Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate

Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased... Hindawi Journal of Interventional Cardiology Volume 2020, Article ID 4587414, 8 pages https://doi.org/10.1155/2020/4587414 Clinical Study Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate Chien-Ho Lee , Shaur-Zheng Chong, Shu-Kai Hsueh, Wen-Jung Chung, and Cheng-I Cheng Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan Correspondence should be addressed to Cheng-I Cheng; chris.chengi.cheng@gmail.com Received 23 February 2020; Revised 6 May 2020; Accepted 27 May 2020; Published 15 June 2020 Academic Editor: Faisal Latif Copyright©2020Chien-HoLeeetal.)isisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. )e outcomes of patients with concomitant left main coronary artery (LMCA) and right coronary artery (RCA) diseasesarereportedlyworsethanthosewithonlyLMCAdisease.Todate,onlyfewstudieshaveinvestigatedtheclinicalimpactof percutaneous coronaryintervention(PCI)onRCAstenosisduringthesamehospitalization,inwhichLMCAdiseasewastreated. )isstudywasaimedatcomparingtheoutcomesbetweenpatientswithandwithoutrightcoronaryarteryinterventionduringthe samehospitalcourseforLMCAintervention. Methods and Results.Fromatotalof776patientswhowereundergoingPCItotreat LMCAdisease,235patientswithconcomitantRCAsignificantstenosis(morethan70%stenosis)wereenrolled.)epatientswere divided into two groups: 174 patients received concomitant PCI for RCA stenosis during the same hospitalization, in which LMCA disease was treated, and 61 patients did not receive PCI for RCA stenosis. Patients without intervention to the right coronary artery had higher 30-day cardiovascular mortality rates and 3-year RCA revascularization rates compared to those with rightcoronaryarteryintervention.PatientswithoutRCAinterventionatthesamehospitalizationdidnotincreasethe30-daytotal death, 3-year myocardial infarction rate, 3-year cardiovascular death, and 3-year total death. Conclusions. In patients with LM disease and concomitant above or equal to 70% RCA stenosis, PCI for RCA lesion during the same hospitalization is rec- ommended to reduce the 30-day cardiovascular death and 3-year RCA revascularization rate. However, the patients with concomitant LM and RCA 1. Introduction disease had higher cardiac death after PCI to the left main With recent significant advancement in devices and tech- disease than those without RCA disease (17.7% vs. 6.7%, niques used for percutaneous coronary intervention (PCI), p � 0.056), and the patient with chronic total occlusion unprotected left main (LM) coronary artery disease (CAD) (CTO) of the right coronary artery had extreme high can be safely and effectively managed. For patients with LM mortality (30% vs 6.7%, p � 0.015) [4]. Residual CTO of the CADwhohavealow-to-moderateSYNTAXscore,thelong- RCA is the predictor of mortality for patients who undergo term results of PCI outcome are not inferior to coronary PCI to unprotected left main disease [5, 6]. Another study artery bypass graft (CABG), whereas coronary artery bypass also showed that patients with unprotected LM and con- graft (CABG) remains the primary choice for LM and comitantRCAlesionswhoundergoPCIhadworseearlyand multivessel CAD in those patients with a high SYNTAX long-termoutcomescomparedtothosewithoutRCAlesions score (>32) [1, 2]. However, PCI to left main disease is still [7]. Current ACC/AHA guideline recommends PCI to the the popular alternative treatment in the real world. In a noninfarct vessel in selected patients with STEMI, and ESC recent meta-analysis, PCI to left main disease had the same guideline recommends revascularization of the noninfarct- all-cause mortality versus the CABG intervention [3]. related artery in patients with ST-segment elevation 2 Journal of Interventional Cardiology myocardial infarction (STEMI) before hospital discharge infarction was defined as symptoms consistent with acute [8, 9]. On the other hand, guidelines have not given any coronary syndrome and a typical rise and fall of troponin-I, with ST-segment elevation on a 12-lead electrocardiogram. comments on the one-time revascularization in patients with multivessel CAD and left main disease. Till date, the Acute non-ST-elevation myocardial infarction was defined impact of treating RCA disease during the same hospitali- assymptomsconsistentwithacutecoronarysyndromeanda zation for LM coronary artery disease treatment has not yet typical rise and fall of troponin-I, without ST-segment el- been well discussed. evation on a 12-lead electrocardiogram. RCA disease was )ere are limited data regarding the effects of PCI for defined as “focal disease” if any lesion length <10mm, RCA stenosis in patients who undergo PCI for unprotected “tubular disease” if any lesion >10mm and <20mm, and LM CAD in the same hospitalization. Our previous study “diffuse disease” if any lesion >20mm. Death from car- showed that PCI in these LM diseased patients in our diovascular causes was defined as death because of acute hospitalisfeasiblewithahighsuccessrateandiscomparable myocardial infarction, heart failure, cardiogenic shock, to CABG in terms of cardiac death and overall survival, and ventricular arrhythmia, or cerebrovascular events. Any unidentified death was attributed to CV causes. RCA re- these results are similar to most other studies [10–13]. )is study was aimed at evaluating the impact of right coronary vascularization was defined as any percutaneous interven- intervention