Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Disease

Circulation, Journal Year: 2020, Volume and Issue: 141(18), P. 1437 - 1446

Published: March 30, 2020

Long-term comparative outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents and coronary-artery bypass grafting (CABG) for left main artery disease are highly debated.In the PRECOMBAT trial (Premier of Randomized Comparison Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients Left Main Coronary Artery Disease), patients unprotected were randomly assigned to undergo PCI sirolimus-eluting (n=300) or CABG 13 hospitals Korea from April 2004 August 2009. The follow-up was extended at least 10 years all (median, 11.3 years). primary outcome incidence major adverse cardiac cerebrovascular events (composite death any cause, myocardial infarction, stroke, ischemia-driven target-vessel revascularization).At years, a event occurred 29.8% group 24.7% (hazard ratio [HR] vs CABG, 1.25 [95% CI, 0.93-1.69]). 10-year composite death, stroke (18.2% 17.5%; HR 1.00 0.70-1.44]) all-cause mortality (14.5% 13.8%; 1.13 0.75-1.70]) not significantly different between groups. Ischemia-driven revascularization more frequent than (16.1% 8.0%; 1.98 1.21-3.21).Ten-year randomized did demonstrate significant difference events. Because study underpowered, results should be considered hypothesis-generating, highlighting need further research. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03871127 NCT00422968.

Language: Английский

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Mortality after drug-eluting stents vs. coronary artery bypass grafting for left main coronary artery disease: a meta-analysis of randomized controlled trials

European Heart Journal, Journal Year: 2020, Volume and Issue: 41(34), P. 3228 - 3235

Published: Feb. 14, 2020

The optimal method of revascularization for patients with left main coronary artery disease (LMCAD) is controversial. Coronary bypass graft surgery (CABG) has traditionally been considered the gold standard therapy, and recent randomized trials comparing CABG percutaneous intervention (PCI) drug-eluting stents (DES) have reported conflicting outcomes. We, therefore, performed a systematic review updated meta-analysis to PCI DES treatment LMCAD.

Language: Английский

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Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial

The Lancet, Journal Year: 2023, Volume and Issue: 401(10383), P. 1172 - 1182

Published: March 5, 2023

Language: Английский

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Clinical quantitative coronary artery stenosis and coronary atherosclerosis imaging: a Consensus Statement from the Quantitative Cardiovascular Imaging Study Group

Nature Reviews Cardiology, Journal Year: 2023, Volume and Issue: 20(10), P. 696 - 714

Published: June 5, 2023

Language: Английский

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Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery

JAMA Internal Medicine, Journal Year: 2020, Volume and Issue: 180(12), P. 1638 - 1638

Published: Oct. 12, 2020

Mortality is a common outcome in trials comparing percutaneous coronary intervention (PCI) with artery bypass grafting (CABG). Controversy exists regarding whether all-cause mortality or cardiac preferred as study end point, because noncardiac should be unrelated to the treatment.To evaluate difference and cause-specific randomized clinical (RCTs) PCI CABG for treatment of patients disease.MEDLINE (1946 present), Embase (1974 Cochrane Library (1992 present) databases were searched on November 24, 2019. Reference lists included articles also searched, additional studies if appropriate.Articles considered inclusion they English, RCTs drug-eluting bare-metal stents disease, reported and/or mortality. Trials involving angioplasty without stenting excluded. For each trial, publication longest follow-up duration was selected.For data extraction, all reviewed by 2 independent investigators, disagreements resolved third investigator accordance Preferred Reporting Items Systematic Reviews Meta-analyses guideline. Data pooled using fixed- random-effects models.The primary outcomes (cardiac vs noncardiac) Subgroup analyses performed left main disease.Twenty-three unique 13 620 (6829 undergoing 6791 CABG; men, 39.9%-99.0% populations; mean age range, 60.0-71.0 years). The weighted (SD) 5.3 (3.6) years. Compared CABG, associated higher rate (incidence ratio, 1.17; 95% CI, 1.05-1.29) 1.24; 1.05-1.45) but 1.19; 1.00-1.41).Percutaneous all-cause, cardiac, compared at 5 significantly suggests that even deaths after may procedure related supports use point myocardial revascularization trials.

