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
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).
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).
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.
"The European System for Cardiac Operative Risk Evaluation (EuroSCORE), one such tool used for patients undergoing cardiac surgery , evaluates the risk of postoperative mortality by integrating several clinical and procedural factors. It has gained wide popularity because of its simplicity, and is used not only for cardiac surgery but also for percutaneous coronary intervention (PCI)  . Because it has been suggested that EuroSCORE often overestimates postoperative mortality  , the EuroSCORE II was created to achieve better calibration than the original . "
[Show abstract][Hide abstract] ABSTRACT: We evaluated the usefulness of the combination of European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) and SYNergy between percutaneous intervention with TAXus drug-eluting stents and cardiac surgery (SYNTAX) score in predicting risks associated with early and late outcomes after coronary artery bypass grafting (CABG).
Between January 2010 and April 2012, 412 patients underwent isolated CABG at our institution. EuroSCORE II and SYNTAX score were calculated retrospectively, and their ability to predict early and long-term outcomes was evaluated. Patients were divided into four groups according to median EuroSCORE II and SYNTAX score: Group 1, low EuroSCORE II, low SYNTAX (n = 103); Group 2, low EuroSCORE II, high SYNTAX (n = 103); Group 3, high EuroSCORE II, low SYNTAX (n = 99); and Group 4, high EuroSCORE II, high SYNTAX (n = 107).
Operative death was not different among the groups; however, Group 4 had the highest major complication rate of the four groups (0 in Group 1, 2.9% in Group 2, 3.0% in Group 3 and 8.4% in Group 4; P = 0.011). Multivariate analyses revealed that both high EuroSCORE II (odds ratio [OR]: 4.154; P = 0.030) and high SYNTAX score (OR: 3.988; P = 0.035) were independent predictors of postoperative major complications and that high EuroSCORE II was an independent predictor of late mortality (OR: 4.673; P = 0.016) but high SYNTAX score was not (OR: 0.808; P = 0.662). Actuarial survival rate at 3 years was the lowest in Group 4 (99.0 ± 1.0% in Group 1, 97.7 ± 1.6% in Group 2, 91.9 ± 2.7% in Group 3 and 90.5 ± 4.7% in Group 4; P = 0.045).
The combination of EuroSCORE II and SYNTAX score was useful in predicting early major complications after CABG. In the long term, EuroSCORE II continued to be associated with late mortality, but SYNTAX score did not.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2014; 47(1). DOI:10.1093/ejcts/ezu045 · 3.30 Impact Factor
"Recently, the EuroSCORE failed to predict the outcome following TAVI in the SOURCE registry . However, it could be shown that the EuroSCORE predicts the long-term survival after complex percutaneous coronary interventions  , although it was not similarly validated for such procedures. "
[Show abstract][Hide abstract] ABSTRACT: Permanent pacemaker (PM) requirement is a known complication after transcatheter aortic valve implantation (TAVI). There are, however, no systematic data concerning this complication.
To determine the incidence and potential predictors of permanent PM requirement after TAVI based on published literature.
We conducted a MEDLINE search to identify potentially relevant literature dealing with PM requirement after TAVI. Data were collected on paper extraction forms by 2 independent investigators.
There were 32 relevant published studies comprising data of 5,258 patients without an implanted PM before TAVI. An Edwards-Sapiens® prosthesis (ESP) was implanted in 2,887 patients, whereas 2,371 patients received a CoreValve® prosthesis (CVP). The crude incidence of PM implantation after TAVI was 15%. Six hundred and fourteen of 2,371 (25.8%) CVP patients and 189 of the 2,887 (6.5%) ESP patients had to receive a permanent PM (odds ratio [OR] 4.91, 95% confidence interval [CI] 4.12-5.86, P < 0.001). Presence of right bundle branch block (RBBB) before TAVI was a significant predictor for development of complete atrioventricular (AV) block and subsequent PM need (OR 1.358, 95% CI 1.001-1.841, P = 0.02). More than 90% of all AV-block requiring PM implantation occurred immediately or within 7 days after TAVI.
Patients undergoing TAVI with implantation of CVP are at significantly higher risk for development of AV block and subsequent need for permanent PM, particularly if RBBB preexists. Since AV block occurs in >90% within the first week after the procedure, careful monitoring should be performed for at least 7 days after TAVI.
[Show abstract][Hide abstract] ABSTRACT: This study aimed to compare the NERS (New Risk Stratification) and SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) scores for prognostication after stenting of unprotected left main stenosis in a "real-world" setting.
In contrast to existing systems, the NERS score encompasses clinical, procedural, and angiographic characteristics.
The NERS score was derived from 260 patients with unprotected left main stenosis who underwent percutaneous coronary intervention and tested in 337 patients in a consecutive left main registry (66.55 +/- 10.49 years, 78.9% men) undergoing percutaneous coronary intervention in a prospective, multicenter trial. Six-month clinical and angiographic follow-up was obtained in 100% and 88.9% of patients, respectively. The primary end point was major adverse cardiac events (MACE), encompassing myocardial infarction, all-cause death, and target vessel revascularization. Receiver-operator characteristic (ROC) curve was generated for the comparison of NERS versus SYNTAX scores.
The NERS score consisted of 54 variables (17 clinical, 4 procedural, and 33 angiographic). A NERS score > or =25 demonstrated a sensitivity and specificity of 92.0% and 74.1% (MACE as state variable), respectively, significantly higher than SYNTAX intermediate risk (20.5% and 25.4%) or SYNTAX higher risk (70.5% and 35.2%, p for all <0.001). At follow-up, myocardial infarction, cardiac death, and target vessel revascularization occurred in 3.0%, 5.6%, and 13.1% of patients, respectively, for a composite MACE of 26.0%. A NERS score > or =25 (hazard ratio: 1.13; 95% confidence interval [CI]: 1.11 to 1.16; p < 0.001) was the only independent predictor of cumulative MACE and stent thrombosis at follow-up (odds ratio: 31.04; 95% CI: 19.36 to 67.07; p < 0.001).
The NERS score was more predictive of MACE than the SYNTAX score was. Further study is needed to address their relative roles in assessment for appropriateness of coronary artery bypass graft versus percutaneous coronary intervention for unprotected left main coronary artery stenosis.
Thibaut Caruba, Karine Chevreul, Kevin Zarca, Benjamin Cadier, Yves Juillière, Olivier Dubourg, Brigitte Sabatier, Nicolas Danchin
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