at the same hospitalization for those patients tion or surgical bypass of any segment of the RCA vessel. with concomitant left main and right coronary artery ste- nosis and received left main PCI. 2.3. Statistical Analysis. Categoricalvariableswerepresented as counts and percentages, and the difference between the 2. Methods two groups was determined by the chi-square or Fisher’s exact test. Continuous variables were presented as the 2.1. Study Population. Patients with unprotected left main mean±standard deviation and were compared by Student’s disease and received PCI in our hospital between July 2001 t-test, and the median value was compared using the and September 2016 were retrospectively enrolled in our Mann–Whitney U test. Survival curves were constructed study. Patients with acute ST-elevation myocardial infarc- with the Kaplan–Meier curves, and the log rank test with tion (STEMI), RCA stenosis less than 70%, or RCA with pairwise comparisons was used to calculate differences chronic total occlusion (CTO) were excluded in this study. between groups. )e Cox multivariate proportional hazard )estudyprotocolwasapprovedbytheInstitutionalReview regression analysis was performed to investigate possible Board of the Chang Gung Medical Foundation. confounders.)efollowingvariableswereconsideredinthis analysis: age, sex, diabetes mellitus, hypertension, smoking, hyperlipidemia, chronic kidney disease, end stage renal 2.2. Study Design and Endpoints. Detailed informed consent diseaseonhemodialysis,oldischemicstroke,oldMI,history for the PCI procedure was obtained from all patients before of coronary artery disease, left ventricular ejection fraction theprocedure,andalltreatmentoptionswerediscussedwith (LVEF) <40%, peripheral arterial occlusive disease (PAOD), thepatients andtheir families.Allpatients weretreated with and clinical status including acute myocardial infarction, the dual antiplatelet therapy (aspirin plus one kind of P Y 2 12 respiratory failure, ventricular tachyarrhythmia, intra-aortic inhibitor) after PCI procedure, and β-adrenergic blocker, balloon pump (IABP) use, temporary pacemaker use, upper angiotensin-converting enzyme inhibitor or angiotensin- gastrointestinal (UGI) bleeding, mean hospital stay, two or receptor blocker, and statin were used as the standard more stents at LM bifurcation, bare-metal stenting in LM, therapy if patient had no contraindication. andintravascular ultrasound- (IVUS-)guided.)eselection )ese patients were divided into two groups, the group ofvariablesinthemultivariatemodelwasbasedona pvalue in which patients had RCA intervention at the same hos- <0.1. )e hazard ratio (HR) and corresponding 95% con- pitalization (either in the same session or before discharge) fidence intervals (CI) were reported. A p value <0.05 was was defined as the group of “with RCA intervention,” and considered significant. All data were processed using the theotherswereassignedintothegroupclassifiedas“without Statistical Package for Social Sciences, version 17 (SPSS, RCAintervention.”Inthisstudy,weevaluatedtheendpoints Chicago, IL, USA), and figures were created by the asthe(1)30-daycardiovasculardeath,(2)30-daytotaldeath, GraphPad Prism 7 (GraphPad Software, Inc., La Jolla, CA). (3) 3-year cardiovascular death, (4) 3-year total death, (5) 3- year new myocardial infarction, and (6) 3-year right coro- nary artery intervention. 3. Results )e SYNTAX score was used to assess the complexity of CAD. )e SYNTAX score calculation was completed bytwo )ere were a total of 776 patients undergoing PCI for un- experienced cardiologists who were blinded to the proce- protected LM disease in our hospital between July 2001 and duraldataandclinicaloutcomes.UnprotectedLMCADwas September 2016. In total, 235 patients with concomitant LM defined as a left main lesion with a diameter stenosis >50% disease and above or equal to 70% RCA stenosis were en- without previous PCI or CABG. A mean serum total cho- rolled. All patients in this study were observed for three lesterollevel>200mg/dlwithoutstatinuseatthetimeofthis years. )ere were 61 patients in the group of “without RCA study or recorded before the present statin therapy was intervention” and 174 patients in the group of “with RCA classified as hyperlipidemia. Acute ST-elevation myocardial intervention.” Journal of Interventional Cardiology 3 RCA intervention” and twelve patients in the group “with Most of these patients were male (75.7%), with hyper- tension(82.6%)anddiabetesmellitus(60.4%).Atotalof152 RCA intervention” had cardiovascular death within three- year, and there was no statistical difference between the two (64.7%)patientshadchronickidneydiseaseorhemodialysis. )ere were no statistical differences between the two groups groups (free of the 3-year cardiovascular death; 84.09% in age, body weight, sex, and comorbidities including hy- vs.92.45%, p � 0.054). )ere was no significant difference in pertension, diabetes mellitus, hyperlipidemia, chronic kid- the 3-year all-cause death (free of the 3-year total death; ney disease, end-stage renal disease on hemodialysis, or 76.02% vs 83.35%, p � 0.16), with 14 patients in the group history of vascular events. )ere were 13.6% patients in the “without RCA intervention” and 27 patients in the group group“withoutRCAintervention”and10.2%patientsinthe “with RCA intervention” dead at the end of three years (Figures 1(c) and 1(d)). )ere was no increase in the 3-year group“withRCAintervention”andhadLVejectionfraction less than 