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The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI).
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Context 1
... invasive strategy has become the standard of care for high-risk patients . A routine invasive strategy in NSTE-ACS has been shown to improve clinical outcomes 163 , a benefit was mainly confined to biomarker-positive patients 164 and patients with other high-risk features as defined in Figure 4. Of importance, the use of radial approach, new-generation DES as well as more effective P2Y12 inhibitors were not available or broadly implemented in these trials and led to a magnified benefit in frail ACS populations. ...
Context 2
... current recommendations on timing of angiography and intervention as defined in Figure 4 are based on evidence discussed in detail by the prior guideline on NSTE-ACS. 151 Specifically, a reduction in recurrent or refractory ischaemia and length of hospital stay was found with early intervention. ...
Context 3
... This approach allows prompt diagnosis of the underlying CAD, identification of the culprit lesion, guidance for antithrombotic management, and the assessment of the suitability of coronary anatomy for PCI or CABG. Numerous factors interplay in the decisionmaking process, including clinical presentation, comorbidities, risk stratification (Figure 4), and high-risk features specific for a revascularization modality such as frailty, cognitive status, estimated life expectancy, and the functional and anatomical severity of CAD. ...
Context 4
... with ECG or echo changes and the use of OCT in the 25% of NSTE-ACS patients with angiographically normal epicardial coronary arteries 164-166 may be helpful for identifying the culprit lesion, or rule out other mechanisms such as dissection or haematomas [MI with non-obstructive coronary arteries (MINOCA)]. [167][168][169] A routine invasive strategy in NSTE-ACS has been shown to improve clinical outcomes, 170 and benefit was mainly confined to biomarker-positive patients 171 and patients with other high-risk features as defined in Figure 4. Of importance, the use of a radial approach, new-generation DES, and more effective P2Y 12 -inhibitors were not available or broadly implemented in these trials, and led to a magnified benefit in frail ACS populations. ...
Context 5
... current recommendations on the timing of angiography and intervention, as defined in Figure 4, are based on evidence discussed in detail by the prior Guidelines on NSTE-ACS. 158 Specifically, a reduction in recurrent or refractory ischaemia and length of hospital stay was found with early intervention. ...
Similar publications
Aims: The ESC/EACTS myocardial revascularization guidelines recently standardized the definition of patients at high ischemic risk (HIR). However, the ability of ESC/EACTS-HIR criteria to stratify ischemic and bleeding risk in a contemporary real-world East Asian cohort remains unexplored.
Methods: A total of 10,167 consecutive patients undergoing...
Citations
... The complexity of coronary artery disease (CAD) directly correlates with its severity and is linked to adverse clinical outcomes [1,2]. The Synergy between the PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score is a widely used angiographic tool for grading the complexity of CAD and helps in decision-making between coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) for patients with complex CAD [1,[3][4][5][6]. Patients with intermediate to high SYN-TAX scores (> 22) face a heightened risk of major adverse cardiovascular events (MACEs) and are better candidates for CABG [1,4,5,7,8]. ...
... The Synergy between the PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score is a widely used angiographic tool for grading the complexity of CAD and helps in decision-making between coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) for patients with complex CAD [1,[3][4][5][6]. Patients with intermediate to high SYN-TAX scores (> 22) face a heightened risk of major adverse cardiovascular events (MACEs) and are better candidates for CABG [1,4,5,7,8]. Diabetes and blood glucose levels are closely linked to CAD development as traditional risk factors. ...
... Second, it guides treatment decisions: several studies have indicated that higher SYNTAX scores predict better outcomes with CABG than with PCI [23][24][25]. Current clinical guidelines for coronary artery revascularization advocate employing the SYNTAX score for evaluating CAD complexity and directing optimal revascularization strategies [4,5]. In essence, investigating the risk factors correlated with the SYNTAX score is highly important for both mechanistic research and the clinical diagnosis and treatment of CAD. ...
