Myocardial Revascularization in Heart Failure: A State-of-the-Art Review.

Patients with heart failure (HF) and underlying coronary artery disease (CAD) have a substantially higher risk of mortality compared with those with HF from other causes. However, identifying individuals with HF for whom revascularization is likely to improve prognosis is a complex clinical decision. Revascularization is likely beneficial for patients with CAD-predominant symptoms, such as those with acute myocardial infarction or stable ischemic heart disease with refractory angina. However, for patients with HF-predominant symptoms, characterized by dyspnea without acute myocardial infarction or refractory angina, the benefits of revascularization are less clear. This state-of-the-art review summarizes the outcomes, clinical trials, and therapeutic approaches for patients with both CAD and HF, and proposes a therapeutic algorithm to guide the diagnosis and comprehensive workup of these complex patients.

Association between kidney function, frailty and receipt of invasive management after acute coronary syndrome.

BACKGROUND: Reduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear. METHODS: A retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates. RESULTS: Among 10 205 people with ACS, an eGFR of <60 mL/min/1.73m2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty. CONCLUSIONS: In people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR. TRIAL REGISTRATION NUMBER: NCT03507309.

Clinical outcomes of patients with deferred revascularisation based on fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) negative coronary artery lesions in Pakistani population.

OBJECTIVE: To assess long-term clinical outcomes and factors associated with target vessel revascularisation in patients with deferred revascularisation based on negative fractional flow reserve and negative instantaneous wave-free ratio. METHODS: The longitudinal, retrospective study was conducted from July 1, 2020, to January 1, 2022, at the Aga Khan University Hospital, Karachi, and comprised medical records from January 2012 to January 2020 of patients with deferred revascularisation having intermediate to severe coronary lesions on coronary angiogram and had negative fractional flow reserve >0.80 or instantaneous wave-free ratio >0.89 and had not undergone immediate or planned revascularisation on the basis of negative physiological assessment. Data was collected from the institutional records, while final follow-up was taken by reviewing the medical records or telephonic interviews regarding any major adverse cardiac event after the index procedure. Data was analysed using Stata 14.2. RESULTS: Of the 345 patients, 245(71%) were males. The overall mean age was 62±11 years. There were 194(56%) patients who presented with stable angina and 151(44%) presented with acute coronary syndrome. Mean fractional flow reserve was 0.87±0.04 and mean instantaneous wave-free ratio was 0.93±0.03. Multivessel disease was present in 223(65%) patients. Median follow-up period was 29 months (IQR: 24-36 months). Major adverse cardiovascular events occurred in 22(6%) patients, and target vessel revascularisation was required in 11(3%). Diabetes and percentage of stenosis were found to be independent predictors of major adverse cardiovascular events (p<0.05). CONCLUSIONS: Deferral of revascularisation and opting for medical treatment for coronary artery stenosis with higher fractional flow reserve or instantaneous wave-free ratio could be considered a safe and reasonable strategy.

Cardiac magnetic resonance imaging-derived pathophysiology and prognosis of diabetes mellitus with acute myocardial infarction after revascularization: a prospective cohort study.

BACKGROUND: Little is known about the underlying factors contributing to unfavourable clinical outcomes in patients with diabetes mellitus (DM) complicated by new-onset acute myocardial infarction (AMI). The aim of this study was to investigate the impact of DM on the pathophysiologic features and prognosis of patients with new-onset AMI following successful revascularization by utilizing cardiac magnetic resonance (CMR). METHODS: Consecutive patients diagnosed with new-onset AMI between June 2022 and January 2024 were included. All patients underwent culprit vessel revascularization upon admission and CMR imaging 3-7 days later. The primary clinical endpoint of this study was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), for which the average follow-up was 10 months. RESULTS: A total of 72 patients were divided into a DM group (n = 23) and a non-DM group (n = 49). Multivariate logistic regression analysis revealed that DM was an independent risk factor for the occurrence of microvascular obstruction. Multivariate linear regression analysis found that DM was the influencing factor of global radial strain (B = -4.107, t = -2.328, p = 0.023), while fasting blood glucose influenced infarct segment myocardial radial strain (B = -0.622, t = -2.032, p = 0.046). DM independently contributed to the risk of MACCEs following successful revascularization in patients with AMI (p < 0.05). CONCLUSION: Comprehensive phenotypic characterization of myocardial injury and microcirculatory status could enable reliable identification of high-risk MACCEs in DM patients with new-onset AMI following successful revascularization.