40% (p � 0.477); 24.6% patients in the group new myocardial infarction rate of patients in the “without RCA intervention” group at index hospitalization (free of “withoutRCAintervention”and32.2%patientsinthegroup “withRCAintervention”receivedPCIbecauseofacutenon- new myocardial infarction; 87.14% vs 90.36%, p � 0.63) (Figure 1(e)). But patients without RCA intervention had ST-elevation myocardial infarction (p � 0.266). )ere was no difference between the two groups in ventricular ar- extremely high risk to receive RCA revascularization within rhythmia, respiratory failure, IABP, and temporary pace- thenext3yearsascomparedtothosewithRCAintervention maker use. )e mean hospital stay was 13.07 ±22.67 days (free ofthe 3-yearRCA revascularization;61.02%vs 89.38%, (median,6days;interquartilerange(IQR), 3–14 days)inthe p<0.0001) (Figure 1(f)). A total of 19 patients in the group group “without RCA intervention” and 9.74±12.63 days “without RCA intervention” will receive RCA PCI in the (median, 6 days; interquartile range (IQR), 4–9 days) in the next 3years,and14 of themwillreceivePCI during thenext first year. group “with RCA intervention” (Table 1). Table 2 showed the angiographic and procedure out- )e univariate analysis showed that “without RCA in- tervention,” female, IABP use, temporary pacemaker use, comes between the two groups. )ere was no significant differenceofthenumberofdiseasedvesselsandsyntaxscore respiratory failure, and implanted bare-metal stent at left main lesion were the risk factors of the 30-day cardiovas- betweenthetwogroups.Mostpatientsinthetwogroupshad triple-vessel CAD (79.7% vs 84.7%, p � 0.369). )ere were cular death. )e multivariate analysis showed that “without 44.3%patientsinthegroup“withoutRCAintervention”and RCA intervention” was still the independent risk factor for 50% patients in the group “with RCA intervention” and had the 30-day cardiovascular death (HR �9.37, 95% CI a high syntax score >33 (p � 0.440). )ere were 26.2% 1.34–65.39. p � 0.024). Other independent risk factors in- patientsinthegroup“withoutRCAintervention”and20.1% clude IABP and temporary pacemaker use, respiratory patientsinthegroup“withRCAintervention”andhadbare- failure, andbare-metal stent implantation at left main lesion (Table 3). metal stent deployed at left main lesion, and the others had drug-eluting stent deployed. Most of the patients between )e univariate analysis showed that without RCA in- tervention, body weight, chronic kidney disease, end-stage the two groups had IVUS-guided PCI for left main lesion (62.3% vs 72.4%, p � 0.139) and stenting with single-stent- renal disease on hemodialysis, history of myocardial in- only strategy at the left main lesion (68.9% vs 73.6% farction, PAOD, and LVEF <40% were the risk factors for p � 0.479). )ere was no significant difference between the the 3-year RCA revascularization. But only “without RCA two stent techniques, including simultaneous kiss-stent, intervention” and end-stage renal diseases were the inde- crushed, T-stent,andculotte’stechniques.)ere were36.1% pendent risk factors in the multivariate analysis (Table 4). patientsinthegroup“withoutRCAintervention”and47.1% patients in the group “with RCA intervention” and had only 4. Discussion single lesion in the RCA (p � 0.134). Others were multiple lesions, and the median lesion number was two. Only 23% )is study provides evidence that PCI for concomitant RCA patientsinthegroup“withoutRCAintervention”and15.5% stenosis with LM intervention during the same hospitali- patients in the group “with RCA intervention” had focal zation significantly lowers the 30-day cardiovascular death lesions only in the RCA (p � 0.188). )ere were 68.9% and3-yearsRCArevascularizationratecomparedtopatients patients in the group “without RCA intervention” and 69% who do not receive PCI for RCA stenosis. Most of the patients in the group “with RCA intervention” and had patients without RCA intervention at the index hospitali- diffuse lesions in the RCA (p � 0.987). )e lesion location zation would receive RCA intervention for any reason between the two groups was similar. within 3 years. Patient without receiving RCA intervention Six patients in the group “without RCA intervention” during the same hospitalization will not increase the 30-day and three patients in the group “with RCA intervention” total death, 3-year total death, and 3-year new myocardial died becauseof cardiovascular causes within 30 days(free of infarction rate. the 30-day cardiovascular death; 90.11% vs. 98.23%, A previous study had reported that a patient with un- p � 0.005). Seven patients in the group “without RCA in- protected LM disease and concomitant RCA disease (RCA tervention” and nine patients in the group “with RCA in- stenosis more than 50%) had a worse 30-day survival rate, tervention” died from any cause within 30 days (free of the and the RCA disease was the independent predictor of total 30-day total death; 76.02% vs. 83.35%, p � 0.096) death [7]. Our study further demonstrated that the RCA (Figures 1(a) and 1(b)). Nine patients in the group “without intervention in those concomitant LM and RCA diseased 4 Journal of Interventional Cardiology Table 1: Baseline characteristics and clinical status between the two groups. Without RCA intervention N �61 (%) With RCA intervention N �174 (%) p value Age (years), mean 69.39±9.68 67.10±10.58 0.138 Body weight (kg), mean 63.93±9.85 66.17±11.55 0.178 Male 46 (75.4%) 132 (75.9%) 0.943 Diabetes mellitus 42 (68.9%) 100 (57.5%) 0.118 Hypertension 46 (75.4%) 148 (85.1%) 0.088 Current smokers 10 (16.4%) 42 (24.1%) 0.210 Hyperlipidemia 35 (57.4%) 111 (63.8%) 0.374 Chronic kidney disease 40 (65.6%) 94 (54%) 0.117 Hemodialysis 5 (8.2%) 13 (7.5%) 0.787 Previous stroke 15 (24.6%) 24 (13.8%) 0.051 Previous myocardial infarction 14 (23.0%) 27 (15.5%) 0.188 Previous coronary artery disease 25 (41.0%) 64 (36.8%) 0.560 Peripheral artery disease 8 (13.1%) 11 (6.3%) 0.094 LVEF <40% 8 (13.6%) 17 (10.2%) 0.477 Atrial fibrillation history 1 (1.6%) 8 (4.6%) 0.453 Warfarin or NOAC use 0 (0%) 2 (1.1%) 1.0 Acute NSTEMI 15 (24.6%) 56 (32.2%) 0.266 Respiratory failure 6 (9.8%) 12 (6.9%) 0.458 Ventricular arrhythmia 3 (4.9%) 4 (2.3%) 0.380 IABP 10 (16.4%) 26 (14.9%) 0.787 Temporary pacemaker 1 (1.6%) 5 (2.9%) 1.000 UGI bleeding 4 (6.6%) 6 (3.4%) 0.290 Hospital stay (mean) 13.07±22.67 9.74±12.63 0.280 Hospital stay (median) 6 (3–14) 6 (4–9) 0.528 Dataarepresentedasthemean±standarddeviation, n(%),andmedian(IQR). Fisher’sexacttest.IABP �intra-aorticballoonpump;LVEF �leftventricular ejection fraction; RCA �right coronary artery; NOAC �novel oral anticoagulants; NSTEMI �non-ST-elevation myocardial infarction; and UGI �upper gastrointestinal bleeding. revascularization in all diseased segments with a diameter patients at the index hospitalization would improve the 30- day cardiovascular death. After adjusting other risk factors, ≧2.5mm had higher all-cause mortality and a composite of RCA intervention is still the independent risk factor of the cardiac death, myocardial infarction, and repeat revascu- 30-day cardiovascular death. Without RCA intervention, larization [17]. A meta-analysis which included 38 publi- these patients will result in more than a nine-fold risk of 30- cations and a total of 156,240 patients concluded that day cardiovascular death (HR �9.37, 95% CI: 1.34–65.39. incomplete revascularization in multiple vessel disease, p � 0.024). anatomically or functionally, increased the risk of death, OurstudyalsoshowedthatresidualRCAstenosishadan myocardial infarction, and repeated revascularization. And influence on the 3-year cardiovascular death. Although our the degree of incomplete revascularization is strongly as- sociated to the odds ratio of mortality [18]. Our study was study failed to achieve the statistical difference, it showed that residual RCA stenosis had a trend of increasing the 3- consistent with previous studies in the 3-year revasculari- zation rate. Without RCA intervention at the same hospi- year cardiovascular death. Capodanno et al. reported that a patient with residual RCA stenosis had a more than four talization will significantly increase the risk of RCA times higher cardiac death (HR 4.41, 95% CI 1.55–12.51, revascularization in the next 3years (HR �3.629, 95% p � 0.005) at the 3-year follow-up [4]. )e number of pa- CI �1.82–7.22, p<0.001). )e multivariate analysis in our tients in our study is relatively small, and a large portion of studydemonstratedthatonlywithoutRCAinterventionand these patients in the group of “without RCA intervention” hemodialysis are the independent risk factors of RCA re- received RCA intervention in the first year after discharge vascularization. However, our study showed that the 30-day and may interfere in the outcome of the 3-year cardiovas- total death, 3-year total death, and 3-year new myocardial cular death in our study. infarction showed no difference whether patient received RCA PCI or not at the same hospitalization for LM inter- In patients with left main and multiple vessel disease, most of the patients can achieve complete revascularization vention.Apossibleexplanationofnodifferenceinthe3-year new myocardial infarction is that there were 14 over 61 after CABG intervention. But if they receive PCI to the left main disease, the interventionists may not treat the RCA patientswhoreceivedRCAinterventionduringthenextfirst stenosis at the index hospitalization. )e importance of year, and it prevented further new cardiovascular events. “complete revascularization” regardless of PCI or CABG in )ere are several limitations in this study. First, it is a complex coronary artery disease was demonstrated by retrospective study, and all data were collected from a previously studies [14–18]. Zhang et al. reported a patient single medical center. Second, patient with or without with unprotected left main disease who did not achieve RCA intervention is dependent on the decision of a Journal of Interventional Cardiology 5 Table 2: Angiographic and procedure outcome between the two groups. Without RCA intervention (n �61) With RCA intervention (n �174) p value SYNTAX score values 33.96±11.52 33.26±9.65 0.523 ≤22 7 (11.5%) 14 (8%) 0.419 23–32 27 (44.3%) 73 (42.0%) 0.754 ≥33 27 (44.3%) 87 (50.0%) 0.440 Number of diseased vessels 2.80±0.40 2.83±0.42 0.626 LM with single vessel 0 (0%) 3 (1.8%) 0.571 LM with two vessels 12 (20.3%) 23 (13.5%) 0.223 LM with triple vessels 49 (80.3%) 148 (85.1%) 0.388 PCI procedure BMS at LM 16 (26.2%) 35 (20.1%) 0.319 IVUS-guided 38 (62.3%) 126 (72.4%) 0.139 Total stent number in LM 1.31±0.47 1.28±0.49 0.681 Single stent 42 (68.9%) 128 (73.6%) 0.479 Two stents 19 (31.1%) 43 (24.7%) 0.326 )ree stents 0 (0%) 3 (1.7%) 0.570 Two stent technique SKS 1 (1.6%) 2 (1.1%) 1.000 Crushed 3 (4.9%) 4 (2.3%) 0.380 T-stent 6 (9.8%) 23 (13.2%) 0.489 Culottes 9 (14.8%) 17 (9.8%) 0.286 RCA vessel classification Multiple lesions 39 (63.9%) 92 (52.9%) 0.134 Lesion numbers (median) 2 (1–2.5) 2 (1-2) 0.055 Focal disease 14 (23.0%) 27 (15.5%) 0.188 Tubular disease 5 (8.2%) 27 (15.5%) 0.151 Diffuse disease 42 (68.9%) 120 (69.0%) 0.987 RCA lesion locations Primary 29 (47.5%) 94 (54.0%) 0.383 Mid 31 (50.8%) 83 (47.7%) 0.675 Distal 27 (44.3%) 71 (40.8%) 0.637 Dataarepresentedasthemean±standarddeviation, n(%),andmedian(IQR). Fisher’sexacttest.BMS �bare-metalstent;IVUS �intravascularultrasound; LM �left main; PCI �percutaneous coronary intervention; RCA �right coronary artery; and SKS �simultaneous kissing-stents. 