with acute coronary syndromes (ACS). However, evidence regarding the safety of fractional flow reserve-based deferral in patients with ACS, compared with patients with stable angina pectoris (SAP), is scarce. ObjectivesThe aim of this study was to evaluate the safety of revascularization deferral on the basis of fractional flow reserve interrogation of nonculprit lesions in patients with ACS. MethodsA pooled analysis was performed of individual patient data included in 5 large international published studies on physiology-guided revascularization. The primary endpoint was major adverse cardiac events (MACE) (a composite of death, nonfatal myocardial infarction, or unplanned revascularization) at 1-year follow-up. Clinical outcomes of patients with ACS and SAP were compared in both the deferred and the revascularized groups. ResultsA total of 8,579 patients were included in the analysis, 6,461 with SAP and 2,118 with ACS and nonculprit stenoses. Using fractional flow reserve, revascularization was deferred in 5,129 patients (59.8%) and performed in 3,450 patients (40.2%). In the deferred ACS group, a higher MACE rate was observed compared with the deferred SAP group (4.46% vs. 2.83%; adjusted hazard ratio [HR]: 1.72; 95% confidence interval [CI]: 1.17 to 2.53; p < 0.01). In particular, early unplanned revascularization (3.34% and 2.04% in ACS and SAP; adjusted HR: 1.81; 95% CI: 1.09 to 3.00; p = 0.02) contributed to this excess in MACE but the difference between the ACS and SAP groups did not reach statistical significance. On the contrary, no differences in outcomes linked to clinical presentation were found in treated patients (MACE rate 6.51% vs. 6.20%; adjusted HR: 1.21; 95% CI: 0.88 to 1.26; p = 0.24). ConclusionsPatients with ACS in whom revascularization of nonculprit lesions was deferred on the basis of fractional flow reserve have more MACE at 1 year compared with patients with SAP with deferred revascularization. Unplanned revascularization mainly contributed to this excess of MACE.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock

ObjectivesThis study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). BackgroundIn patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). MethodsFrom July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. ResultsOf 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). ConclusionsIn patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.

The Role of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Measurements in Patients with Acute Coronary Syndrome.

The role of fractional flow reserve to guide revascularization in patients with stable angina is well established. The instantaneous wave-free ratio (iFR) is an emerging adenosine-free resting index that is non-inferior to FFR and has potential to streamline the functional evaluation of coronary artery disease. The feasibility and utility of intracoronary physiology in patients with acute coronary syndrome (ACS) is unclear. This review will discuss the physiological principles and validity of using FFR and iFR in patients presenting with ACS. We will also provide an overview of the available evidence for their role in guiding revascularization in this patient group. The use of intracoronary physiology in culprit lesions of patients presenting with STEMI is not recommended and its accuracy is uncertain in patients with NSTEMI. In contrast, the physiological assessment of non-culprit vessels with FFR and IFR is a reliable measure of lesion-specific ischemia. Recent studies have demonstrated that FFR-guided revascularization of non-culprit lesions improves clinical outcomes although the role of iFR in this patient cohort is unknown. Physiology-guided revascularization of non-culprit ACS lesions improves clinical outcomes. Future studies investigating the complementary role of plaque morphology, biomechanics, and systemic inflammation may provide clinicians with a more comprehensive framework to guide treatment decisions.

P1511Promising prognostic value of negative stress echocardiography in patients with incomplete revascularization after successful primary PCI

Abstract Background The specific role of non-invasive functional testing in a risk stratification of patients with incomplete revascularization after primary percutaneous coronary intervention (pPCI) still needs to be evaluated. The aim of our study was to assess negative prognostic value of stress echocardiography (SECHO) after successful pPCI and incomplete revascularization of non-culprit lesions. Methods Our study consisted of 202 patients (mean age 59±10 years, male 142) successfully treated with pPCI, who performed SECHO according to Bruce protocol in order to assess residual ischemia in coronary artery with non-culprit lesion. Duke treadmill score, functional capacity (Metabolic Equivalents - METs), achieved target heart rate (THR), heart rate recovery (HRR), wall motion score index (WMSI) and ejection fraction were interrogated in all patients. Slow HRR was defined as ≤18 beats/min. Median follow-up of the patients was 70 months (IQR 55–83 months) for the occurrence of cardiovascular death and non-fatal myocardial infarction. We also assessed the independent predictors for the occurrence of the adverse events. Results Out of 202 patients, 42 (20.8%) had positive SECHO test, 4 patients (1.98%) had died due to non-cardiac causes and 7 patients (3.5%) were lost to follow-up. From the remaining 149 patients with negative SECHO, 13 (8.7%) had an adverse event (7 cardiovascular deaths and 6 non-fatal MI). Negative predictive value of SECHO test was 91.3%. Univariate predictors of adverse events were slow HRR (HR 4.343 [95% CI 1.473–14.011], p=0.008), and not achieved THR (HR 0.322 [95% CI 0.105–0.985], p=0.047). By multivariate analysis, only slow HRR remained independent predictor of adverse events (HR 3.324 [95% CI 1.013–10.906], p=0.048). Conclusion SECHO test has excellent negative prognostic value in patients with incomplete revascularization of non-culprit lesions after successful pPCI. Still, particular care should be taken to the patients with slow HRR and negative SECHO due to increased risk for the occurrence of adverse events. Acknowledgement/Funding Ministry of Education and Science of the Republic of Serbia (Grant No III41022)

Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review.

