The analysis of in-hospital and long-term results of percutaneous coronary intervention supported by extracorporeal membrane oxygenation in patients with coronary artery disease

Aim. To analyze in-hospital and long-term (12 months) results of percutaneous coronary intervention (PCI) supported by extracorporeal membrane oxygenation (ECMO) in patients with stable coronary heart disease and multivessel coronary artery disease, and to justify the use of such approach in the treatment of this group of patients.Methods. The retrospective analysis included 13 patients with stable coronary artery and multivessel coronary disease. The mean SYNTAX score before the intervention was 31.4±10.8. Between 30 days and 12 months in the postoperative period, the frequency and type of the following major adverse cardiovascular events (MACE) was assessed: all-cause death, myocardial infarction, stroke, repeat revascularization. Twelve months after the event, the data on the frequency and type of adverse cardiovascular events were collected by means of telephone follow-up.Results. Coronary intervention supported by ECMO was performed in all patients. 8 (61.6%) patients required an open surgical approach for ECMO cannula insertion. Door to balloon time was 109.6±79.2 minutes. The mean duration of ECMO support was 101.7±45.4 minutes. Haemodynamic instability, abnormalities in pulmonary gas exchange and rhythm disturbances were not revealed during primary PCI, making it possible to wean off the ECMO post-PCI. The mean residual SYNTAX score was 9.3±11.8. BARC class ≥3 bleeding complications were observed in 6 of 13 patients. Long-term major adverse cardiovascular events with fatal outcomes occurred in 3 (23.1%) patients.Conclusion. Supporting high-risk PCI with ECMO in patients with stable coronary artery disease, multivessel coronary artery disease and low left ventricular ejection fraction made it possible to successfully perform the intervention in all patients. Nevertheless, the long-term (12 months) results show a high percentage of recurrent myocardial infarction, which can be associated with high residual SYNTAX score.

Prognostic value of characteristics of plaque combined with residual syntax score among patients with STEMI undergoing primary PCI: an intravascular optical coherence tomography study

Aim The present study aimed to explore these characteristics, particularly thin-cap fibroatheroma (TCFA), in relation to residual syntax score (rSS) in patients who presented with acute MI. Methods and outcomes A total of 434 consecutive patients with MI aged ≥18 years who had STEMI underwent primary PCI. Notably, compared with other subgroups, the presence of TCFA in culprit lesions and a higher level of rSS, were significantly associated with MACE. When rSS was divided into three groups, high rSS levels were associated with a higher incidence of MACE, in the subgroups of without TCFA (P = 0.005), plaque erosion (P = 0.045), macrophage infiltration (P = 0.026), and calcification (P = 0.002). AUC of ROC curve was 0.794 and 0.816, whereas the AUC of the survival ROC was 0.798 and 0.846. Conclusion The results of this study could be used in clinical practice to support risk stratification. Trial registration This study was registered at ClinicalTrials.gov as NCT03593928.

Impaired autonomic function after incomplete revascularisation

IntroductionIncomplete cardiac revascularisation (ICR) assessed by residual SYNTAX score (rSs) is associated with increased 5-year mortality. Furthermore, in the general population, our group has demonstrated that impaired autonomic function determined by heart rate recovery time between 10 and 20 s (HRR10–20) following an active stand is associated with increased all-cause mortality.PurposeWe hypothesised that ICR would be associated with impaired autonomic function determined by HRR10–20.MethodsAfter ethical approval and informed consent, consecutive patients attending cardiac rehabilitation in a tertiary referral centre were enrolled. All patients had percutaneous coronary revascularisation. During an active stand, real-time heart rate, blood pressure and ECG recordings were taken using non-invasive digital photoplethysmography and HRR10–20 determined. Assessment of autonomic function was performed by determining speed of HRR10–20 post-orthostatic challenge.Patients with an rSs >0 were considered incompletely revascularised and those with an rSs of 0 fully revascularised. Demographic data were recorded and statistical analysis performed.ResultsPatients (n=53) comprised those with complete revascularisation (CR) (n=37) and ICR (n=16). In the ICR group, mean rSs was 9.4.HRR10–20 was impaired in the ICR group (−3±0.60) compared with the CR cohort (−6.56±0.52) (p<0.0001). Completeness of revascularisation was strongly associated with HRR10–20 (Pearson’s correlation coefficient 0.529; p<0.0001). Baseline demographics did not differ significantly. Use of rate-limiting medication was similar between cohorts (beta blockers, calcium channel blockers, ivabradine).ConclusionsOur data confirm significant correlation between ICR and impaired autonomic function determined by speed of heart rate recovery. Thus, determining autonomic dysfunction post-ICR may identify those at increased mortality risk.