30-day CV death 30-day total death 100 100 98.23% 94.79% 90.11% 90 90 88.53% 80 80 Log test p = 0.005 Log test p = 0.096 0 10 20 30 0 10 20 30 Days Days Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 58 56 54 No intervention 61 58 55 54 No intervention Intervention 174 168 164 162 Intervention 174 168 164 162 (a) (b) Figure 1: Continued. Percent survival (%) Percent survival (%) 6 Journal of Interventional Cardiology 3-years CV death 3-year total death 92.45% 84.09% 83.35% 76.02% 60 60 Log test p = 0.16 Log test p = 0.054 50 50 0 12 24 36 0 12 24 36 Months Months Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 47 44 39 No intervention 61 47 44 39 No intervention Intervention 174 151 137 118 Intervention 174 151 137 118 (c) (d) 3-year new MI 3-year RCA revascularization 100 100 90.36% 90 90 89.38% 87.14% 80 80 61.02% Log test p < 0.0001 Log test p = 0.63 0 12 24 36 0 12 24 36 Months Months Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 44 40 35 No intervention 61 35 30 23 No intervention Intervention 174 143 124 107 Intervention 174 145 131 114 (e) (f) Figure1:Kaplan–Meiercurvesforevent-freesurvival.Solidline—patientswithconcomitantleftmaindiseaseandRCAsignificantstenosis (>70% stenosis) and received PCI to left main disease and right coronary artery at the same hospitalization; dotted line—patients with concomitant left maindisease and RCA significantstenosis (>70% stenosis) onlyreceived PCI to left main diseaseand wasdischarged with residualRCAsignificantstenosis.(a)30-daycardiovasculardeath-freesurvival.(b)30-daytotaldeath-freesurvival.(c)3-yearcardiovascular death-freesurvival.(d)3-yeartotaldeath-freesurvival.(e)3-yearnewmyocardialinfarction-freesurvival.(f)3-yearRCArevascularization- free survival. Table 3: Cox regression for the 30-day cardiovascular death. Univariate analysis Multivariate analysis 30 day CV death HR 95% CI p HR 95% CI p Without RCA intervention 4.548 2.334–8.862 <0.001 9.370 1.343–65.387 0.024 Female 4.188 1.124–15.599 0.033 IABP 12.988 3.243–52.021 <0.001 7.480 1.463–38.252 0.016 Temporary pacemaker 29.095 7.416–118.459 <0.001 28.628 3.242–252.778 0.003 Respiratory failure 6.800 1.697–27.258 0.007 LM BMS 4.623 1.241–17.217 0.022 4.766 1.108–20.510 0.036 CI �confidence interval; CV �cardiovascular; HR �hazard ratio; IABP �intra-aortic balloon pump; LM �left main; and RCA �right coronary artery. Percent survival (%) Percent survival (%) Percent survival (%) Percent survival (%) Journal of Interventional Cardiology 7 Table 4: Cox regression for the 3-year RCA revascularization. Univariate analysis Multivariate analysis 3-year RCA revascularization HR 95% CI p HR 95% CI p Without RCA intervention 5.756 1.439–23.014 0.013 3.629 1.816–7.216 <0.001 Body weight 0.964 0.935–0.993 0.017 Diabetes mellitus 2.026 0.973–4.222 0.059 Chronic kidney disease 3.555 1.552–8.143 0.003 Hemodialysis 4.706 2.037–10.872 <0.001 3.421 1.379–8.488 0.008 Previous MI 2.251 1.080–4.693 0.030 PAOD 4.367 1.803–10.576 0.001 LVEF <40% 3.182 1.387–7.299 0.006 CI �confidence interval; HR �hazard ratio; IABP �intra-aortic balloon pump; LM �left main; LVEF �left ventricular ejection fraction; MI �myocardial infarction; PAOD �peripheral arterial occlusive disease; and RCA �right coronary artery. physician and is therefore not randomized. Although References neither groups had significance in clinical presentation [1] P. W. Serruys, M.-C. Morice, A. P. Kappetein et al., “Per- status and syntax score, there will still be some selection cutaneous coronary intervention versus coronary artery by- bias in this study. )ird, this study had a small patient pass grafting for severe coronary artery disease,” ,e New population, and many patients in the group of “without England Journal of Medicine, vol. 360, no. 10, pp. 961–972, RCAintervention”receivedRCArevascularizationduring the observation period. )is may interfere in the long- [2] W. Wijns, P. Kolh, N. Danchin et al., “Guidelines on myo- term outcome of our study and underestimate the risk of cardial revascularization: )e Task Force on Myocardial residual RCA critical stenosis after LM revascularization. Revascularization of the European Society of Cardiology Fourth, we excluded the patients with either chronic total (ESC) and the European Association for Cardio-)oracic occlusion or RCA lesion under 70% stenosis, so our result Surgery (EACTS),” European Heart Journal, vol. 31, no. 20, cannot be applied in these groups. Last, we adopted the pp. 2501–2555, 2010. angiographic definition of the RCA critical stenosis, and [3] S. J. Head, M. Milojevic, J. Daemen et al., “Mortality after not all of patients in this study received the PCI procedure coronary arterybypass graftingversus percutaneous coronary under IVUS-guide. Accordingly, some patients with intervention with stenting for coronary artery disease: a physiological ischemia of RCA territory were possibly pooled analysis of individual patient data,” ,e Lancet, vol. 391, no. 10124, pp. 939–948, 2018. excluded in our study. Despite the limitations mentioned [4] D. Capodanno,M.