Language: Английский

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Recent advances in percutaneous coronary intervention

Heart, Journal Year: 2020, Volume and Issue: 106(18), P. 1380 - 1386

Published: June 10, 2020

Percutaneous coronary intervention (PCI) continues to advance at pace with an ever-broadening indication. In this article we will review the recent technological advances in PCI that have enabled more complex disease be treated. The choice of revascularisation strategy must take into account evidence-just because can treat by does not necessarily mean should. When is indicated, a safe, precision approach guided physiology, imaging and optimal lesion preparation should goal obtain complete durable long-term result. these standards are adhered to, outcomes excellent, even disease. We provide contemporary trial evidence justify treatment algorithms ensure decision making achieve best patient outcomes.

Language: Английский

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Implications of Alternative Definitions of Peri-Procedural Myocardial Infarction After Coronary Revascularization

Journal of the American College of Cardiology, Journal Year: 2020, Volume and Issue: 76(14), P. 1609 - 1621

Published: Sept. 28, 2020

Language: Английский

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Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

European Heart Journal, Journal Year: 2021, Volume and Issue: 42(27), P. 2630 - 2642

Published: April 26, 2021

Abstract A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk major adverse cardiac events (MACE). Due lack scientific data, the cut-off thresholds post-PCI troponin (cTn) elevation used for defining and infarction, have been selected based on expert consensus opinions, prognostic relevance remains unclear. In this Consensus Document from ESC Working Group Cellular Biology Heart European Association Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, measurement baseline (pre-PCI) cTn values in all CCS PCI. We confirm >5× 99th percentile URL threshold define type 4a infarction (MI). absence angiographic flow-limiting electrocardiogram (ECG) imaging evidence new ischaemia, propose same (>5× URL) prognostically relevant ‘major’ injury. As both MI are strong independent predictors all-cause mortality at 1 year post-PCI, they as quality metrics surrogate endpoints clinical trials. Further research needed evaluate treatment strategies reducing injury, MI, MACE

Language: Английский

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Impact of Peri-Procedural Myocardial Infarction on Outcomes After Revascularization

Journal of the American College of Cardiology, Journal Year: 2020, Volume and Issue: 76(14), P. 1622 - 1639

Published: Sept. 28, 2020

Language: Английский

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SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease

Catheterization and Cardiovascular Interventions, Journal Year: 2020, Volume and Issue: 96(2), P. 346 - 362