Impact of Immediate Versus Staged Complete Revascularization on Short-Term and Long-Term Clinical Outcomes in Patients With Acute Coronary Syndrome and Multivessel Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves prognosis. This meta-analysis, summarizing recent RCTs, contrasts short-term and long-term clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR). METHODS: We systematically searched the online database and eight RCTs were involved. The primary outcomes included long-term unplanned ischemia-driven revascularization, re-infarction, combined cardiovascular (CV) death or myocardial infarction (MI), all-cause death, CV death, stroke, and hospitalization for heart failure (HHF). The secondary outcomes were 1-month unplanned ischemia-driven revascularization, re-infarction, all-cause death, and CV death. Safety endpoints included stent thrombosis and major bleeding. RESULTS: Eight RCTs comprising 5198 patients were involved. ICR reduced long-term unplanned ischemia-driven revascularization (RR 0.64, 95% CI 0.51-0.81, p < 0.001), combined CV death or MI (HR 0.51, 95% CI 0.34-0.78, p = 0.002), and re-infarction (RR 0.66,95% CI 0.48 to 0.91, p = 0.012) compared with SCR. ICR also decreased 1-month unplanned ischemia-driven revascularization (RR 0.41, 95% CI: 0.21-0.77, p = 0.006) and re-infarction (RR 0.33, 95% CI:0.15-0.74, p = 0.007) but increased 1-month all-cause death (RR 2.22, 95% CI 1.06-4.65, p = 0.034). CONCLUSION: In ACS patients with MVD, we first found that ICR significantly lowered the risk of both short-term and long-term unplanned ischemia-driven revascularization and re-infarction, as well as the long-term composite outcome of CV death or MI compared with SCR. However, there may be an increase in 1-month all-cause death in the ICR group.

Aneurisma gigante de ponte safena para artéria circunflexa com compressão do tronco da coronária esquerda causando isquemia com padrão circunferencial / Giant saphenous bypass aneurysm for the circumflex artery with compression of the left main coronary artery causing ischemia with a circumferential pattern

INTRODUÇÃO: A cirurgia de revascularização miocárdica continua sendo realizada em grande número de pacientes. Apesar dos enxertos arteriais serem preferidos devido sua patência, enxertos de veia safena continuam sendo usados regularmente. Os aneurismas de enxertos venosos são uma rara complicação cirúrgica tardia, aprensentandose em média 10 anos após a revascularização. A maioria dos pacientes com aneurisma são assintomáticos e suas principais complicações são embolização distal, IAM e formação de fístula e rotura. RELATO DE CASO: Paciente feminina, 65 anos, com antecedente de RVM com ponte mamária para coronária descendente anterior (MIE-DA) e pontes safena para diagonal, primeiro e segundo marginal e coronária direita. Em cateterismo 2023, ponte MIE-DA estava pérvia, com oclusão das demais. Relatou dor torácica típica, com piora do padrão há 15 dias. Apresentou ECG com padrão de isquemia circunferencial e curva ascendente de troponina, sendo Internada por IAMSSST. No ecocardiograma visualizou-se aumento da porção distal de aorta ascendente com grande dilatação e formação de uma neocavidade medindo 63x57mm, adjacente a parede posterior da aorta ascendente próximo a junção sinotubular com fluxo, rechaçando a parede do átrio esquerdo e o anel valvar mitral e possível compressão do tronco da coronária esquerda e artéria pulmonar. À ressonância cardíaca evidenciou neocavidade junto à raiz da aorta e porção ascendente com sinais de compressão extrínseca importante das artérias pulmonares. Foi considerado como hipótese diagnóstica um aneurisma do enxerto Ao-MG2, com compressão extrínseca da circulação coronariana causando dor e isquemia. DISCUSSÃO: Aneurisma de enxertos venosos geralmente são assintomáticos, mesmo quando possuem diâmetros entre 5 e 10 cm. A compressão do leito coronariano nativo por efeito de massa pode levar a IAM, até mesmo com alteração de ECG, como observado no caso relatado. O tratamento mais comumente proposto é a correção cirúrgica, contudo, em pacientes com múltiplas toracotomias e alto risco cirúrgico, pode-se optar pela embolização percutânea. CONCLUSÃO: Apesar de complicação relativamente rara, os aneurismas de enxertos venosos devem ser considerados diante de episódio de dor torácica em pacientes previamente submetidos à revascularização miocárdica.

