Timing Of Revascularization Research Articles

Vascular Complications of Percutaneous Coronary Intervention Via Distal Radial Artery Approach in Patients With Acute Myocardial Infarction With and Without ST-Segment Elevation.

Distal radial artery (DRA) access is a novel alternative to conventional radial artery access for coronary catheterization. This study investigated the incidence of vascular complications with percutaneous coronary intervention (PCI) from DRA access among patients with acute myocardial infarction (AMI) with and without ST-segment elevation. Between April 2018 and October 2019, a total of 131 consecutive patients underwent primary PCI for AMI, among whom DRA access was used in 116 (88.5%), comprising 77 with ST-segment elevation myocardial infarction (STEMI) and 39 with non-ST-segment elevation myocardial infarction. The mean patient age was 70.4 ± 12.9 years and 71.6% were male. Right DRA was used in 110 patients (94.8%). A 5 or 6 Fr sheath was used in the PCI procedure. Patient backgrounds, procedural characteristics, and procedural complications were retrospectively analyzed. Patency of the radial artery was examined using Doppler ultrasound. Minor bleeding (Bleeding Academic Research Consortium [BARC] 2) was observed in 2 patients (1.7%) while no major bleedings (BARC 3a, 3b, 3c, and 5) were observed. On the Early Discharge After Transradial Stenting of Coronary Arteries Study (EASY) hematoma scale, a grade III hematoma (≥10 cm) was observed in 1 patient (0.9%), and no patients with hematoma were > grade IV. Doppler ultrasound of the radial artery was performed on 95 patients (81.9%). The incidence of radial artery occlusion was 1.1% (n = 1). The door-to-balloon time for STEMI patients was 40.0 ± 30.8 minutes. The current study demonstrated that DRA access was associated with a low incidence of access-site complications within optimal revascularization time among patients with AMI who underwent PCI.

Surgical revascularization as a procedure to prevent neurological complications in children with moyamoya syndrome associated with neurofibromatosis I: a single institution case series.

The optimal timing and surgical approach for surgical revascularization in patients with moyamoya syndrome (MMS) associated with neurofibromatosis type I (NF1) remain so far elusive. We aimed to compare the long-term clinical, radiological, and cognitive effects of different revascularization procedures in a pediatric cohort of NF1-associated MMS. We reviewed the clinical, radiological, and surgical data of 26 patients with NF1-associated MMS diagnosed at our institution between 2012 and 2022, at the clinical onset and last follow-up. Indirect bypasses were performed in 12/26 patients (57.1%), while combined direct and indirect procedures in 9/26 subjects (42.9%); 5 patients did not undergo surgery. Through logistic regression analysis, pathological Wechsler Intelligence Scale for Children (WISC) at onset was found to be associated with symptom improvement at 1-year follow up (p = 0.006). No significant differences were found in long-term neurocognitive outcome and stroke rate in patients receiving combined or indirect bypass (p > 0.05). Currently, whether combined or indirect bypass should be considered the treatment of choice in pediatric patients with NF1-associated MMS remains unclear, as well as the optimal time approach. In our series, no significant differences were found in long-term neurocognitive outcome and stroke rate between patients treated with either of these two approaches. Clinical evidence supports the crucial role of early diagnosis and surgical revascularization in subjects with MMS-associated NF1, even in case of mildly symptomatic vasculopathy. This allows to achieve a good long-term outcome with improved intellectual function and prevention of stroke and seizure in these patients.

Evaluation and management of coronary artery disease in patients undergoing transcatheter aortic valve implantation

Significant coronary artery disease (CAD) and severe aortic stenosis (AS) are frequent findings in patients who undergo transcatheter aortic valve implantation (TAVI). With the extension of TAVI in patients who have intermediate and even low surgical risk, the optimal evaluation and management of concomitant CAD needs to be determined. Both pre-TAVI evaluation of CAD and indications for revascularization remain a matter of debate. In this review, we provide an updated overview of the prevailing landscape of CAD in patients undergoing TAVI with a focus on its prognostic impact, diagnostic evaluation pre-procedure, indications for revascularization, optimal timing of revascularization, and future directions.

