Complete Revascularization in Patients Undergoing Multivessel PCI is an Independent Predictor of Improved Long‐term Survival

Background: The prognostic relevance of complete revascularization (CR) in patients with multivessel coronary artery disease (MV‐CAD) has been established so far for surgical treatment strategies rather than for percutaneous coronary revascularization (PCI). In addition, different definitions of CR have further complicated the interpretation of clinical studies. Methods: Procedural characteristics and long‐term overall survival were assessed in 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. We adapted three definitions of CR from the coronary artery bypass grafting (CABG) trials. CR was achieved if following MV‐PCI one of the three criteria was met: (1) no residual stenosis in a main coronary vessel, (2) no residual stenosis in any coronary segment, or (3) no residual stenosis in the left anterior descending (LAD) and at least one further main branch. The main objective was the evaluation of predictors of incomplete revascularization and the prognostic impact of CR in MV‐PCI patients. Results: CR was achieved in 76%, 67%, and 95%, respectively, (definitions 1–3). Patients without CR were older, had a lower ejection fraction, and presented more often with acute coronary syndromes (ACS). Clinical long‐term follow‐up regarding survival was available in 664 patients (98%) with a mean follow‐up of 2.5 ± 1.6 years. Independent of the specific definition, CR was associated with a reduced long‐term mortality by approximately 50%. After adjusting for relevant baseline parameters, only absence of residual stenosis in all coronary segments remained as an independent predictor of long‐term prognosis (hazard ratio [HR]= 0.51, 95% confidence interval [CI]: 0.28–0.93; P = 0.025). Conclusions: CR of all coronary segments is associated with improved overall survival after MV‐PCI. (J Interven Cardiol 2010;23:256–263)     

Favorable Long‐Term Survival in Patients Undergoing Multivessel‐PCI Compared to Predicted Prognosis of CABG Estimated by EuroSCORE: Procedural and Clinical Determinants of Long‐Term Outcome

Aims/Methods: Treatment of patients with multivessel coronary artery disease (CAD) has been an ongoing focus of recent clinical studies, questioning the ideal treatment. Randomized trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have so far only included a minority of screened patients. Therefore, we analyzed data from 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. Expected in‐hospital mortality for CABG was calculated using the EuroSCORE and compared to the observed mortality rate during in‐hospital as well as long‐term follow‐up. Results: The patients were suffering from 2.5 ± 0.6 diseased vessels, and 2.8 ± 1.0 lesions were stented (32% of patients received at least one drug‐eluting stent [DES]; 20% of lesions were treated with DES). Forty‐seven percent of patients were treated for acute coronary syndrome (ACS) ( N = 176 ST‐elevation myocardial infarction [STEMI]; N = 140 non‐ST‐elevation myocardial infarction [NSTEMI]). The EuroSCORE was significantly higher in ACS patients compared to stable patients (logistic: STEMI 16.3 ± 17.2; NSTEMI 13.6 ± 13.0; stable CAD 3.9 ± 4.2). The observed in‐hospital mortality (STEMI 13.0%; NSTEMI 2.9%; stable CAD 1.7%, P < 0.001) was far lower than the estimated 30‐day mortality. Cox regression analysis identified an elevated logistic EuroSCORE (HR per quartile 2.7, P = 0.003), severely reduced left ventricular ejection fraction (HR 2.7, P < 0.001), elevated C‐reactive protein (HR 1.8, P = 0.012), and chronic renal failure (HR 2.8, P = 0.001) as independent predictors of long‐term mortality. Conclusions: The EuroSCORE, which is routinely used to estimate the perioperative risk of patients undergoing CABG, also predicts short‐ and long‐term prognosis of patients undergoing MV‐PCI. The observed mortality of patients undergoing MV‐PCI seems to be much lower than the estimated mortality of CABG.     

Intracoronary Beta-Radiation Therapy for In-stent Restenosis: Long-Term Success Rate and Prediction of Failure

Objective: The following retrospective observational study assesses the long-term results of intracoronary beta-radiation therapy for patients with in-stent restenosis.
Background: Beta-radiation has been used to treat patients with coronary in-stent restenosis. However, long-term clinical success using this technique has not at this time been established.
Methods: Two-hundred and thirteen consecutive patients received intracoronary brachytherapy (noncentered beta-emitter, Novoste BetaCath™) for in-stent restenosis and were followed up over a period of 39.1 ± 18.4 months. The combined end-point was defined as a major adverse clinical event (MACE) and comprised mortality, acute myocardial infarction, or target vessel revascularization (TVR).
Results: MACE occurred in 110 patients (51.6%): death in 27 patients (12.7%), acute myocardial infarction in 8 patients (3.8%), TVR in 90 patients (42.3%). TVR comprised percutaneous coronary reinterventions in 76 patients (35.7%) and coronary bypass surgery in 24 patients (11.3%). Secondary end-point was determined as target vessel failure and occurred in 93 patients (43.7%). Of note, the frequency of at least two previous target lesion interventions as well as impairment of left ventricular function was associated with reduced success rate, whereas other clinical parameters did not indicate outcome after treatment with intracoronary radiation therapy.
Conclusion: During the mean, a period of 3 years, more than half of the patients receiving intracoronary radiation therapy reached primary end-point, representing, in the main, TVR. During this period a mortality rate of nearly 13% was documented. These results signify a delayed, though continued, restenotic process after index procedure. (J Interven Cardiol 2010;23:60–65)     