Avaliação do desempenho do Euroscore II e STS score na cirurgia de revascularização do miocárdio isolada em centro de referência em cardiologia do estado de São Paulo, Brasil / Evaluation of the performance of Euroscore II and STS score in isolated myocardial revascularization surgery in a cardiology reference center in the state of São Paulo, Brazil

INTRODUÇÃO. A utilização de modelos preditores de risco, como o "The Society of Thoracic Surgeons (STS) risk score" e o "European System for Cardiac Operative Risk Evaluation (EuroSCORE II)", é recomendada para avaliação da mortalidade operatória na cirurgia de revascularização do miocárdio (CRM). Entretanto, seus desempenhos são questionáveis em centros brasileiros. Objetivo. Avaliar o desempenho do STS score e do EuroSCORE II na cirurgia revascularização do miocárdio isolada em um centro de referência no Brasil. MÉTODOS. Estudo observacional e prospetivo incluindo 438 pacientes submetidos à CRM isolada no período de maio de 2022 a maio de 2023 em um centro de referência brasileiro. A mortalidade observada foi comparada com a mortalidade predita (STS score e EuroSCORE II) por discriminação (área abaixo da curva - AUC) e calibração (razão observado/esperado - O/E) na amostra total e nos subgrupos de doença arterial coronariana (DAC) estável e síndrome coronariana aguda (SCA). RESULTADOS. A mortalidade observada foi de 4,3% (n=19) e estimada em 1,21% e 2,74% pelo STS e EuroSCORE II, respetivamente. Avaliação da discriminação foi deficitária para o STS (AUC=0,646; IC95% 0,760-0,532) e Euro II (AUC=0,697; IC95% 0,802-0,593). A calibração foi ausente para o modelo norte-americano (p<0,05) e razoável para o modelo europeu (O/E=1,59, p=0,056). Nos subgrupos, o EuroSCORE II apresentou AUC de 0,616 (IC95% 0,752-0,480) e 0,826 (IC95% 0,991-0,661), enquanto o STS obteve AUC de 0,467 (IC95% 0,622-0,312) e 0,855 (IC95% 1,0-0. 706) em pacientes com SCA e DAC (figura 1), respetivamente, demonstrando bom desempenho dos modelos em pacientes estáveis (eletivos), como observado em outros estudos (tabela 1), provavelmente por se tratar de uma população semelhante àquela onde esses modelos foram criados/validados. CONCLUSÃO. Os modelos preditores não apresentaram desempenho ideal na amostra total, mas o modelo europeu foi superior, sobretudo em pacientes estáveis eletivos, onde a acurácia foi satisfatória.

Revascularização completa versus parcial para idosos com síndrome coronariana aguda: uma metanálise e revisão sistemática de dados randomizados e ajustados multivariáveis / Complete versus partial revascularization for elderly people with acute coronary syndrome: a meta-analysis and systematic review of randomized, multivariable-adjusted data

Introdução: Evidências de estudos randomizados apoiam a revascularização completa em vez do culpado apenas para pacientes com síndrome arterial coronariana aguda (SCA) e doenças coronarianas multiarteriais. Se estes resultados se estendem a pacientes idosos, no entanto, não foi completamente explorado. Métodos: Realizamos uma revisão sistemática e meta-análise comparando os resultados clínicos de idosos (definidos como idade >;75 anos) com SCA e DMV submetidos à intervenção coronária percutânea (ICP) completa vs. parcial. Foram pesquisados ​​PubMed, Embase e Cochrane. Calculamos razões de risco agrupadas com intervalos de confiança (IC) de 95% para preservar os dados de tempo até o evento. Resultados: Incluímos 7 estudos, dos quais 2 eram RCT e 5 eram coortes ajustadas multivariáveis, compreendendo um total de 10 147, dos quais 43,8% foram submetidos à revascularização completa. Em comparação com PCI apenas parcial, a revascularização completa foi associada a uma menor mortalidade por todas as causas (razão de risco 0,71; IC 95% 0,60-0,85; P < 0,01), mortalidade cardiovascular (razão de risco 0,64; IC 95% 0,52-0,79; P < 0,01) e infarto do miocárdio recorrente (razão de risco 0,65; IC 95% 0,50-0,85; P < 0,01). Não houve diferença significativa entre os grupos em relação ao risco de revascularizações (razão de risco 0,80; IC 95% 0,53-1,20; P = 0,28). Conclusão: Entre pacientes idosos com SCA e DAC multiarterial, a revascularização completa está associada a um menor risco de mortalidade por todas as causas, mortalidade cardiovascular e infarto do miocárdio recorrente.

