Characteristics and outcomes of surgically ineligible patients with multivessel disease treated with percutaneous coronary intervention

Abstract

Objectives In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI). Background Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials. Methods Out of 1,061 consecutive patients who underwent a non‐emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1‐year. Results The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one‐year outcomes. Conclusions Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one‐year outcomes after PCI compared to the SYNTAX score.

Clinical outcomes of percutaneous coronary intervention in high‐risk patients turned down for surgical revascularization

“…Of note, the predicted operative mortality for the whole cohort was 6.3%, as calculated by the EuroSCORE II (Table 2). This finding is in line with previous reports demonstrating that the short‐term risk of death with PCI in surgically ineligible patients is considerably lower than the validated operative risk estimates 1,4,5,7–9 …”

“…This finding is in line with previous reports demonstrating that the short-term risk of death with PCI in surgically ineligible patients is considerably lower than the validated operative risk estimates. 1,4,5,[7][8][9] Patients who are deemed ineligible for surgical revascularization are usually excluded from clinical trials with no consensus on their management. These patients usually have complex coronary disease and there is little contemporary data with regard to PCI, which can bring both survival and a better quality of life.…”

Surgical Turned-Downed CHIP Cases—Can PCI Save the Day?

“…Shield et al have similarly focused on patients with advanced CAD who were deemed to be ineligible for surgery, retrospectively reviewing a smaller cohort (137 patients) and showing even better results for PCI (mortality 2.2% at 30 days and 11% at 1 year) but in a healthier population (Syntax Score >33 pcts in 14% of patients vs 45% in OPTIMUM, STS >8% only 17%) ( 18 ). It is not surprising that mortality increases with the level of comorbidity but also with the complexity of the coronary disease.…”

“…This is a crucial aspect as, in randomized controlled trials, our pivotal objective addresses only if “there is a mortality benefit in these patients.” Still, we must acknowledge that, often in this particular morbid population, it is unlikely we are going to impact on their longer-term prognosis, but the quality of life and symptoms are still important to patients, and the sight of that should not be lost. OPTIMUM and other registries of its kind ( 6 , 9 – 11 , 16 , 18 ) show that we should reflect on the patients' cohort that we are undertaking these procedures on and think about what really matters to them.…”

Surgical turndowns are not no option patients

“…The first of these issues is addressed by Dr. Shields and colleagues 3 in the current issue of this journal. These investigators analyzed their institutional experience between 2012 and 2015 of 137 high-risk (left main or multivessel disease) patients who were initially referred for CABG, believing this to be the best option but were ultimately turned down for CABG after heart team evaluation.…”