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.

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists

BackgroundBecause of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations. AimWe designed a survey to compare management of different APE phenotypes according to the physicians’ medical specialty, and to compare the results with what experts would do and European guidelines. MethodsFour clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case. ResultsThe intention is to present the results at national and international conferences and publish them in a peer-reviewed journal. ConclusionsThe results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Management of acute coronary syndromes 2023 European Society of Cardiology guidelines

For the first time, the European Society of Cardiology has drafted guidelines which encompass the management of the entire spectrum of patients with acute coronary syndrome, ranging from cardiogenic shock or cardiac arrest to ST-segment as well as non-ST-segment elevation myocardial infarction, to unstable angina. Some of the modified, as well as new recommendations include cardiac arrest, cardiogenic shock, diagnostic workup, antithrombotic therapy, timing of invasive strategy, intravascular imaging and revascularization in multivessel coronary artery disease. In addition, and for the first time, one entire section is dedicated to the patient's perspective and shared decision.

Coronary artery bypass grafting versus percutaneous coronary intervention in single-vessel left anterior descending artery disease: mid-term propensity matching study.

Coronary artery bypass grafting (CABG) has been considered to be the proven therapeutic choice for coronary artery disease. However, percutaneous coronary intervention (PCI) with drug-eluting stents is increasingly used for extensive coronary artery disease with contradictory results. The aim of this study is to compare immediate- and mid-term results of CABG where skeletonized internal mammary artery (IMA) was used as in situ graft versus PCI with serolimus drug eluted stents (SES) in single-vessel left anterior descending artery (LAD) disease. In 2014-2022, 938 patients treated for isolated LAD revascularization were included in this study. Among them, there were 346 patients with CABG-IMA and 592 patients with SES-PCI. CABG-IMA patients (n = 266) were compared with SES-PCI patients (n = 266) in propensity score-matched method.Primary outcome measures were identified as all-cause mortality at 30days and 3years after surgery, while secondary outcome measures were length of hospital stay and the incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE). Increased incidence for post procedural MACCE after PCI was recorded (CABG = 1.2% vs. PCI = 5.3%; p < 0.05). There was no difference in immediate-term (30days: CABG = 1.2% vs. PCI = 1.5%; p = ns) and mid-term (3years: CABG = 3.7% vs. PCI = 4.5%; p = ns) mortality between the groups. Patient after SES-PCI had shorter length of hospital stay (CABG = 7.7days vs. PCI = 3.8days; p < 0.05). The results of the study indicated that CABG-IMA performed at the time of myocardial revascularization in single-vessel LAD disease is better than SES-PCI. Our conclusion is independent of traditionally accepted risk factors incorporated in the Logistic EuroSCORE II (European System for Cardiac Operative Risk Evaluation) and SYNTAX score II (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery Score II) and is exclusively method related.

Optimal timing of surgical revascularization in patients with acute myocardial infarction

Acute myocardial infarction (AMI) is the leading cause of cardiovascular mortality in developed countries. While primary percutaneous coronary intervention is the gold-standard first-line therapy for initial revascularization of a culprit vessel, coronary artery bypass grafting (CABG) surgery can allow for subsequent complete revascularization when additional high-risk coronary stenoses remain. The optimal timing of CABG after AMI remains controversial. Early surgery during the acute period can lead to a detrimental systemic inflammatory response and may be associated with a higher bleeding risk due to the use of antiplatelet and fibrinolytic agents. On the other hand, later surgery increases the risk of ischemic recurrence while waiting, with the potential for an irreversible decrease in myocardial function or death. This narrative review summarizes the evidence supporting decision-making for optimal timing of surgical revascularization in patients with AMI.

Does MULTISTARS shed light on the timing of complete revascularization in ST-elevation myocardial infarction?

Does MULTISTARS shed light on the timing of complete revascularization in ST-elevation myocardial infarction?

Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial

BackgroundIn the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, the risk of ischemic events was similar in patients with stable coronary artery disease treated with an invasive (INV) strategy of angiography and percutaneous coronary intervention (PCI) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization and a conservative (CON) strategy of initial medical therapy. ObjectivesThe authors analyzed separately the outcomes of INV patients treated with PCI or CABG. MethodsPatients without preceding primary outcome events were categorized as INV-PCI or INV-CABG from the time of revascularization. The ISCHEMIA primary outcome (composite of cardiovascular death, protocol-defined myocardial infarction or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) was used. ResultsAmong INV-CABG patients, primary outcome events occurred in 84 of 512 (16.4%) at a median follow-up of 2.85 years; 48 events (57.1%) occurred within 30 days after CABG, including 40 procedural MIs. Among INV-PCI patients, primary outcome events occurred in 147 of 1,500 (9.8%) at median follow-up of 2.94 years; 31 of which (21.1%) occurred within 30 days after PCI, including 24 procedural MIs. In comparison, 352 of 2,591 CON patients (13.6%) had primary outcome events at a median follow-up of 3.2 years, 22 of which (6.3%) occurred within 30 days of randomization. The adjusted primary outcome risks were higher after both CABG and PCI within 30 days (HR: 16.25 [95% CI: 11.44-23.07] and HR: 2.99 [95% CI: 1.97-4.53]) and lower thereafter (0.63 [95% CI: 0.44-0.89] and 0.66 [95% CI: 0.53-0.82]). ConclusionsIn ISCHEMIA, early revascularization by PCI and CABG was associated with higher early risks and lower long-term risks of cardiovascular events compared with CON. The early risk was greatest after CABG, owing to protocol-defined procedural MIs.

Abstract 15875: Immediate Complete Revascularization Reduces Recurrent Myocardial Infarction and Repeat Revascularization in Patients Presenting With Acute Myocardial Infarction

Introduction: Studies have suggested that complete revascularization has better outcome compared with culprit-only revascularization for the treatment of enzyme-positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a meta-analysis of randomized controlled trials (RCT) comparing immediate complete revascularization with staged revascularization in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) with multi-vessel disease. Methods: We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed and clinicaltrials.gov databases for RCT comparing immediate complete revascularization with staged revascularization in patients with enzyme-positive acute coronary syndrome. The pooled outcome were major cardiovascular adverse event (MACE), all-cause death, cardiovascular death, recurrent MI and repeat revascularization. The random effect and Mantel-Haenszel method was used to analyze the data. Heterogeneity was measured using I 2 . Results: Five studies met the inclusion criteria ( 1187 patients in immediate complete revascularization group and 1176 patients in staged revascularization group). We did not find any significant difference in the rate of MACE (OR: 0.75 [95 % CI: 0.44-1.29] I 2 : 35%, p value = 0.30). Similarly, there was no significant difference in the rates of all-cause death (OR: 0.93 [95 % CI: 0.47-1.86] I 2 : 40%, p value = 0.84)and cardiac death (OR: 1.02 [95 % CI: 0.52-1.98] I 2 : 14%, p value = 0.96). However, immediate complete revascularization group had significant reduction in the rates of repeat revascularization (OR: 0.59 [95 % CI: 0.43-0.82] I 2 : 0%, p value = 0.002) and recurrent MI (OR: 0.52 [95 % CI: 0.32-0.84] I 2 : 1%, p value = 0.008). Subgroup analysis including STEMI patients only showed similar rate of MACE ((OR: 0.92 [95 % CI: 0.60-1.41] I 2 : 0%, p value = 0.70). Conclusions: Our results suggest that immediate complete revascularization is safe. There was significant reduction in recurrent MI and need for repeat revascularization in patients undergoing immediate complete revascularization.