Expanding revascularization trials to women and underserved minorities and shifting to patient-centered outcomes: RECHARGE trials program.

PURPOSE OF REVIEW: We review the limited available evidence informing coronary revascularization decisions in women and minorities, and introduce the RECHARGE trial program, which consists of two separate but integrated parallel multicenter, randomized trials comparing coronary artery bypass grafting (CABG) to percutaneous coronary intervention (PCI), one exclusively enrolling women (RECHARGE:Women) and one exclusively enrolling Black or Hispanic patients (RECHARGE:Minorities). RECENT FINDINGS: The extensive evidence base supporting coronary revascularization suffers from under-representation of women, minorities and minoritized populations, and the use of heterogeneous primary composite outcomes whose components have varying strengths of association with prognosis and quality-of-life (QOL). In RECHARGE, participants will be followed for up to 10 years, with QOL assessments at baseline, 30 days, 3 months, every 6 months for 3 years, and annually thereafter. The primary endpoint is the hierarchical composite of time to all-cause mortality, time-averaged change from baseline in the physical component of the SF-12v2 physical summary score, and time-averaged change from baseline in the mental component of the SF12v2 summary score, evaluated using a win ratio. Independently adjudicated major adverse cardiovascular and noncardiovascular events and disease-specific QoL will be secondary endpoints. SUMMARY: The RECHARGE trials are the first revascularization trials to enroll exclusively women and minority patients and to use patient-centered outcomes as their primary outcome.

Value of Ischemia and Coronary Anatomy in Prognosis and Guiding Revascularization Among Patients With Stable Ischemic Heart Disease.

BACKGROUND: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated. METHODS: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index. RESULTS: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21). CONCLUSIONS: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).

Long-Term Survival after Coronary Artery Surgical Revascularization-Does Ambient Temperature Matter?

Background and Objectives: The progression of global warming results in an increased exposure to extreme heat, leading to exaggeration of preexisting diseases and premature deaths. The aim of the study was to present possible risk factors for all-cause long-term mortality in patients who underwent surgical revascularization, including an assessment of the influence of ambient temperature exposure. Materials and Methods: Retrospective analysis included 153 (123 (80%) males and 30 (20%) females) patients who underwent off-pump revascularization and were followed for a median time of 2533 (1035-3250) days. The demographical, clinical data and ambient temperature exposure were taken into analysis for prediction of all-cause mortality. Individual exposure was calculated based on the place of habitation. Results: In the multivariate logistic regression model with backward stepwise elimination method, risk factors such as dyslipidaemia (p = 0.001), kidney disease (p = 0.005), age (p = 0.006), and body mass index (p = 0.007) were found to be significant for late mortality prediction. In addition to traditional factors, environmental characteristics, including tropical nights (p = 0.043), were revealed to be significant. Conclusions: High night-time ambient temperatures known as tropical nights may be regarded as additional long-term mortality risk factor after surgical revascularization.

The uric acid/albumin ratio might be a better indicator for predicting repeat revascularization in young patients with acute coronary syndrome: Beyond inflammatory biomarkers.