-E. D.Salvo, and C. Tamburino, “Impactof above, giventhepaucityof reports regarding thebenefitof right coronary artery disease on mortality in patients un- concomitant PCI for RCA lesions in patients with LMCA dergoing percutaneous coronary intervention of unprotected diseaseandRCAstenosis,thisstudystillprovidesvaluable left main coronary artery disease,” EuroIntervention, vol. 6, information for clinical practice. no. 4, pp. 454–460, 2010. [5] A. Migliorini, R. Valenti, G. Parodi et al., “)e impact of right 5. Conclusions coronaryarterychronictotalocclusiononclinicaloutcomeof patients undergoing percutaneous coronary intervention for Rightcoronaryarteryinterventionforconcomitantleftmain unprotected left main disease,” Journal of the American andrightcoronaryarterystenosisatthesamehospitalization College of Cardiology, vol. 58, no. 2, pp. 125–130, 2011. will reduce the 30-day cardiovascular death and the 3-year [6] K. Takagi, A. Ielasi, A. Chieffo et al., “Impact of residual RCA revascularization rate compared to those without RCA chronic total occlusion of right coronary artery on the long- intervention. Without RCA intervention is both the inde- term outcome in patients treated for unprotected left main pendent risk factor for the 30-day cardiovascular death and disease: the Milan and New-Tokyo registry,” Circulation: the3-yearRCArevascularization.Itisreasonabletoperform Cardiovascular Interventions, vol. 6, no. 2, pp.154–160, 2013. [7] T.-M. Lu, Y.-L. Jou, Y.-H. Chen et al., “)e clinical signifi- RCA intervention for those patients with concomitant left cance of right coronary artery stenosis on the prognosis of main and right coronary artery disease during the same patients with unprotected left main disease undergoing per- hospitalization for left main percutaneous coronary cutaneous coronary intervention,” Acta Cardiologica Sinica, intervention. vol. 27, pp. 14–20, 2011. [8] G. N. Levine, E. R. Bates, J. C. Blankenship et al., “2015 ACC/ Data Availability AHA/SCAI focused update on primary percutaneous coro- nary intervention for patients with ST-elevation myocardial )e data used to support the findings of this study are infarction: an update of the 2011 ACCF/AHA/SCAI guideline available from the corresponding author upon request. for percutaneous coronary intervention and the 2013 ACCF/ AHA guideline for the management of ST-elevation myo- cardial infarction: a report of the American college of car- Conflicts of Interest diology/American heart association task force on clinical All authors declare that they have no conflicts of interest. practice guidelines and the society for cardiovascular 8 Journal of Interventional Cardiology angiography and interventions,” Catheterization and Car- diovascular Interventions, vol. 87, no. 6, pp. 1001–1019, 2016. [9] B. Ibanez, S. James, S. Agewall et al., “2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients pre- senting with ST-segment elevation of the European Society of Cardiology (ESC),” European Heart Journal, vol. 39, no. 2, pp. 119–177, 2018. [10] A. Chieffo, N. Morici, F. Maisano et al., “Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience,” Circulation,vol.113,no.21,pp.2542–2547,2006. [11] C.-I. Cheng,C.-J. Wu, C.-Y.Fang et al., “Feasibility and safety of transradial stenting for unprotected left main coronary artery stenoses,” Circulation Journal, vol. 71, no. 6, pp. 855–861, 2007. [12] C.-I. Cheng, F.-Y. Lee, J.-P. Chang et al., “Long-term out- comes of intervention for unprotected left main coronary artery stenosis: coronary stenting vs coronary artery bypass grafting,” Circulation Journal, vol. 73, no. 4, pp. 705–712, [13] D.-W. Park, K. B. Seung, Y.-H. Kim et al., “Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (revascularization for unprotectedleftmaincoronaryarterystenosis:comparisonof percutaneous coronary angioplasty versus surgical revascu- larization) registry,” Journal of the American College of Car- diology, vol. 56, no. 2, pp. 117–124, 2010. [14] B.Xu,N.Bettinger,C.Guanetal.,“Impactofcompletenessof revascularization in complex coronary artery disease as measured with the SYNTAX revascularization index: an SEEDS substudy,” Catheterization and Cardiovascular In- terventions, vol. 89, no. S1, pp. 541–548, 2017. [15] T. A. Schwann, M. B. Yammine, A.-K. M. El-Hage-Sleiman, M. C. Engoren, M. R. Bonnell, and R. H. Habib, “)e effect of completeness of revascularization during CABG with single versus multiple arterial grafts,” Journal of Cardiac Surgery, vol. 33, no. 10, pp. 620–628, 2018. [16] G.Sarno,S.Garg,Y.Onumaetal.,“Impactofcompletenessof revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft pa- tients (from the ARTS-II study),” ,e American Journal of Cardiology, vol. 106, no. 10, pp. 1369–1375, 2010. [17] Y.-J. Zhang, J. Iqbal, B. Xu et al., “Clinical outcomes of “complete, partially complete, and incomplete” revascular- isation at the five-year follow-up after percutaneous inter- vention of unprotected left main coronary artery disease with drug-eluting stents,” EuroIntervention, vol. 12, no. 8, pp. e957–e963, 2016. [18] V. Nagaraja, S.-Y. Ooi, J. Nolan et al., “Impact of incomplete percutaneous revascularization in patients with multivessel coronary artery disease: a systematic review and meta-anal- ysis,” Journal of the American Heart Association,vol.5,no.12, http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate

Download PDF
8 pages

Loading next page...