Prognostic Value of Characteristics of Plaque Combined With Residual Syntax Score Among Patients With STEMI Undergoing Primary PCI: an Intravascular Optical Coherence Tomography Study

AimThe present study aimed to explore these characteristics, particularly thin-cap fibroatheroma (TCFA), in relation to residual syntax score (rSS) in patients who presented with acute MI.Methods and outcomesA total of 434 consecutive patients with MI aged ≥18 years who had STEMI underwent primary PCI. Notably, compared with other subgroups, the presence of TCFA in culprit lesions and a higher level of rSS, were significantly associated with MACE. When rSS was divided into three groups, high rSS levels were associated with a higher incidence of MACE, in the subgroups of without TCFA (P= 0.005), plaque erosion (P= 0.045), macrophage infiltration (P= 0.026), and calcification (P= 0.002). AUC of ROC curve was 0.794 and 0.816, whereas the AUC of the survival ROC was 0.798 and 0.846.ConclusionThe results of this study could be used in clinical practice to support risk stratification.Trial registrationThis study was registered at ClinicalTrials.gov as NCT03593928.

Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was &gt;8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS &gt; 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p &lt; 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.

Impacts of Residual SNYTAX Score on The Clinical Outcomes following Percutaneous Coronary Intervention in Chronic Coronary Syndrome Patients

Background: The residual SYNTAX score (RSS) can be used to measure the residual stenosis severity and complexity. The prognostic role of RSS in CCS patients is still unknown. We purposed to investigate the impact of RSS on the clinical outcomes following PCI in CCS patients. Methods: A prospective cohort study was performed. Based on the residual SYNTAX score, patients were divided into three groups: RSS 0, RSS 0 to 9.5, and RSS >9.5. The primary outcome was patient-oriented composite endpoint (POCE), including repeat revascularization, myocardial infarction, and all-cause mortality. Results: After 1-year follow-up period, patients in RSS >9.5 group revealed the greater POCE (4.3% vs. 6.4% vs. 23.9%; p = 0.016) than others. The repeat revascularization rate also was greater in the RSS >9.5 group (0.0% vs. 6.4% vs. 19.6%; p = 0.012). However, the hospitalization due to angina rates in all groups was not significantly different (4.3% vs. 4.2% vs. 4.3%; p = 1.000). The multivariate analysis revealed that RSS >9.5 was the strong predictor for repeat revascularization during 1 year follow-up (Odds ratio [OR] = 9.605; 95% confidence interval [CI] = 1.207 - 76.458; p = 0.033). Conclusion: The greater RSS was associated with the higher 1-year POCE and repeat revascularization rate in CCS patients. The high RSS was also the strong predictor for 1-year repeat revascularization for CCS patients.

The Incremental Prognostic Value of the Clinical Residual SYNTAX Score for Patients With Chronic Renal Insufficiency Undergoing Percutaneous Coronary Intervention

Background: The residual SYNTAX score (RSS) is considered a powerful prognostic indicator for determining a reasonable revascularization strategy in patients undergoing percutaneous coronary intervention (PCI), but the absence of clinical parameters is one of the limitations of RSS, especially in the chronic renal insufficiency (CRI) comorbidity setting. The present work aimed to investigate the incremental prognostic value of clinical residual SYNTAX score (CRSS) compared with RSS in CRI cases after PCI.Methods: Totally 2,468 consecutive CRI cases who underwent PCI from January 2014 to September 2017 were included in this retrospective analysis. CRSS was obtained by multiplying RSS by the modified ACEF score. Individuals with CRSS &gt;0 were considered to have incomplete revascularization and stratified by CRSS tertiles, the remaining cases constituted the complete revascularization (CR) group. The outcomes between these groups were compared.Results: At a median follow-up of 3 years, compared with CR group, individuals with CRSS &gt;12 showed elevated rates of all clinical outcomes, and those with CRSS ≤ 12 showed similar all-cause and cardiac mortality rates. In multivariable analysis, CRSS was a powerful independent predictive factor of all clinical outcomes. The net reclassification improvement levels of CRSS over RSS for all-cause and cardiac mortality rates were 10.3% (p = 0.007) and 16.4% (p &lt; 0.001), respectively. Compared with RSS, CRSS markedly ameliorated all-cause and cardiac mortality risk stratification.Conclusions: Compared with RSS, CRSS has incremental predictability for long-term all-cause and cardiac mortality in CRI cases following PCI.