BACKGROUND: Despite advancements in percutaneous and surgical revascularization techniques, nearly 20% of patients who undergo myocardial revascularization need repeat revascularization. Recently, identified as a prognostication factor for adverse cardiovascular events, the uric acid/albumin ratio (UAR) serves as a new marker for assessing inflammation and oxidative stress. Our objective was to investigate the association between UAR levels and repeat revascularization in young patients with acute coronary syndrome (ACS). METHODS: We enrolled 371 patients with ACS who were under the age of 55 years and who had previously undergone primary percutaneous coronary intervention. Due to their recurrent symptoms, these patients underwent subsequent coronary angiographic examination. The study cohort was splitted into two groups based on whether repeat revascularization was needed. RESULTS: The study and control groups consisted of 99 and 272 patients, respectively. The mean age of the patients in the study cohort was 41.99±4.99 years. Patients who needed repeat revascularization, in comparison to those who did not, exhibited significantly greater levels of the UAR and uric acid, along with lower levels of neutrophils, stent diameter and high density lipoprotein-cholesterol. Additionally, they had more complex disease, as described by the SYNTAX score. To identify the influential factors associated with repeat revascularization, multivariate logistic regression was performed. SYNTAX score, stent diameter, uric acid levels and the UAR were predictive of the need for repeat revascularization. CONCLUSIONS: UAR was found to be an inexpensive, easily accessible marker for identifying young patients with ACS requiring repeat revascularization.

Quality of life assessment of patients infected with COVID-19 and prior coronary artery bypass graft surgery in Brazil: four years follow-up

BACKGROUND The COVID-19 pandemic has been a worldwide challenge. In patients with coronary artery disease (CAD), previously submitted to coronary artery bypass graft surgery (CABG), such impact should be analyzed. OBJECTIVES Evaluate the impact on quality of life of COVID-19 infection in patients with prior CABG. METHODS Patients undergoing isolated CABG between July 2016 and July 2017 were enrolled. This is an observational, cross-sectional, prospective study. Patients were divided into two groups: Group (COVID-19) and Group (No-COVID), for analysis of variables. The World Health Organization's (WHO) definitions of confirmed cases were used to define the diagnosis of COVID-19 infection. Quality of life was assessed using the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire, applied 30 days, 6 months, 1 year, and 4 years after surgery. The primary endpoint was improvement in quality of life at 4 years after CABG. The local ethics committee approved the study. Continuous variables were described by their means and standard deviations (SD). Categorical variables were described using absolute or relative frequencies. The items that make up the quality of life questionnaire were added together to calculate the score. A linear mixed model was used to assess the effect of time on the score. The significance level adopted was 5%. The analyses were carried out using R software, version 4.2.1. RESULTS The total sample consisted of 434 patients who underwent isolated CABG; the mean age was 63 years, with a prevalence of males (71%). Among the patients followed up at the 4-year follow-up (115), 60 (52%) were positive according to the WHO's definitions. After multiple comparisons, there was a statistical difference in quality of life in all periods (P<0.001). Between patients with and without COVID-19, a statistical difference was observed at 1 and 4 years (p = 0.0039). CONCLUSION Patients who underwent CABG and had a history of COVID-19 infection experienced worsening quality of life within 4 years. There was no difference between groups regarding new acute myocardial infarction (AMI), stroke, or hospitalization.

Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions.

Angina pectoris may arise from obstructive coronary artery disease (CAD) or in the absence of significant CAD (ischemia with nonobstructed coronary arteries [INOCA]). Therapeutic strategies for patients with angina and obstructive CAD focus on reducing cardiovascular events and relieving symptoms, whereas in INOCA the focus shifts toward managing functional alterations of the coronary circulation. In obstructive CAD, coronary revascularization might improve angina status, although a significant percentage of patients present angina persistence or recurrence, suggesting the presence of functional mechanisms along with epicardial CAD. In patients with INOCA, performing a precise endotype diagnosis is crucial to allow a tailored therapy targeted toward the specific pathogenic mechanism. In this expert opinion paper, we review the evidence for the management of angina, highlighting the complementary role of coronary revascularization, optimal medical therapy, and lifestyle interventions and underscoring the importance of a personalized approach that targets the underlying pathobiology.

Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions.

Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.

Optimal timing of revascularization for patients with non-ST segment elevation myocardial infarction and severe left ventricular dysfunction.