 
/lp/hindawi-publishing-corporation/residual-right-coronary-artery-stenosis-after-left-main-coronary-iSQAbUfvwM

References (20)

Publisher
Hindawi Publishing Corporation
Copyright
Copyright © 2020 Chien-Ho Lee et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ISSN
1540-8183
eISSN
0896-4327
DOI
10.1155/2020/4587414
Publisher site
See Article on Publisher Site

Abstract

Hindawi Journal of Interventional Cardiology Volume 2020, Article ID 4587414, 8 pages https://doi.org/10.1155/2020/4587414 Clinical Study Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate Chien-Ho Lee , Shaur-Zheng Chong, Shu-Kai Hsueh, Wen-Jung Chung, and Cheng-I Cheng Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan Correspondence should be addressed to Cheng-I Cheng; chris.chengi.cheng@gmail.com Received 23 February 2020; Revised 6 May 2020; Accepted 27 May 2020; Published 15 June 2020 Academic Editor: Faisal Latif Copyright©2020Chien-HoLeeetal.)isisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. )e outcomes of patients with concomitant left main coronary artery (LMCA) and right coronary artery (RCA) diseasesarereportedlyworsethanthosewithonlyLMCAdisease.Todate,onlyfewstudieshaveinvestigatedtheclinicalimpactof percutaneous coronaryintervention(PCI)onRCAstenosisduringthesamehospitalization,inwhichLMCAdiseasewastreated. )isstudywasaimedatcomparingtheoutcomesbetweenpatientswithandwithoutrightcoronaryarteryinterventionduringthe samehospitalcourseforLMCAintervention. Methods and Results.Fromatotalof776patientswhowereundergoingPCItotreat LMCAdisease,235patientswithconcomitantRCAsignificantstenosis(morethan70%stenosis)wereenrolled.)epatientswere divided into two groups: 174 patients received concomitant PCI for RCA stenosis during the same hospitalization, in which LMCA disease was treated, and 61 patients did not receive PCI for RCA stenosis. Patients without intervention to the right coronary artery had higher 30-day cardiovascular mortality rates and 3-year RCA revascularization rates compared to those with rightcoronaryarteryintervention.PatientswithoutRCAinterventionatthesamehospitalizationdidnotincreasethe30-daytotal death, 3-year myocardial infarction rate, 3-year cardiovascular death, and 3-year total death. Conclusions. In patients with LM disease and concomitant above or equal to 70% RCA stenosis, PCI for RCA lesion during the same hospitalization is rec- ommended to reduce the 30-day cardiovascular death and 3-year RCA revascularization rate. However, the patients with concomitant LM and RCA 1. Introduction disease had higher cardiac death after PCI to the left main With recent significant advancement in devices and tech- disease than those without RCA disease (17.7% vs. 6.7%, niques used for percutaneous coronary intervention (PCI), p � 0.056), and the patient with chronic total occlusion unprotected left main (LM) coronary artery disease (CAD) (CTO) of the right coronary artery had extreme high can be safely and effectively managed. For patients with LM mortality (30% vs 6.7%, p � 0.015) [4]. Residual CTO of the CADwhohavealow-to-moderateSYNTAXscore,thelong- RCA is the predictor of mortality for patients who undergo term results of PCI outcome are not inferior to coronary PCI to unprotected left main disease [5, 6]. Another study artery bypass graft (CABG), whereas coronary artery bypass also showed that patients with unprotected LM and con- graft (CABG) remains the primary choice for LM and comitantRCAlesionswhoundergoPCIhadworseearlyand multivessel CAD in those patients with a high SYNTAX long-termoutcomescomparedtothosewithoutRCAlesions score (>32) [1, 2]. However, PCI to left main disease is still [7]. Current ACC/AHA guideline recommends PCI to the the popular alternative treatment in the real world. In a noninfarct vessel in selected patients with STEMI, and ESC recent meta-analysis, PCI to left main disease had the same guideline recommends revascularization of the noninfarct- all-cause mortality versus the CABG intervention [3]. related artery in patients with ST-segment elevation 2 Journal of Interventional Cardiology myocardial infarction (STEMI) before hospital discharge infarction was defined as symptoms consistent with acute [8, 9]. On the other hand, guidelines have not given any coronary syndrome and a typical rise and fall of troponin-I, with ST-segment elevation on a 12-lead electrocardiogram. comments on the one-time revascularization in patients with multivessel CAD and left main disease. Till date, the Acute non-ST-elevation myocardial infarction was defined impact of treating RCA disease during the same hospitali- assymptomsconsistentwithacutecoronarysyndromeanda zation for LM coronary artery disease treatment has not yet typical rise and fall of troponin-I, without ST-segment el- been well discussed. evation on a 12-lead electrocardiogram. RCA disease was )ere are limited data regarding the effects of PCI for defined as “focal disease” if any lesion length <10mm, RCA stenosis in patients who undergo PCI for unprotected “tubular disease” if any lesion >10mm and <20mm, and LM CAD in the same hospitalization. Our previous study “diffuse disease” if any lesion >20mm. Death from car- showed that PCI in these LM diseased patients in our diovascular causes was defined as death because of