Background
Mounting evidence supports a significant correlation between the stress hyperglycemia ratio (SHR) and both short- and long-term prognoses in patients with acute coronary syndrome (ACS). Nevertheless, research examining the association between the SHR and the complexity of coronary artery disease (CAD) is scarce. Therefore, this study aimed to explore the association between the SHR and CAD complexity, as assessed by the SYNTAX score, in patients with ACS.
Methods
A total of 4715 patients diagnosed with ACS were enrolled and divided into five groups according to the quintiles of the SHR. CAD complexity was assessed using the SYNTAX score and categorized as low (≤ 22) or mid/high (> 22) levels. Logistic regression was utilized to examine the association between the SHR and CAD severity (mid-/high SYNTAX score). Restricted cubic spline (RCS) curves were generated to assess the association between the SHR and CAD severity. Subgroup analyses were conducted to stratify outcomes based on age, sex, diabetes mellitus (DM) status, and clinical presentation.
Results
Among the total ACS population, 503 (10.7%) patients had mid/high SYNTAX scores. Logistic regression analysis revealed that the SHR was an independent risk factor for mid/high SYNTAX scores in a U-shaped pattern. After adjusting for confounding variables, Q1 and Q5 demonstrated elevated odds ratios (ORs) relative to the reference category Q3, with ORs of 1.61 (95% CI: 1.19 ∼ 2.19) and 1.68 (95% CI: 1.24 ∼ 2.29), respectively. Moreover, the ORs for Q2 (1.02, 95% CI: 0.73 ∼ 1.42) and Q4 (1.18, 95% CI: 0.85 ∼ 1.63) resembled that of Q3. Compared with the merged Q2-4 group, the ORs were 1.52 (95% CI: 1.21 ∼ 1.92) for Q1 group and 1.58 (95% CI: 1.25 ∼ 2) for the Q5 group. Subgroup analysis revealed that the U-shaped association between the SHR and mid/high SYNTAX score was attenuated in DM patients (P for interaction = 0.045).
Conclusions
There were U-shaped associations between the SHR and CAD complexity in ACS patients, with an SHR ranging from 0.68 to 0.875 indicating a relatively lower OR for mid/high SYNTAX scores. Further studies are necessary to both evaluate the predictive value of the SHR in ACS patients and explore the underlying mechanisms of the observed U-shaped associations.
... Since the bare-metal stent era, primary plain old balloon angioplasty (POBA) with provisional stenting has been superseded by routine coronary stenting for the treatment of de novo coronary lesions because POBA had a higher risk of repeat revascularization [1]. This notion was maintained in the drug-eluting stents (DES) era, even for patients who require urgent non-cardiac surgery or high bleeding risks, as short-duration dual antiplatelet therapy may be reasonable with both strategies [2][3][4]. However, stent implantation continues to face notable challenges as there is a permanent metallic scaffold left behind in the vessel. ...
... However, stent implantation continues to face notable challenges as there is a permanent metallic scaffold left behind in the vessel. Stents may distort and constrain the coronary vessel, limit vessel pulsatility, and adaptive remodeling [5], and promote chronic inflammation, which in turn increases the risk of late stent thrombosis and restenosis by approximately 2% per year [2]. ...
... This feature of DCB has the potential to minimize the negative effects associated with stentrelated maladaptive biologic response [8]. Currently, the management of in-stent restenosis (ISR) by DCB is considered a Class IA recommendation [2]. The safety and effectiveness of the DCB strategy have also been demonstrated in de novo small vessels [9], acute coronary syndromes [10,11], and high-bleeding risk patients [12]. ...
Background
Percutaneous coronary intervention (PCI) with primary stenting, which stands for stent implantation regardless of obtaining satisfactory results with balloon angioplasty, has superseded conventional plain old balloon angioplasty with provisional stenting. With drug-coated balloon (DCB), primary DCB angioplasty with provisional stenting has shown non-inferiority to primary stenting for de novo coronary small vessel disease. However, the long-term efficacy and safety of such a strategy to the primary stenting on clinical endpoints in de novo lesions without vessel diameter restrictions remain uncertain.