Published: May 14, 2020

The anatomic and clinical complexity of patients with coronary artery disease (CAD) is increasing in the United States.1-3 While terms "complex CAD" or "high-risk have not been formally defined, they encompass both complex lesions parameters including advanced age, frailty, comorbidities, compromised hemodynamic status, depressed ventricular function concomitant valvular disease.4-6 Such features increase procedural percutaneous intervention (PCI) risk adverse patient outcomes. direct relationship between CAD appropriateness for revascularization also emphasized current societal guidelines appropriate use criteria documents; however, precise guidance managing this growing group lacking.7-9 In document, Society Cardiovascular Angiography Interventions (SCAI) has produced an expert consensus a two-fold objective: (a) to present state-of-the art evidence regarding PCI anatomical features, (b) provide achieve optimal outcomes challenging group. This companion document jointly published SCAI statement on performance ambulatory surgical centers (ASC).177 Together these documents aim best practices settings across spectrum (Figure 1). Below, we first discuss pre-procedural stratification patients, then detail interventional specific lesion subsets. was developed according Publications Committee policies writing composition, disclosure management relationships industry, internal external review, organizational approval.10 need position paper treating identified by working from Executive Ischemic Heart Disease Council. By design, included multidisciplinary physicians who care CAD, cardiologists, general cardiologists specialized noninvasive imaging, cardiothoracic surgeons. Before appointment, members were asked disclose financial 12 months prior nomination (Table S1). A majority disclosed no relevant relationships. Disclosures periodically reviewed during development updated as needed. policy requires that interest are recused participating discussions voting recommendations. work committee supported exclusively SCAI, nonprofit medical specialty society, without commercial support. primarily reflects opinion. draft manuscript peer April 2020 revised address pertinent comments. unanimously approved final version document. endorsed official society May 2020. Defining procedure "complex" "high-risk" usually integrates several domains, profile technical intervention(s) planned 2). To go beyond subjectivity inherent judgment, multiple methods validated objectively assess revascularization. Clinical scores such thoracic surgeons (STS) score, EuroSCORE II, National Data Registry (NCDR), others can insights into complications.11-13 addition, integrated anatomical-clinical Synergy Between Taxus Cardiac Surgery (SYNTAX) II score additional value assessing comparative 4-year mortality rates bypass grafting (CABG) surgery.5 Current ACC/AHA recommend calculation STS SYNTAX unprotected left main (LM) disease.7 For multivessel LM utilization heart team guide decision-making Class I recommendation American European guidelines.8, 14 As cardiac surgeons, failure specialists, other offer different treatment perspectives, facilitate patient-centered Group center around patient-specific presentation various scores, implementation guideline recommendations decision-making. Moreover, approach may better outcomes, suggested favorable registry arms randomized controlled trials routine practice.15-17 Recent further shows utilizing structured form formal cardiology consultative service improve operation team.18 Therefore, encouraged guiding CAD. certain situations, PCI-based require approaches atherectomy, chronic total occlusion (CTO) capabilities, temporary durable mechanical circulatory support, availability on-site surgery. If potentially indicated but available at initially center, arrangements should be made refer transfer equipped capabilities. Collaboration expertise more complicated scenarios therefore patients. Multivessel common undergoing high-risk, PCI.19 Multiple observational studies CABG demonstrate completeness associated improved among disease.20-22 However, trial data supporting complete only ST-elevation myocardial infarction (STEMI) primary PCI, where significant nonculprit reduces cardiovascular events.21, 23 indicated, careful assessment benefit required optimize safety. disease, ischemia viability testing, invasive physiologic considering staged reduce any single procedure.22, 24, 25 Utilizing state-of-the-art techniques intravascular imaging physiology, discussed below, leads excellent CTO, lesions.5 proportion prohibitive complications CABG. calculator useful determining expected complication rate CABG, it less decision created help define strategy (CABG vs. PCI) individual based anatomy select comorbidities.26 which used conjunction approach, highly evidence-based determine relative merits hybrid strategies, therapy disease.18 Patients declined surgery high and/or severe comorbidities represent particularly high-risk subgroup referred PCI. These increased out assessed traditional tools.9, 27 Randomized comparing strategies lacking. combination ability tolerate sustained make evaluation valuable morbidity acute syndromes (ACS), ST-segment elevation.28, 29 Minimizing time reperfusion critical STEMI coordinated systems early activation catheterization laboratory.30, 31 Additionally, preferred