Abstract 12186: A Challenging Case of Acute Superior Mesenteric Artery Embolism Diagnosed by Gastroscopy

Introduction: Acute superior mesenteric artery (SMA) occlusion is one of the most lethal causes of acute abdomen that we often experience but mistake for gastrointestinal diseases. The golden time for revascularization in cases of SMA main trunk occlusion is within 5 hours of onset, requiring prompt diagnosis and treatment. We describe a challenging case of acute SMA embolism diagnosed by gastroscopy. Case Summary: A 66-year-old man with a history of hypertension presented to the emergency department for marked epigastric pain after eating raw seafoods. On arrival, electrocardiogram showed atrial flutter with no significant ST-segment changes. Despite the elevation of white blood cell count and lactate dehydrogenase in blood exam, computed tomography (CT) indicated no findings to cause his symptoms. Emergency gastroscopy performed on suspicion of anisakiasis demonstrated pallor findings with hematologic material in the duodenum, suggesting intestinal ischemia (Figure A). Since contrast-enhanced CT revealed an occlusion of SMA (Figure B), we diagnosed acute SMA embolism based on the finding of atrial flutter without anticoagulation. After discussion among cardiologists and gastroenterology surgeons, we selected to perform endovascular treatment. The epigastric pain was improved after reperfusion using a self-expandable stent, but flared up as oral intake progressed. Follow-up CT suggested ischemic enteritis of the proximal jejunum, leading to conduct laparoscopic partial jejunectomy. He was discharged 18 days after the operation with the ability to eat a normal diet. Conclusions: This case highlights that we should keep in mind SMA embolism when examining acute abdomen patients with atrial fibrillation or flutter without anticoagulation.

Abstract 011: Endovascular therapy for acute ischemic stroke utilizing SOFia Aspiration System as first line Technique (SOFAST)

Introduction Mechanical thrombectomy using stent retrievers and aspiration techniques has emerged as the standard of care for patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (LVO). This study intended to collect real‐world clinical evidence on the safety and effectiveness of endovascular treatment of AIS using the SOFIA Flow Plus 6F aspiration catheter. The primary endpoint was the proportion of subjects achieving mTICI ≥2b. Secondary endpoints included good functional outcomes (mRS 0‐2) at Day 90, revascularization time, first line and first pass mTICI ≥2b, occurrence of procedure‐related SAEs, vasospasm involving the accessed vascular tree, embolization to new territories (ENTs), symptomatic intracerebral hemorrhage (sICH) within 24 hours and mortality at Day 90. Methods SOFAST was a prospective, multicenter, single‐arm, observational post‐market study. The enrolled subjects were ≥21 and ≤85 years with large vessel (ICA or MCA) proximal occlusion, pre‐morbid mRS ≤1, baseline NIHSS ≥5, and for whom groin puncture was within 8 hours of symptom onset. A total of 108 patients were enrolled and treated using aspiration thrombectomy with SOFIA 6F as the first line treatment device. Patients were followed at 24 hours, 7 days/discharge, and 90 days post‐procedure. Cerebral angiography was performed pre‐ and post‐procedure. Clinical assessments included the NIHSS and mRS scales. All neurological, device‐related, and procedure‐related AEs and deaths were adjudicated by independent medical reviewers. Angiographic and other imaging data was adjudicated by an independent core laboratory. Results A total of 108 subjects were enrolled (mean age 62.7 years, 50% men) with a median NIHSS of 15.5. Of 108 subjects, 97.2% (105/108), 85.2% (92/108) and 55.6% (60/108) achieved mTICI ≥2b, ≥2c and =3 revascularization, respectively. With first line aspiration using SOFIA 6F, 87.0%, 79.6% and 52.8% achieved mTICI ≥2b, ≥2c and =3 revascularization, respectively. Median number of passes was one (range 1‐3). First pass rate of mTICI 2c or 3 using SOFIA 6F was 70.4%, of which 50.9% patients achieved mTICI score of 3. Mean duration from groin puncture to initial clot contact was 13.0 min and to successful revascularization was 17.9 min. Good functional outcome was achieved in 66.7% (72/108) of subjects at Day 90 (mRS 0‐2), procedure‐related SAEs occurred in 2.8% (3/108) of subjects and sICH in 0.9% (1/108) of subjects within 24 hours. Procedural vasospasm was recorded in in 9.3% (10/108) of subjects, and mortality in 7.4% (8/108) subjects at Day 90 (none related to the study device). No ENTs occurred. Conclusion In SOFAST study, mTICI ≥2b revascularization was achieved in the majority of patients at the end of all procedures (97.2%) and with first line treatment (87.0%) with a large fraction of these subjects achieving mTICI ≥2c following the first SOFIA 6F pass (70.4%). Durations from groin puncture to clot contact and successful revascularization were relatively short. The study presented high rates of good functional outcome at Day 90 and low rates of safety events. In summary, the study provides encouraging evidence of the safety and effectiveness of the SOFIA 6F device for aspiration thrombectomy in acute ischemic stroke subjects.

