376 Incomplete functional revascularization is associated with adverse clinical outcomes after TAVI

Aims Whether incomplete functional revascularization has an impact on the clinical outcome of patients treated with transcatheter aortic valve implantation (TAVI) is still unknown. We aim to assess the prognostic value of residual functional Syntax score (rFSS) in a cohort of patients undergoing TAVI. Methods and results One-hundred-twenty-four patients (229 lesions) with severe aortic stenosis and coronary artery disease (CAD) underwent fractional flow reserve (FFR)-guided revascularization. The primary endpoint of the study was the composite of cardiac death, myocardial infarction and revascularization at last available follow-up after TAVI. Median Syntax score (SS) and Functional Syntax score (FSS) at baseline were 7 (range 5–12) and 0 (range 0–7) respectively. After revascularization or deferral according to FFR, residual SS (rSS) and rFSS were 5 (range 0–8) and 0 (range 0–0), respectively. At COX regression analysis, angiographic incomplete revascularization (rSS = 0) was not associated with the primary endpoint (HR: 1.26; 95% CI: 0.40; 3.95; P-value 0.698), whereas functional incomplete revascularization was associated with worse event-free survival at Follow-up after adjusting for clinical confounders (HR: 3.74, 95% CI: 1.02–13.75, P = 0.047). Conclusions Incomplete functional revascularization is associated with adverse clinical outcome after TAVI. rFSS may be regarded as a treatment goal for patients with CAD undergoing TAVI. Further studies are warranted to confirm our hypothesis. 376 Central FigureMACEs free survival analysis of patients stratified according to complete revascularization vs. incomplete revascularization assessed according to anatomy (residual SYNTAX score) (A) or physiology (residual functional SYNTAX score) (B).

The Clinical Characteristics of Acute Myocardial Infarction with Ventricular Septal Perforation and the Prognosis Comparison of Different Treatment Methods

Objective: To explore the clinical characteristics of acute myocardial infarction (AMI) with ventricular septal perforation (VSR), the prognosis comparison of different treatment methods, and analysis of related risk factors. Methods: From January 2006 to February 2020, 29 patients with AMI and VSR diagnosed in the People's Hospital of Peking University were selected as the study group. Among them, 16 cases were male (55.2%), 13 cases were female (44.8%), and the average age was 64.69 ± 10.32 years old. They were divided into two groups: the survival group (N = 16) and non-survival group (N = 13), according to whether they survived within 30 days of surgical or drug conservative treatment. The clinical characteristics, coronary angiography, and treatment of the two groups were summarized, and the prognosis and related risk factors were analyzed. Results: There was no significant difference in the basic clinical characteristics between the two groups (P > 0.05). Compared with the results of coronary angiography in the two groups, the proportion of the culprit vessel, which was a simple anterior descending branch in the non-survival group, was higher than that in the survival group. There was a statistical difference between the two groups (P < 0.05). The perioperative data of the two groups showed that the proportion of patients with complete revascularization, simultaneous bypass, and recanalization of culprit vessels in the survival group was significantly higher than that in the non-survival group (P < 0.05). However, the incidence of postoperative low cardiac output and mortality during hospitalization in the survival group were significantly lower than those in the non-survival group (P < 0.05). Logistic regression analysis showed that complete revascularization (OR = 0.021, 95% CI 0.001-0.374, P = 0.009) and recanalization of culprit vessels (OR = 0.045, 95% CI 0.004-0.548, P = 0.015) were independent risk factors for 30-day mortality. Kaplan-Meier survival curve showed that during the follow-up period, the long-term survival rate of patients with operation and complete revascularization was significantly higher than that of patients with drug conservative treatment and incomplete revascularization. There was a statistical difference between the two groups (P < 0.05). Conclusion: Complete revascularization and recanalization of culprit vessels are independent risk factors for 30-day mortality in patients with AMI and VSR. The long-term survival rate of patients after surgery and complete revascularization is significantly higher than that of patients with conservative medical treatment and incomplete revascularization. Surgery and complete revascularization are important factors affecting the long-term prognosis of patients with AMI and VSR.

Efficacy of INtensive Treatment Versus Standard Treatment of COmpound DanshEn Dripping Pills in Refractory Angina Patients With Incomplete Revascularization (INCODER Study): Study Protocol for a Multicenter, Double-blind, Randomized Controlled, Superiority Trial

Introduction: Patients with incomplete revascularization (ICR) tend to develop refractory angina despite optimal medical therapy. Compound Danshen Dripping Pills (CDDP) is a widely used antianginal drug in China and is showed to significantly alleviate myocardial ischemia. Previous studies showed dose-efficacy tendency when increasing doses of CDDP. The study is aim to investigate the efficacy and safety of intensive doses of CDDP in patients with refractory angina with ICR.Methods and Analysis: The INCODER study is a multicenter, double-blind, randomized controlled, superiority trial. We plan to recruit 250 patients aged 18 to 85 years with a diagnosis of refractory angina with ICR. Patients will be randomized (1:1) to intensive treatment group (CDDP 20 pills three times per day) or control group (10 pills CDDP and 10 pills placebo three times per day). Patients will have a 6-week medication period and be followed up every two weeks. The primary end point is the change of total exercise time from baseline to week 6 as assessed by cardiopulmonary exercise testing (CPET). Secondary end points include changes in frequency of angina, Canadian Cardiovascular Society angina class, nitroglycerin use, Seattle Angina Questionnaire scores, O2 uptake kinetics and other parameters as measured by CPET, and levels of plasma C-reactive protein, homocysteine and N-terminal pro-B-type natriuretic peptide. Safety events related to CDDP use will be monitored.Ethics and dissemination: The research had been approved by the Clinical research and laboratory animal ethics committee of the First Affiliated Hospital, Sun Yat-sen University ([2019]65). The results will be reported through peer-reviewed journals, seminars and conference presentations.Trial registration number: www.chictr.org.cn (ChiCTR2000032384). Registered on 27 April 2020.