Study design
The REC-CAGEFREE I is an investigator-initiated, multicenter, randomized, open-label trial aimed to enroll 2270 patients with acute or chronic coronary syndrome from 43 interventional cardiology centers in China to evaluate the non-inferiority of primary paclitaxel-coated balloons angioplasty to primary stenting for the treatment of de novo, non-complex lesions without vessel diameter restrictions. Patients who fulfill all the inclusion and exclusion criteria and have achieved a successful lesion pre-dilatation will be randomly assigned to the two arms in a 1:1 ratio. Protocol-guided DCB angioplasty and bailout stenting after unsatisfactory angioplasty are mandatory in the primary DCB angioplasty group. The second-generation sirolimus-eluting stent will be used as a bailout stent in the primary DCB angioplasty group and the treatment device in the primary stenting group. The primary endpoint is the incidence of Device-oriented Composite Endpoint (DoCE) within 24 months after randomization, including cardiac death, target vessel myocardial infarction, and clinically and physiologically indicated target lesion revascularization.
Discussion
The ongoing REC-CAGEFREE I trial is the first randomized trial with a clinical endpoint to assess the efficacy and safety of primary DCB angioplasty for the treatment of de novo, non-complex lesions without vessel diameter restrictions. If non-inferiority is shown, PCI with primary DCB angioplasty could be an alternative treatment option to primary stenting.
Trial registration
Registered on clinicaltrial.gov (NCT04561739).
... The integrated "Heart Team" approach is critical to providing care tailored to patients' needs. According to the ESC/EACTS and ACC/AHA/SCAI guidelines for coronary revascularization, the development of local institutional protocols is essential to determine the most appropriate revascularization strategy [5,6]. ...
... Long-term follow-up data showed that CABG was superior to PCI in terms of major adverse cardiac and cerebrovascular events, especially in patients with higher SYNTAX scores [46,47]. The SYN-TAX trial has significantly influenced guidelines [5,6] and the treatment of complex coronary artery disease by emphasizing a personalized approach based on anatomic complexity. However, it is important to note that the SYNTAX trial used a first-generation drug-eluting stent. ...
The treatment of coronary artery disease (CAD) has considerably evolved over the last three decades thanks to innovations in percutaneous and surgical revascularization techniques. The demographic shift towards an aging population with complex coronary anatomy and multiple comorbidities necessitates a personalized approach. A primary challenge for Heart Teams is to integrate new strategies into their decision-making process. Hybrid coronary revascularization (HCR) combines the long-term benefits of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) to treat complex coronary artery disease. Selection of the ideal candidate for HCR requires careful evaluation of anatomic challenges and risk profiles. Although recent evidence demonstrates the safety and efficacy of HCR and makes it a viable alternative to conventional methods, further large-scale randomized controlled trials (RCTs) are needed to establish its role in routine practice. In this manuscript, we have provided an overview of the major advances in both percutaneous and surgical techniques. In addition, we have addressed the innovative implications of robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) and described the surgical procedure and postoperative care in detail. Finally, we have outlined the key principles that guide our clinical practice in selecting the appropriate approach for hybrid coronary revascularization.
... Despite the 2018 ESC/EACTS guidelines on myocardial revascularisation recommending MAG and OPCAB in selected groups of patients, the volume of advanced coronary surgery cases has reduced signifcantly in recent years [1,2,22]. With limited surgeons/centres performing advanced coronary surgery, trainees often require travelling around the country/abroad for fellowship which may not be always feasible due to various reasons. ...