Optimal timing of revascularization for patients who presented with non-ST segment elevation myocardial infarction (NSTEMI) and severe left ventricular (LV) dysfunction is unclear. A total of 386 NSTEMI patients with severe LV dysfunction from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction Registry V (KAMIR-V) were enrolled. Severe LV dysfunction was defined as LV ejection fraction ≤ 35%. Patients with cardiogenic shock were excluded. Patients were stratified into two groups: PCI within 24 hours (early invasive group) and PCI over 24 hours (selective invasive group). Primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, non-fatal MI, repeat revascularization, and stroke at 12 months after index procedure. Early invasive group showed higher incidence of in-hospital death (9.4% vs 3.3%, P = .036) and cardiogenic shock (11.5% vs 4.6%, P = .030) after PCI. Early invasive group also showed higher maximum troponin I level during admission (27.7 ±â€…44.8 ng/mL vs 14.9 ±â€…24.6 ng/mL, P = .001), compared with the selective invasive group. Early invasive group had an increased risk of 12-month MACCE, compared with selective invasive group (25.6% vs 17.1%; adjusted HR = 2.10, 95% CI 1.17-3.77, P = .006). Among NSTEMI patients with severe LV dysfunction, the early invasive strategy did not improve the clinical outcomes. This data supports that an individualized approach may benefit high-risk NSTEMI patients rather than a routine invasive approach.

NLRP3 inflammasome-induced pyroptosis and serum ASC specks are increased in patients with cardiogenic shock.

Cardiogenic shock (CS) is characterized by impaired cardiac function, very high mortality, and limited treatment options. The proinflammatory signaling during different phases of CS is incompletely understood. We collected serum and plasma (n = 44) as well as freshly isolated peripheral blood mononuclear cells (PBMCs, n = 7) of patients with CS complicating acute myocardial infarction on admission and after revascularization (24, 48, and 72 h) and of healthy controls (serum and plasma, n = 75; PBMCs, n = 12). PBMCs of patients with CS had increased gene expression of NLRP3, CASP1, PYCARD, IL1B, and IL18 and showed increased rates of pyroptosis (control, 4.7 ± 0.3 vs. 9.9 ± 1.7% in patients with CS, P = 0.02). Serum interleukin (IL)-1ß levels were increased after revascularization. IL-18 and IL-6 were higher in patients with CS than in healthy controls but comparable before and after revascularization. Proinflammatory apoptosis-associated speck-like proteins containing CARD (ASC) specks were elevated in the serum of patients with CS on admission and increased after revascularization (admission, 11.1 ± 4.4 specks/µL; after 24 h, 19.0 ± 3.9, P = 0.02). ASC specks showed a significant association with 30-day mortality in patients with CS (P < 0.05). The estimated regression coefficients and odds ratios indicated a positive relationship between ASC specks and mortality (odds ratio: 1.029, 95% confidence interval, 1.000 to 1.072; P = 0.02). Pyroptosis and circulating ASC specks are increased in patients with CS and are particularly induced after reperfusion. This underscores their potential role as a biomarker for poor outcomes in patients with CS. ASC specks represent promising new therapeutic targets for patients with CS with high inflammatory burden.NEW & NOTEWORTHY The expression of NLR family pyrin domain containing-3 (NLRP3) inflammasome-related genes and the rate of pyroptosis are increased in PBMCs from patients with CS. Furthermore, patients with CS are characterized by higher serum concentrations of ASC specks and IL-1ß, IL-6, and IL-18. This current study adds circulating ASC specks to the portfolio of biomarkers for the identification of patients with a high inflammatory burden paving the way for precision medicine approaches to improve clinical outcomes.

[Life insurance after percutaneous revascularization in a patient with severe left ventricular dysfunction and left bundle branch block: benefit of revascularization in the post-REVIVED-BCIS2 era]. / Un'assicurazione sulla vita dopo rivascolarizzazione percutanea in un paziente con severa disfunzione ventricolare sinistra e blocco di branca sinistro: beneficio della rivascolarizzazione coronarica nell'era post-REVIVED-BCIS2.

The recent results of the REVIVED-BCIS2 randomized clinical trial added further controversy on the utility of myocardial revascularization in patients with chronic coronary syndrome with reduced ejection fraction. However, coronary artery disease still represents the leading cause of heart failure with reduced ejection fraction, with the potential for functional recovery following complete revascularization due to the restoration of the so-called hibernating myocardium. We report an emblematic case of a patient with recovery of contractile function and normalization of the left bundle branch block after percutaneous coronary intervention of the right coronary artery chronic total occlusion.