Effect of Revascularization on Coronary Chronic Total Occlusion in Patients Undergoing Coronary Artery Bypass Grafting

Background: Bypass grafting for chronic total occlusions remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on chronic total occlusions undergoing coronary artery bypass surgery.Methods: Among 828 patients who underwent isolated coronary artery bypass surgery from January 2010 to December 2018, 245 patients (29.5%) diagnosed with at least one chronic total occlusion were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events. Results: With a mean follow-up of 56.6 ± 6.5 months in 245 patients with chronic total occlusions, 51 patients (20.9%) received incomplete revascularization for chronic total occlusions. Risk factor analysis showed that incomplete revascularization was associated with increased 30-day (odds ratio 8.62; 95% confidence interval (CI) 1.64 – 50; p = 0.011) and overall mortality (hazard ratio (HR) 2.13; 95% CI 1.07 – 4.21; p = 0.03). ICR also increased the risk of major adverse cardiac and cerebrovascular events (HR 1.98; 95% CI 1.12 – 3.54; p = 0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the incomplete revascularization group, at 1, 3, and 5 years, respectively (p = 0.004).Conclusions: In patients with chronic total occlusions undergoing coronary artery bypass surgery, the rate of incomplete revascularization was 20.9%, and it significantly increased the risk of mortality and major adverse cardiac and cerebrovascular events. Further studies in a large cohort are needed.

Abstract 15087: Identifying Clinical Predictors of Mortality After PCI and the Impact of Complete Revascularization in Patients With Multi-vessel Coronary Artery Disease

Coronary revascularization for multi-vessel coronary artery disease (mvCAD) can be established through PCI or CABG. The benefit of surgical intervention over PCI has been attributed, in part, to more complete revascularization. However, among patients treated with PCI in the present era of drug-eluting stents, it is important to understand whether the completeness of revascularization is associated with mortality. Further, it is important to investigate this relationship in specific patient populations to determine which patients, if any, derive a survival benefit from complete revascularization. Moreover, it is critical to identify which factors are associated with higher mortality in this population to pinpoint potential areas of intervention to mitigate risk. In this propensity-score adjusted analysis, outcomes among 1,580 mvCAD patients who underwent PCI were analyzed and stratified by complete versus incomplete revascularization. The primary outcome was all-cause mortality. Complete revascularization was achieved in 28.4% of the cohort. Complete revascularization was not independently associated with survival compared with incomplete revascularization in the overall cohort (p=0.16). The predictors of increased all-cause mortality included advanced age, chronic lung disease, cardiogenic shock, diabetes, renal insufficiency, reduced left ventricular function, and left main stenosis. Complete revascularization was associated with reduced all-cause mortality in specific patient subsets including those with congestive heart failure and chronic lung disease. Our analysis elucidated numerous clinical predictors of all-cause mortality for mvCAD patients undergoing PCI. Complete revascularization was not among the independent predictors of mortality in the overall population and was associated with reduced mortality in patients with chronic lung disease, history of congestive heart failure and those who did not have previous PCI. While this study was not designed to test whether complete revascularization was superior to incomplete revascularization, the results suggest that when PCI is pursued among patients with mvCAD, achieving complete revascularization does not contribute to increased mortality.

Abstract 13346: The Rate of Incomplete Revascularization Following Coronary Artery Bypass Surgery Has Increased Over Time

Introduction: Incomplete revascularization following coronary artery bypass surgery (CABG) is associated with increased repeat revascularization, myocardial infarction and death. However, whether the rate of incomplete revascularization is increasing over time has not been previously described. Methods: We performed a retrospective review of consecutive patients who underwent elective and isolated CABG for multi-vessel coronary artery disease in 2007 (n=291) and in 2017 (n=290) at a single Institution. All coronary angiograms and CABG operative reports were reviewed and a Revascularization Index Score (RIS) was created to compare rates of incomplete revascularization between the two time periods based on the coronary anatomy and degree of stenosis. Thus a patient with complete revascularization will have an RIS score of 1.0 while a patient who has 3 of 4 eligible vessels bypassed will have an RIS score of 0.75. Results: Over a 10 year period, the rate of incomplete revascularization increased from 17.9% to 28.3% (p = 0.003) and was accompanied by a decline in the RIS score from 0.73 to 0.67 (p= 0.005). Mortality significantly increased over time with incomplete compared to complete revascularization in the 2007 cohort. Conclusions: The incidence of incomplete revascularization following CABG significantly increased over a 10-year time period between 2007 and 2017. These differences may be attributable to patient factors including more severe coronary artery disease associated with older age, greater incidence of smoking and previous PCI. In line with previous. meta-analyses, the incidence of mortality over time was higher in those patients with incomplete compared to those with complete revascularization. These results suggest that patients with incomplete revascularization represents an important target for the development of novel therapies.

Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial

OBJECTIVES In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin. METHODS Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG. RESULTS Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16–3.16; P &lt; 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13–3.35; P &lt; 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances. CONCLUSIONS Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.