Objective. The learning curve of coronary artery bypass grafting with multiple arterial grafting and without the use of cardiopulmonary bypass (off-pump) is perceived as an advanced subspeciality associated with increased surgical risk. We compared the trends and early clinical outcomes between trainees and consultants as the first operator in the United Kingdom. Methods. All patients who underwent elective or urgent isolated coronary artery bypass grafting from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. Trends and early clinical outcomes between trainees and consultants as the first operator were compared in the whole cohort and after propensity score matching. Results. Of the total coronary artery bypass graft procedures, trainees performed 24.39% (n = 79759/327025). Trainees performed 27.10% (63934/235920) on-pump without multiple arterial graft procedures compared to consultants. The consultants had a shorter cardiopulmonary bypass time (82.81 (SD: 35.36) vs 86.21 (SD: 30.07) minutes, p<0.001) and aortic cross-clamp time (48.05 (SD: 22.46) vs 50.66 (SD: 19.49) minutes, p<0.001). However, consultants had a higher mortality (1.6% vs 1.0%, p<0.001) and incidence of postoperative dialysis (2.1% vs 1.5%, p<0.001). Trainees performed 16.78% (8089/48220) multiple arterial graft procedures, with no differences compared with consultants for in-hospital mortality (1.0% vs 0.9%, p=0.42), cerebral vascular accident (transient ischaemic attack (0.5% vs 0.5%) and permanent stroke (0.6% vs 0.4%), p=0.33, return to theatre (4.2% vs 4.47%, p=0.089), postoperative renal dialysis (1.4% vs 1.1%, p=0.076), and deep sternal wound infection (0.6% vs 0.6%, p=0.87). Trainees performed 17.17% (8661/41778) off-pump cases. Consultants had a higher in-hospital mortality (1.2% vs 0.9%, p=0.045) with no differences in cerebral vascular accident (transient ischaemic attack (0.2% vs 0.3%) and permanent stroke (0.4% vs 0.4%), p=0.27), return to theatre (3.8% vs 3.9%, p=0.69), postoperative renal dialysis (2.0% vs 1.6%, p=0.059), and deep sternal wound infection (1.0% vs 0.8%, p=0.66). Conclusion. Trainees in the United Kingdom have adequate exposure to advanced coronary surgery without compromising patients’ safety.
... The high rate of culprit-only PCI (72.6%) might reflect the results of the CULPRIT-SHOCK trial, which showed a lower rate of death and severe renal failure in patients with infarct-related cardiogenic shock and multivessel disease who initially underwent culprit-only PCI compared with those who underwent immediate multivessel PCI [18]. Notably, despite the recommendation of current guidelines to use the radial access as the default strategy [19,20], more than two-thirds of the procedures were performed via femoral access. According to the annual report of the GRR 2022, CAG was performed in 26.9%, which is much lower than in our cohort. ...
Background
In Europe, more than 300,000 persons per year experience out-of-hospital cardiac arrest (OHCA). Despite medical progress, only few patients survive with good neurological outcome. For many issues, evidence from randomized trials is scarce. OHCA often occurs for cardiac causes. Therefore, we established the national, prospective, multicentre German Cardiac Arrest Registry (G-CAR). Herein, we describe the first results of the pilot phase.
Results
Over a period of 16 months, 15 centres included 559 consecutive OHCA patients aged ≥ 18 years. The median age of the patients was 66 years (interquartile range 57;75). Layperson resuscitation was performed in 60.5% of all OHCA cases which were not observed by emergency medical services. The initial rhythm was shockable in 46.4%, and 29.1% of patients had ongoing CPR on hospital admission. Main presumed causes of OHCA were acute coronary syndromes (ACS) and/or cardiogenic shock in 54.8%, with ST-elevation myocardial infarction being the most common aetiology (34.6%). In total, 62.9% of the patients underwent coronary angiography; percutaneous coronary intervention (PCI) was performed in 61.4%. Targeted temperature management was performed in 44.5%. Overall in-hospital mortality was 70.5%, with anoxic brain damage being the main presumed cause of death (38.8%). Extracorporeal cardiopulmonary resuscitation (eCPR) was performed in 11.0%. In these patients, the in-hospital mortality rate was 85.2%.
Conclusions
G-CAR is a multicentre German registry for adult OHCA patients with a focus on cardiac and interventional treatment aspects. The results of the 16-month pilot phase are shown herein. In parallel with further analyses, scaling up of G-CAR to a national level is envisaged.
Trial registration
ClinicalTrials.gov identifier: NCT05142124.