Favorable Long-Term Survival in Patients Undergoing Stent PCI of Unprotected Left Main Coronary Artery Compared to Predicted Short-Term Prognosis of CABG Estimated by EuroSCORE: Clinical Determinants of Long-Term Outcome

Aims/Methods: The long-term outcome of patients (pts) undergoing percutaneous coronary intervention (PCI) of unprotected left main coronary artery (LMCA) is unclear so far . We prospectively investigated the outcome of 102 consecutive patients who underwent stent PCI of unprotected LMCA. Patients were divided according to clinical indication for PCI: stable coronary artery disease (CAD) (N = 60), NSTEMI (N = 18), STEMI (N = 24). Expected in-hospital mortality of coronary artery bypass grafting (CABG) was calculated using the European System for Cardiac Operative Risk Evaluation ( EuroSCORE ) and compared to the observed survival rate during long-term follow-up (mean 1.8 ± 1.2 years).
Results: The observed 30-day mortality was 1.7% (1/60 pts) in patients with stable CAD, 11% (2/18 pts) in NSTEMI patients, and 13% (3/24 pts) in STEMI patients. The observed mortality was lower than the predicted mortality of CABG as calculated by the logistic EuroSCORE. Using receiver-operator characteristics curves (ROC), EuroSCORE demonstrated a high predictive value for both 30-day mortality as well as 1-year mortality (AUC > 0.8; P < 0.01). Prognostically relevant patient related factors (P < 0.01) included severely reduced left ventricular ejection fraction (HR 3.24), ACS (HR 3.18), STEMI (HR: 3.01), Killip class IV (HR 7.69), occurrence of neoplastic disease (HR 3.97), and elevated CRP (HR 3.86).
Conclusions: LMCA-PCI was associated with lower long-term mortality rates compared to the estimated mortality of CABG. This prospective observational study suggests that DES-PCI of unprotected LMCA in "all-comers" can be carried out with reasonable risk .     

Risk Stratification Following Complex PCI: Clinical Versus Anatomical Risk Stratification Including “Post PCI Residual SYNTAX‐Score” as Quantification of Incomplete Revascularization

Background

EuroSCORE and completeness of revascularization predicts long‐term survival after multivessel PCI (MV‐PCI). The SYNTAX‐Score has also been proposed to predict clinical outcome. The prognostic impact of these scores to predict long‐term survival after PCI has not yet been compared.

Methods and Results

Long‐term survival was assessed in 740 patients undergoing MV‐PCI. We calculated EuroSCORE, SYNTAX‐Score, STS‐Score, the clinical SYNTAX‐Score (CSS), and the “post‐PCI residual SYNTAX‐Score.” Mean follow‐up time was 4.5 ± 2.5 years. 341 patients (46%) were treated for ACS (STEMI N = 191; NSTEMI N = 150). 113 patients (15%) underwent PCI of left main coronary artery. The EuroSCORE was significantly lower for stable patients compared to patients with ACS (stable 4.1 ± 4.5, NSTEMI 13.9 ± 13.3, STEMI 18.1 ± 18.7, p < 0.001). The differences in the SYNTAX‐Score were less obvious but even significant (stable 14.9 ± 8.6, NSTEMI 17.8 ± 9.9, STEMI 18.3 ± 9.0; p < 0.001). Patients in the highest tertiles of each risk score experienced a dramatically elevated mortality rate compared to the extremely low mortality rate in the lower tertiles (p log‐rank <0.001). This comparison remained significant for the EuroSCORE and STS‐Score but not for the SYNTAX‐Score, when analysis was restricted to stable patients. The multivariate Cox‐regression‐analysis confirmed the logistic EuroSCORE, EuroSCORE II, and the STS‐Score as independent predictors of long‐term mortality, whereas the SYNTAX‐Score (including residual form) and the CSS had no predictive value.

Conclusion

The EuroSCORE and the STS‐Score outperforms the SYNTAX‐Score and the CSS in predicting long‐term survival following MV‐PCI. In addition, the residual SYNTAX‐Score predicts long‐term survival not independently.