Outcomes of atherectomy in treating severely calcified coronary lesions in patients with reduced left ventricular ejection fraction: A systematic review and meta-analysis

Abstract

BackgroundSeverely calcified coronary lesions with reduced left ventricular (LV) function result in worse outcomes. Atherectomy is used in treating such lesions when technically feasible. However, there is limited data examining the safety and efficacy of atherectomy without hemodynamic support in treating severely calcified coronary lesions in patients with reduced left ventricular ejection fraction (LVEF).ObjectiveTo evaluate the clinical outcomes of atherectomy in patient with reduced LVEF.MethodsWe searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 21, 2021) for studies evaluating the outcomes of atherectomy in patients with severe LV dysfunction. We used random-effect model to calculate risk ratio (RR) with 95% confidence interval (CI). The endpoints were in-hospital and long term all-cause mortality, cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR).ResultsA total of 7 studies consisting of 2,238 unique patients were included in the analysis. The median follow-up duration was 22.4 months. The risk of in-hospital all-cause mortality using atherectomy in patients with severely reduced LVEF compared to the patients with moderate reduced or preserved LVEF was [2.4vs.0.5%; RR:5.28; 95%CI 1.65–16.84; P = 0.005], the risk of long term all-cause mortality was [21 vs. 8.8%; RR of 2.84; 95% CI 1.16–6.95; P = 0.02]. In-hospital TVR risk was 2.0 vs. 0.6% (RR: 4.15; 95% CI 4.15–15.67; P = 0.04) and long-term TVR was [6.0 vs. 9.9%; RR of 0.75; 95% CI 0.39–1.42; P = 0.37]. In-hospital MI was [7.1 vs. 5.4%; RR 1.63; 95% CI 0.91–2.93; P = 0.10], long-term MI was [7.5 vs. 5.7; RR 1.74; 95%CI 0.95–3.18; P = 0.07).ConclusionOur meta-analysis suggested that the patients with severely reduced LVEF when using atherectomy devices experienced higher risk of clinical outcomes in the terms of all-cause mortality and cardiac mortality. As we know that the patients with severely reduced LVEF are inherently at increased risk of adverse clinical outcomes, this information should be considered hypothesis generating and utilized while discussing the risks and benefits of atherectomy in such high risk patients. Future studies should focus on the comparison of outcomes of different atherectomy devices in such patients. Adjusting for the inherent mortality risk posed by left ventricular dysfunction may be a strategy while designing a study.

Clinical research of drug-coated balloon after rotational atherectomy for severe coronary artery calcification

“…First, heavily calcified plaques impair the trabecular meshwork, disrupting drug-polymer from the stent surface and reducing the success rate and long-term effectiveness of PCI [ 7 ]. Second, the existence of calcified nodules impedes complete stent expansion and accurate apposition, leading to an increased rate of in-stent restenosis and stent thrombosis [ 8 ]. Despite being rare, stent thrombosis may cause myocardial infarction (MI) or cardiac death [ 9 ].…”

Rotational atherectomy for chronically and totally occluded coronary lesions: A propensity score-matched outcomes study

“…Under-expanded stents have been associated with poor long-term results (11). The outcomes of rotablation for coronary lesions could be affected by various clinical factors such as age, diabetes, renal insufficiency, LV function, and acute coronary syndrome (12)(13)(14)(15). In our previous studies, we have identified age, diabetes, renal insufficiency, ACS, cardiogenic shock, and residual Syntax score as prognostic factors for short and intermediate outcomes (16,17).…”