non-STEMI especially those higher risk.29, 32 ACS event compared elective Adjunctive antiplatelet anticoagulant risk. Furthermore, presence long-term STEMI.21, Whether performed remains unknown, maybe data.33 Staging procedures non-culprit stenoses appears safe if timely fashion.34 Surgical addition impaired (LV) (EF <= 35%) shown all-cause alone.35, 36 setting concurrent cardiogenic shock mortality.37 performing LV rates, likely due lack reserve.38 MCS devices, axial centrifugal flow safety efficacy very includes procedures, emergent (AMI), decompensated shock.4, 39-42 Several proposed algorithms incorporate area myocardium treated risk, estimated duration, underlying dysfunction, systemic state, degree shock, major eligibility.9, 39, 40, 43 Device selection guided ease implantation use, vascular risks, mechanism device contraindications, acuity severity, anticipated duration support operator/center-specific volume 3).39, 40 decisions weigh risks benefits MCS-assisted unassisted therapeutic options revascularization, assist implantation, transplantation. Appropriate light potential device-related complications.44-46 There limited devices procedures. Observational hemodynamics despite higher-risk profiles. ischemic cardiomyopathy, function.47 limitations routinely using include device-specific learning curves variable rates.48-51 Low-dose contrast peripheral angiography, arterial duplex scans, computed tomography angiography preprocedural planning suspected known inverse eGFR incidence CAD.52 Furthermore kidney (CKD) experience 2–3-fold CAD.53 diagnostic underutilized CKD end-stage renal dialysis, illustrating risk-treatment paradox.53, 54 part elevated contrast-induced injury (CIAKI) diffuse, calcific often encountered amount delivered angiography/PCI CIAKI.55 volume-administration normal saline invasively measured filling pressures CIAKI.56 Ultra-low upon calculated considered, maximum allowed target ideally than eGFR.57 either same staged. Regardless setting, minimizing ratio ≤ 2.0–3.7, CIAKI.58-60 Contrast reduced liberal physiology PCI.61 Initial images coregistration catheters road mapping software mark proximal distal edges dry cineangiography usage contrast.62 Concomitant mitral aortic infrequent conditions entity isolation.63-65 Percutaneous valve their lower tolerance ischemia. essential evaluate timing intervention. obstructive stenosis, transcatheter replacement (TAVR) unknown. TAVR minimize issues related accessibility post-TAVR.64 some simultaneous 30-day TAVR.66 (MV) minimally MV mobility.67, 68 Further understand how manage subset. guideline-recommended choice diabetes mellitus presenting average risk.8, 31, 69, 70 poor targets, conduits grafts. prefer approach. cases, even minimally-invasive appropriate.71 undergo periprocedural events well stent restenosis, non-diabetics.11 It postulated occur prothrombotic resistance therapies, diffuse atherosclerosis, negative vessel remodeling.72-74 requiring insulin poorly hyperglycemia rates.75, 76 following glycemic control needed, consideration newer pharmacotherapies outcomes.77 Radial access similar success femoral offers bleeding complications.78-80 Complex interventions bifurcations, CTO large burr atherectomy now safely effectively via radial standard sheathless up eight French size, incorporating catheter extensions anchor balloons.79, 81 Evidence suggests when necessary, still operators ultrasound-guided access, micropuncture needles.82-85 sites needed adjunctive thereby bleeding, complications, mortality.86 hazards mitigated ulnar second-access site, bilateral single-access PCI.79, 87, 88 dedicated long-shaft equipment effective obtaining hemostasis resolving large-bore access.89 transaxillary transcaval feasible alternatives cases operators.90 goal anticoagulation subacute while bleeding-related complications.91 Unfractionated heparin (UFH), low molecular weight heparin, bivalirudin each anticoagulation. Despite head-to-head comparisons UFH cornerstone intravenous population.92, 93 monitoring activated clotting (ACT), reversibility case cost. Safety Efficacy Enoxaparin Coronary Intervention (STEEPLE) trial, ACT 300–350 s lowest values typically targeted involving coronaries extended periods (e.g., retrograde PCI). Bivalirudin option heparin-induced thrombocytopenia risk.91, 94, 95 pretreated potent dual (DAPT) before PCI.93 sufficiently preloaded DAPT, glycoprotein IIb/IIIa antagonists cangrelor considered.96, 97 Considerations postoperative length DAPT below. Intracoronary two important defining achieving alone incompletely defines morphology significance, so appear be, vice versa.98, 99 contemporary interventionalist needs proficient interpretation.100, 101 Physiology-based (adenosine-generated fractional reserve [FFR] resting measures instantaneous wave-free [iFR], full-cycle [RFR], diastolic hyperemia-free [dFR], pressure [dPR]) component hemodynamically ischemia-producing, functional testing absent inconclusive. impacts patient's status prognosis, considerations overall 1).102 example, FFR refine prognostic estimation alone. consequence missing stenosis intervening unnecessarily high.5, 103, 104 Intravascular ultrasound (IVUS) optical coherence (OCT) resolve ambiguity plaque burden calcification, through accurate sizing. imaging-guided improves 2).105-108 Imaging prevention failure, frequently under expansion. given importance