... Especially in bifurcation lesion, intravascular imaging might be useful to assess lesion characteristics, calcifcation profles, and the relationship between MB and SB [33]. It is important to acknowledge the absence of intravascular imaging in our study, which contrasts with its increasing use in complex PCI, as recommended by the latest guidelines from the European Societies (ESC/EAPCI) and the American Societies (ACC/AHA/SCAI) [34][35][36][37]. In our study, measurements of bifurcation lesion as well as calcifcation profles were based on angiographic images. ...
Background. Side branch (SB) compromise represents a frequent challenge encountered during percutaneous coronary intervention (PCI) for bifurcation lesions. Numerous techniques have emerged for predilating the main branch (MB), aiming to mitigate the occurrence of SB compromise. Among these approaches, scoring balloons have gained recognition for their ability to reduce carina shift and migration, consequently lowering the risk of SB compromise. However, the optimal treatment strategy remains a topic of debate. Thus, the current study is designed to investigate and compare effects of using scoring versus nonscoring balloons for MB predilatation on the incidence of SB compromise. Methods. A total of 102 patients who underwent elective PCI were enrolled at Jakarta Heart Center, Jakarta, Indonesia, from July 2022 to July 2023. Patients were randomized into two arms, i.e., scoring balloon predilatation arm (n = 52) and nonscoring balloon predilatation arm (n = 50). Outcome was measured as a composite endpoint of reduced thrombolysis in myocardial infarction (TIMI) flow in SB after MB stenting, SB intervention needed, and new or progressing ostial SB stenosis more than 50% compared to baseline. Results. Both study arms were comparable in various aspects, including gender distribution with a male majority, the predominant involvement of the left anterior descending (LAD) vessel, the presence of minimal to mild calcification, type A lesion, SB diameter, SB angulation, and the use of SB wire protection. In-depth analysis was conducted that revealed no significant differences between encompassed factors such as TIMI flow, the necessity for SB intervention, new or progression of ostial SB stenosis exceeding 50% when compared to the baseline, as well as the composite endpoint. Furthermore, these confounding factors did not exhibit any association with the incidence of SB compromise. Conclusion. Our study revealed that employing either scoring or nonscoring balloon predilatation in the MB has equivalent effects on SB compromise.
... Similarly, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) guidelines have downgraded it to a Class IIb B recommendation. (Weak/Usefulness or unknown/unclear/uncertain) [8][9][10][11]. While a recent meta-analysis, consisting of data from more than 10 thousand patients, has shown improved mortality reduction outcomes with IABP over ECMO and Impella, no reasonable grounds seem to exist for explaining this reclassification by guidelines [12]. We recently presented our data comparing Impella and intra-aortic balloon pumps (IABP) in patients with cardiogenic shock revealing highest mortality with the use of Impella and lowest mortality with IABP [13]. ...
... This aligns with a recent meta-analysis of 10,985 patients concluding that IABP outperforms both Impella and ECMO in improving mortality [12]. The contrast between our results and recent guideline adjustments by the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) prompts questions about the rationale behind downgrading device use [8,9,34]. Our data underscores the need to reconsider recent guideline changes, given their substantial impact on clinical practice and patient outcomes. ...
Background: The goal of this study was to evaluate the effect of Extracorporeal Membrane Oxygenator (ECMO) on mortality in patients with cardiogenic shock excluding Impella and IABP use. Method: The large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of ECMO in adults over age of 18 on mortality and complications with a diagnosis of cardiogenic shocks. Results: ICD-10 codes for ECMO, and cardiogenic shock for available years 2016-2020 were utilized. A total of 796,585 (age 66.5±14.4) patients had a diagnosis of cardiogenic shock excluding Impella. 13,160 (age 53.7±15.4) were treated with ECMO without IABP . Total inpatient mortality without any device was 32.7%. It was 47.9% with ECMO. Using multivariate analysis adjusting for 47 variables such as age, gender, race, lactic acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., ECMO utilization remained highly associated with mortality (OR: 1.78, CI: 1.6-1.9, p
... [9,10] When revascularization is decided, it is recommended that the main approach should aim at achieving minimal residual ischemia. [11] From this perspective, CABG is a good option for suitable patients who have decided to undergo revascularization. ...