Outcomes following carotid revascularization for stroke stratified by Modified Rankin Scale and time of intervention

ObjectivesThe relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS. MethodsWe identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate. ResultsWe identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03). ConclusionsIn patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.

TCT-139 Timing of Complete Multivessel Revascularization in Patients Presenting With Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-139 Timing of Complete Multivessel Revascularization in Patients Presenting With Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-577 The Optimal Timing of Complete Revascularization in Heterogeneous Cohorts With Multivessel Coronary Artery Disease: An Updated Meta-Analysis of 116,730 Patients

TCT-577 The Optimal Timing of Complete Revascularization in Heterogeneous Cohorts With Multivessel Coronary Artery Disease: An Updated Meta-Analysis of 116,730 Patients

Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion

BackgroundEarly endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency...

Optimal management of coronary artery disease in patients undergoing TAVI: The heart team holds the power.

Key Points The presence and complexity of coronary artery disease (CAD) as well as angiography‐guided percutaneous coronary intervention regardless of completeness were not associated with worse outcomes compared to those without CAD undergoing transcatheter aortic valve implantation (TAVI). Revascularization of CAD in patients undergoing TAVI is safe, but should not be performed routinely. Revascularization should be guided by the heart team. Future randomized studies are needed to address whether revascularization in patients with CAD undergoing TAVI impacts clinical outcomes post‐TAVI and if so, does completeness or timing of revascularization play a role.

Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

BackgroundIn patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown.MethodsWe performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan–Meier estimates at 6 months and at 1 year.ResultsWe assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event.ConclusionsAmong patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.)

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy.

Patients with simultaneous relevant internal carotid artery stenosis and coronary artery heart or valve disease represent a high-risk collective with respect to cerebral or cardiovascular severe events when undergoing surgery. There exist several concepts regarding the timing and modality of carotid revascularization, which are controversially discussed in patients with heart disease. More data regarding outcome predictors and measures are needed to gain a better understanding of the best treatment option of the discussed patient collective. This single-center study retrospectively analyzed n = 111 patients undergoing heart surgery with coronary artery bypass grafting or heart-valve surgery and concomitant carotid surgery due to significant internal carotid artery stenosis. In order to do so, patients were divided into two groups with respect to postoperative major adverse cardiac and cerebrovascular events (MACCE) with thirty-day all-cause mortality, valve related mortality, myocardial infarction, stroke and transitory ischemic attack. Preoperative patient's characteristic in the no-MACCE and MACCE group were mainly balanced, other than higher rates of chronic obstructive pulmonary disease, chronic kidney disease, instable angina pectoris and prior transitory ischemic attack in the MACCE cohort. The analysis of intraoperative characteristics revealed a higher number of intra-aortic balloon pump implantation, which is in line for a higher number of postoperative supports. Besides MACCE, patients suffered significantly more often from postoperative bleeding events and re-thoracotomy, cardiopulmonary reanimation, new onset postoperative dialysis and prolonged intensive care unit stay related complications. Within the reported patient population suffering from MACCE after a simultaneous carotid endarterectomy and heart surgery, a preoperative history of transitory ischemic attack and kidney disease might account for worse outcomes, as severe events were not only neurologically driven but also associated with postoperative cardiovascular complications following heart surgical procedures.