nature artery, PCI.105 wire crossing optimization, limit diabetes, CKD, dysfunction.2, 109, 110 Severely calcified portend thrombosis restenosis dissection, slow/no-reflow, embolization entrapment, perforation, bleeding.111-113 calcification incomplete death.114 reasons, calcium crucial most (CT) helpful calcification.115 noncompliant balloons, cutting/scoring (rotational, orbital, laser), lithoplasty (not FDA time). ideal evolving, algorithm Figure 4.115 ongoing ECLIPSE (NCT03108456) role conventional balloon-based strategies. successful severely competency order adequately treat entire range lesions, anticipating dissection perforation. (ISR) progressive re-narrowing stented segment occurs 3 after placement presents recurrent angina.116 ISR practice second- third-generation drug-eluting stents (DES), ~2% per year year; therefore, challenge. Risk factors saphenous vein graft (SVG) lesion, ostial ISR, expansion, length.106, 110, 117-119 since image-guided decrease failure.106, 120 under-expanded (often surrounding insufficient preparation placement), step attain expansion previously placed high-pressure balloon inflation, laser administration), currently approved).121, 122 After optimized, depends whether versus layers site lesion. single-layer second layer second-generation DES superior modalities.123, 124 Unfortunately, there scant layers.125 Stent optimization followed brachytherapy States (US) group, >2 site.126 future, drug-coated balloons US alternative treatment.127 Due (especially mammary) grafts (SVGs).128, 129 SVG carries leading no-reflow AMI. embolic protection possibly vasodilator administration, stenting, undersized stents.130-135 Filters unfortunately underutilized, challenges operator experience, added cost time. recent conflicting trials, suggest whenever technically (Class guideline—ACC/AHA).93, 128, 136-139 Long-term bare-metal DES.128, 140 result, experts corresponding native feasible, referral indicated.141 AMI one recanalize culprit SVG, revascularization.142 supplied failing contain Prolonged beneficial patients.143 bifurcation involve origin side branch reported 15–20% PCI.144, 145 Numerous classification schemes characterize Medina being simplest widely used.146 difficult nonbifurcation variability anatomy, angle comes off vessel, differences diameters, two-stent strategy, short- events.147 general, bifurcations within 5 mm ostium branch, provisional stenting technique employed (as opposed up-front 5).148 Bifurcation involves wiring branch. Routine pre-dilation discouraged. adequate allow diameter lumen diameter; avoids over-sizing carina shift. (POT) aspect post-dilation re-wiring required. post-PCI thrombolysis (TIMI)-3 completed. kissing discouraged acceptable angiographic result obtained.149 angioplasty, rescue employed, T-stent protrusion (TAP) culotte approach.150 non-LM upfront (i.e., extends bifurcation, heavily takeoff unfavorable approach), used, double kiss (DK) crush, mini-crush, culotte, Significant observed 5–7% 80% occurring bifurcation.151 intermediate comparable provided baseline ≤32.152-154 repeat rate, CABG.155 percutaneously. and, (Medina 1,1,1 0,1,1, > = 70% 10 mm), DK crush (preferred) 6).151, 156 Ad hoc facility high-volume, experienced interventionalists.157 2014 class IIa indication stable < 22, IIb (22–32) score. recommended cases.8 prevalence ranges 18 52%, depending angiography.158 quality-of-life.159 cardiomyopathy.160, 161 ESC/EACTS Guidelines Myocardial Revascularization ACC/AHA/SCAI give symptoms.92, basic principles PCI.162 First, ad avoided. Second, proper Third, include: antegrade escalation (AWE), anterograde re-entry (ADR), (RWE), (RDR).163 Operators facile all four rates. Fourth, crossed, meticulous preparation, utilized outcomes.164 Finally, commitment acquire skillset. collaborate proficiency, high-volume appropriate. 162, 165 type subject studies. meta-analysis six Giustino et al. found (defined having three vessels treated, implanted 60 CTO) had increasingly greater durations longer number characteristics.166 contrast, international multicenter Dual Antiplatelet Therapy study, 30 derived level characteristics PCI.167 Based data, 6 characteristics.168 Conversely, able shortened monotherapy ticagrelor risk.168 Decisions extending could governed risk–benefit PRECISE-DAPT rather initial procedure.143, 169 No exist P2Y12 inhibitors regimens reasonable coupled presentation. Same day discharge (SDD) compromising demonstrated registries savings.170-172 identifying SDD published.173 Specific requirements symptoms complications. Additional home proximity hospital capable addressing PCI-related events, social system, compliance therapy, outpatient follow-up. note relatively considered ASC). allows overnight postprocedural event. distinctly undergoes ASC, low.177 emergency dire consequences.174 task force believes hospitals onsite 1).177 become comorbidities. evolved substantially over last decade meet need. continue provides platform future investigations population. We would like acknowledge Emily Senerth her contribution manuscript. Megan Kavy Dr. Lawrence Ang creating Figures Supplemental Table 1 Author Relevant Relationships Industry Please note: publisher responsible content functionality information authors. Any queries (other content) directed author article.

Language: Английский

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