Background
Controlling Nutritional Assessment (CONUT) score has been shown to have a higher predictive value compared to other nutritional scores in acute coronary syndrome.
Aim
To determine the relationship between CONUT score and long-term mortality in patients with chronic coronary syndrome (CCS).
Methods
Between 2017 and 2020, 585 consecutive patients newly diagnosed and proven to have CCS by coronary angiography were included in the study. CONUT score and demographic and laboratory data of all patients were evaluated. The relationship between results and mortality was evaluated.
Results
The mean age of the patients was 64 years and 75% were male. Mortality was observed in 56 (9.6%) patients after a median follow-up period of 3.5 years. The median CONUT score was significantly higher in patients with mortality ( P < 0.001). In multivariate regression analysis, the CONUT score was associated with mortality (Hazard ratio (HR): 1.63 (95% confidence interval (CI): 1.34–1.98 P < 0.001)). The area under curve (AUC) for long-term mortality estimation for the CONUT score was 0.75 (95% CI 0.67–0.82 P < 0.001). When the CONUT score value was accepted as 0.5, the sensitivity was 78% and the specificity was 60
%. Conclusion
CONUT score was found to be predictive of mortality in long-term follow-up of patients with CCS.
... While the clinical consequences of ASM continue to be debated [7][8][9][10], several studies have associated ASM with an elevated risk of thrombotic events, based on findings associated with stent strut mal-apposition in patients diagnosed with stent thrombosis [9,10]. The distinct anatomical nuances of the left main coronary artery (LMCA), especially the pronounced mismatch between stent strut and vessel lumen diameters, continue to be hurdles to effective vessel revascularization [11]. However, a comprehensive appraisal of LMCA-ASM is lacking. ...
... OCT's accurate surpasses that of angiography and IVUS in identifying subtle morphological details such as malapposition, residual thrombus, plaque prolapse, and residual dissections, contributing to improved procedural outcomes [6]. In instances of stent failure, OCT should be considered to identify and address underlying mechanical factors [7]. However, evidence supporting OCT guidance in PCI is promising yet limited albeit. ...
Background
Optical coherence tomography (OCT) guidance in percutaneous coronary intervention (PCI) has been shown to improve procedural outcomes. However, evidence supporting its superiority over angiography-guided PCI in terms of clinical outcomes is still emerging and limited. This study aimed to compare the efficacy and safety of OCT-guided PCI versus angiography‐guided PCI in patients with coronary artery disease (CAD).
Methods
A systematic search of electronic databases was conducted to identify randomized control trials (RCTs) comparing the clinical outcomes of OCT-guided and angiography‐guided PCI in patients with CAD. Clinical endpoints including all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), stent thrombosis and major adverse cardiac events (MACE) were assessed.
Results
Eleven RCTs, comprising 2,699 patients in the OCT-guided group and 2,968 patients in the angiography-guided group met inclusion criteria. OCT-guided PCI was associated with significantly lower rates of cardiovascular death(RR 0.56; 95%CI: 0.32–0.98; p = 0.04; I² = 0%), stent thrombosis(RR 0.56; 95%CI: 0.33–0.95; p = 0.03; I² = 0%), and MACE (RR 0.79; 95%CI: 0.66–0.95; p = 0.01; I² = 5%). The incidence of all-cause death (RR 0.71; 95%CI: 0.49–1.02; p = 0.06; I² = 0%), myocardial infarction (RR 0.86; 95%CI: 0.67–1.10; p = 0.22; I² = 0%) and TLR (RR 0.98; 95%CI: 0.73–1.33; p = 0.91; I² = 0%) was non-significantly lower in the OCT-guided group.
Conclusions
Among patients undergoing PCI, OCT-guided PCI was associated with lower incidences of cardiovascular death, stent thrombosis and MACE compared to angiography-guided PCI.
Trial registration
PROSPERO registration number: CRD42023484342.
