Complete Revascularisation is associated with Improved Survival after Out of Hospital Cardiac Arrest

Introduction Coronary artery disease (CAD) is common in patients with Out of Hospital Cardiac Arrest (OOHCA) but the clinical relevance of burden of CAD and evidence for revascularisation strategies in relation to outcomes and modes of death remains unclear. Purpose This study sought to assess the extent of CAD as defined by the SYNTAX score and prognostic value of complete compared with incomplete revascularisation by evaluating the SYNTAX revascularisation index (SRI) in patients with OOHCA. Methods 619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 237 were excluded for having a non-cardiac aetiology or prior neurological disability. 398 patients were included into the study and of these 272 (68.3%) had early coronary angiography (CAG) and were included in the final analysis. The baseline SYNTAX score (bSS) and residual SYNTAX score (rSS) were determined from the coronary angiograms by a cardiologist blinded to the outcome. Patients were subdivided into 4 subgroups according to quartiles of the baseline syntax score (bSS) of 0, Group A: 1–10, Group B: 11–20 and Group C: ≥21. Complete revascularisation (CR) was defined as SRI of 1 and incomplete (IR) as SRI <1 where the SRI=(1-[rSS/bSS]) ×100 (Figure 1). Results Patients with a bSS of 0 were younger, had less shockable initial arrest rhythms and worse lactate and pH on arrival.Patients with bSS>0 (i.e., those with coronary artery disease) had similar cardiac arrest circumstances in terms of rates of witnessed, bystander CPR and shockable rhythms. Admission metabolic status reflected by pH and lactate and rates of ST elevation/LBBB were also identical for all three groups. However, LVEF on admission decreased significantly as coronary complexity increased (P<0.0001). While early angiography was more preferentially performed in those with higher coronary complexity, paradoxically, those with bSS 1–4 had highest rates of culprit lesions which was reflected in higher rates of PCI (Figure 1). 124 (45.4%) had CR compared with 54.2% with IR. CR was most likely to be achieved as the coronary complexity reduced (Group A – 71.7%, Group B – 41.1%, Group C - 23.3%). There was no difference in rates of cardiogenic shock between both groups (CR 61.1% vs. IR 69% p=ns), but patients with complete revascularisation were younger (58.8 vs 67.8, p<0.0001), lower rates of hypertension and previous CABG (16.2% vs 3.2%, p≤0.0001) CR was associated with decreased mortality at 30 days (45.9% vs 34.6%, p=0.046) and 12 months (49.3% vs 35.4%, p=0.022). The lower mortality rate in CR appeared to partly be driven by lower cardiac deaths though this was not statistically significant (22% vs 7%, p=0.1) (Figure 2). Conclusions CR in a primary coronary aetiology OOHCA group is associated with reduced early and long-term mortality, which may be driven by a reduction in cardiac deaths. Prospective randomised trials in this population are warranted. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Acute lower extremity ischaemia after surgical interventricular communication closure in a newborn

We report a 5-month-old infant who developed an unexpected acute ischaemia of the right lower limb following a surgical perimembranous interventricular communication closure. This rare case of ischaemia was due to an occlusive right common iliac artery dissection. It was early managed by angioplasty with two ABSORB® bioresorbable stents, resulted in complete revascularisation of the right leg.

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 >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 > 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 < 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.

Sex disparities in completeness of revascularisation and outcomes in patients with ST-elevation myocardial infarction and multivessel coronary artery disease

Background In patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD), complete revascularisation is associated with reduced mortality compared to culprit only revascularisation. However, there are limited data regarding the relationship between sex and revascularisation strategy in STEMI with multivessel CAD and outcomes. Purpose Our aim is to evaluate sex related differences in treatment strategies and outcomes in patients with STEMI and multi-vessel CAD. Methods We included all consecutive patients from a provincial registry presenting with STEMI and multivessel CAD treated with percutaneous coronary intervention (PCI) from 2008–2015. The study population consisted of 856 females and 3152 males who were treated with culprit vessel only PCI or complete revascularisation using staged-PCI. The outcomes were death, admission for acute coronary syndrome (ACS), and admission for heart failure (HF). Multivariate Cox proportional hazard models were used to examine the association between treatment strategy and outcomes. Backward stepwise logistic regression was used to identify predictors of patients undergoing staged-PCI versus culprit vessel only PCI. Results At 3 years, the incidence of death was higher in females than males (15.9% vs. 8.2%, p<0.001), as were HF admissions (10.3% vs. 5.0%, p<0.001). Females underwent less staged-PCI than males (10.4% vs. 14.8%; adjusted odds ratio 0.75; 95% CI 0.57–0.97). Younger age and increasing Duke jeopardy score were also associated with performing staged-PCI. After adjusting for baseline characteristics, females had a higher risk of death (HR 1.35; 95% CI 1.07–1.71), ACS admission (HR 1.27; 95% CI 1.00–1.60), and HF admission (HR 1.38; 95% CI 1.03–1.85). Following additional adjustment for revascularisation strategy, only death and HF admission remained significant. Females undergoing staged-PCI had similar survival to males (figure), with no significant interaction between revascularisation strategy and sex (p for interaction = 0.19) Conclusion Females with STEMI and multivessel CAD were less likely to be treated with complete revascularisation by staged-PCI and had worse outcomes when compared to males. Survival in both males and females treated with staged-PCI was similar. Our study suggests that addressing the lack of complete revascularisation in females presenting with STEMI may improve outcomes. Figure 1 Funding Acknowledgement Type of funding source: None

Recent advances in percutaneous coronary intervention

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 coronary disease to be treated. The choice of revascularisation strategy must take into account the evidence—just because we can treat by PCI does not necessarily mean we should. When PCI is indicated, a safe, precision PCI approach guided by physiology, imaging and optimal lesion preparation should be the goal to obtain complete revascularisation and a durable long-term result. When these standards are adhered to, the outcomes can be excellent, in even complex coronary disease. We provide contemporary trial evidence to justify PCI and treatment algorithms that ensure optimal revascularisation decision making to achieve the best patient outcomes.