In ST-segment elevation myocardial infarction, urgent revascularization of the culprit coronary vessel and restoration of coronary flow is the goal of the initial management. However, obstructive non-culprit disease is frequently concomitantly found during initial angiography and portends a poor prognosis. Management of non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive debate. This review will examine the currently available evidence, with a specific focus on randomized clinical trials performed to date. Although early observational data suggested better outcomes with culprit-only revascularization, more recent data from several randomized trials have suggested improved outcomes with complete multivessel revascularization, either during the index PCI procedure or as a staged procedure. Data from recent randomized controlled trials have suggested the superiority of complete or multivessel revascularization and have subsequently led to changes to the most recent iterations of STEMI guidelines. However, the optimal management and timing of revascularization of non-culprit lesions in STEMI remain controversial.

Pathfinding to an optimal strategy of revascularization in primary coronary intervention in patients with multivessel disease: a network meta-analysis of randomized trials

Objectives: In ST-segment elevation myocardial infarction (STEMI), current guidelines discourage treatment of the non-culprit lesions at the time of the primary intervention. Latest trials have challenged this strategy suggesting benefit of early complete revascularization. We performed a Bayesian multiple treatment network meta-analysis of randomized clinical trials (RCTs) in STEMI on culprit-only intervention (CO) versus different timing multivessel revascularization, including immediate (IM), same hospitalization (SH) or later staged (ST).Methods: Outcome parameters were pooled with a random-effects model. For multiple-treatment meta-analysis, a Bayesian Markov chain Monte Carlo method was used.Results: Eight RCTs involving 2077 patients were identified. ST and IM revascularization was associated with a decrease in major adverse cardiac events (MACEs) compared to culprit-only approach (risk ratio [RR]: 0.43 credible interval [CrI]: 0.22–0.77 and RR: 0.36 CrI: 0.24–0.54, respectively). IM was superior to SH (RR: 0.49 CrI: 0.29–0.80). With regards to myocardial infarction IM was superior to SH (RR: 0.18 CrI: 0.02–0.99). The posterior probability of being the best choice of treatment regarding the frequency of MACEs was 71.2% for IM, 28.5% for ST, 0.3% for SH and 0.05% for culprit-only approach.Conclusions: Results from RCTs indicate that immediate or staged revascularization of non-culprit lesions reduces major adverse events in patients after primary percutaneous coronary intervention. Differences in MACEs suggest superiority of the immediate or staged intervention; however, further randomized trials are needed to determine the optimal timing of revascularization of the non-culprit lesions.

Preliminary Report on the Safety and Efficacy of Staged versus Complete Revascularization in Patients with Multivessel Disease at the Time of Primary Percutaneous Coronary Intervention.

This study aims to determine the safety and efficacy of complete versus staged-percutaneous coronary intervention (PCI) of nonculprit lesions at the time of primary PCI in patients with multivessel disease. Recent trials had suggested that revascularization of nonculprit lesions at the time of primary PCI is associated with better outcomes, however; the optimum timing and overall safety of this approach is not well known. An observational prospective study was conducted, including 50 patients who presented with ST-segment elevation myocardial infarction and found to have at least an additional nonculprit significant (> 70%) type A or B lesion. According to the operator's discretion, patients either underwent complete revascularization of nonculprit significant lesions during primary PCI procedure or within 60 days of primary PCI (staged-PCI). Safety outcomes evaluated were contrast-induced nephropathy (CIN), the amount of contrast used, and fluoroscopy time. Efficacy outcome assessed was major adverse events (MACE) at 1 year. The fluoroscopy time and amount of contrast used were increased in complete revascularization group (35.3 ± 9.6 vs. 26.3 ± 6.7 minutes, p < 0.001, and 219.5 ± 35.1 vs. 187.5 ± 45.5 mL, p = 0.01, respectively); while incidence of CIN remained similar ( p = 0.73). The incidence of MACE at 1 year was similar in both groups (23% in the complete revascularization group vs. 25% in the staged-PCI group, p = 0.43). Complete revascularization and staged-PCI of nonculprit type A or B lesions at the time of primary PCI were associated with similar long-term outcomes and safety profile. Larger studies are needed to further validate these results.

How Should We Treat Multi-Vessel Disease in STEMI Patients?

Primary angioplasty of the culprit coronary artery lesion is the preferred reperfusion strategy for ST-elevation myocardial infarction (STEMI) when timely access to a catheterization laboratory is available. The presence of multi-vessel disease (MVD) in patients undergoing primary PCI is common, occurring in about 40%-50% of patients. The presence of MVD in patients who have undergone successful primary PCI substantially increases the risks of mortality and major adverse cardiac events, such as reinfarction or need for urgent revascularization. The current evidence supporting revascularization of non-culprit lesions is sparse, with no large, adequately powered randomized trials to guide clinical practice. An analysis combining observational data and small randomized trials suggests that complete revascularization with PCI to significant non-culprit lesions may afford a benefit compared with medical management alone. However, this benefit appears to be confined to when revascularization is performed as a separate, staged procedure. By contrast, when non-culprit lesion PCI is performed during the initial primary PCI procedure, the risk of death or cardiovascular events is higher than medical management alone or to staged revascularization. A large, adequately powered randomized trial is urgently needed to determine whether routine staged PCI plus optimal medical therapy is superior to optimal medical therapy alone for significant non-culprit coronary artery lesions in patients who have undergone successful primary PCI for STEMI.