acute hospitalisfeasiblewithahighsuccessrateandiscomparable myocardial infarction, heart failure, cardiogenic shock, to CABG in terms of cardiac death and overall survival, and ventricular arrhythmia, or cerebrovascular events. Any unidentified death was attributed to CV causes. RCA re- these results are similar to most other studies [10–13]. )is study was aimed at evaluating the impact of right coronary vascularization was defined as any percutaneous interven- intervention at the same hospitalization for those patients tion or surgical bypass of any segment of the RCA vessel. with concomitant left main and right coronary artery ste- nosis and received left main PCI. 2.3. Statistical Analysis. Categoricalvariableswerepresented as counts and percentages, and the difference between the 2. Methods two groups was determined by the chi-square or Fisher’s exact test. Continuous variables were presented as the 2.1. Study Population. Patients with unprotected left main mean±standard deviation and were compared by Student’s disease and received PCI in our hospital between July 2001 t-test, and the median value was compared using the and September 2016 were retrospectively enrolled in our Mann–Whitney U test. Survival curves were constructed study. Patients with acute ST-elevation myocardial infarc- with the Kaplan–Meier curves, and the log rank test with tion (STEMI), RCA stenosis less than 70%, or RCA with pairwise comparisons was used to calculate differences chronic total occlusion (CTO) were excluded in this study. between groups. )e Cox multivariate proportional hazard )estudyprotocolwasapprovedbytheInstitutionalReview regression analysis was performed to investigate possible Board of the Chang Gung Medical Foundation. confounders.)efollowingvariableswereconsideredinthis analysis: age, sex, diabetes mellitus, hypertension, smoking, hyperlipidemia, chronic kidney disease, end stage renal 2.2. Study Design and Endpoints. Detailed informed consent diseaseonhemodialysis,oldischemicstroke,oldMI,history for the PCI procedure was obtained from all patients before of coronary artery disease, left ventricular ejection fraction theprocedure,andalltreatmentoptionswerediscussedwith (LVEF) <40%, peripheral arterial occlusive disease (PAOD), thepatients andtheir families.Allpatients weretreated with and clinical status including acute myocardial infarction, the dual antiplatelet therapy (aspirin plus one kind of P Y 2 12 respiratory failure, ventricular tachyarrhythmia, intra-aortic inhibitor) after PCI procedure, and β-adrenergic blocker, balloon pump (IABP) use, temporary pacemaker use, upper angiotensin-converting enzyme inhibitor or angiotensin- gastrointestinal (UGI) bleeding, mean hospital stay, two or receptor blocker, and statin were used as the standard more stents at LM bifurcation, bare-metal stenting in LM, therapy if patient had no contraindication. andintravascular ultrasound- (IVUS-)guided.)eselection )ese patients were divided into two groups, the group ofvariablesinthemultivariatemodelwasbasedona pvalue in which patients had RCA intervention at the same hos- <0.1. )e hazard ratio (HR) and corresponding 95% con- pitalization (either in the same session or before discharge) fidence intervals (CI) were reported. A p value <0.05 was was defined as the group of “with RCA intervention,” and considered significant. All data were processed using the theotherswereassignedintothegroupclassifiedas“without Statistical Package for Social Sciences, version 17 (SPSS, RCAintervention.”Inthisstudy,weevaluatedtheendpoints Chicago, IL, USA), and figures were created by the asthe(1)30-daycardiovasculardeath,(2)30-daytotaldeath, GraphPad Prism 7 (GraphPad Software, Inc., La Jolla, CA). (3) 3-year cardiovascular death, (4) 3-year total death, (5) 3- year new myocardial infarction, and (6) 3-year right coro- nary artery intervention. 3. Results )e SYNTAX score was used to assess the complexity of CAD. )e SYNTAX score calculation was completed bytwo )ere were a total of 776 patients undergoing PCI for un- experienced cardiologists who were blinded to the proce- protected LM disease in our hospital between July 2001 and duraldataandclinicaloutcomes.UnprotectedLMCADwas September 2016. In total, 235 patients with concomitant LM defined as a left main lesion with a diameter stenosis >50% disease and above or equal to 70% RCA stenosis were en- without previous PCI or CABG. A mean serum total cho- rolled. All patients in this study were observed for three lesterollevel>200mg/dlwithoutstatinuseatthetimeofthis years. )ere were 61 patients in the group of “without RCA study or recorded before the present statin therapy was intervention” and 174 patients in the group of “with RCA classified as hyperlipidemia. Acute ST-elevation myocardial intervention.” Journal of Interventional Cardiology 3 RCA intervention” and twelve patients in the group “with Most of these patients were male (75.7%), with hyper- tension(82.6%)anddiabetesmellitus(60.4%).Atotalof152 RCA intervention” had cardiovascular death within three- year, and there was no statistical difference between the two (64.7%)patientshadchronickidneydiseaseorhemodialysis. )ere were no statistical differences between the two groups groups (free of the 3-year cardiovascular death; 84.09% in age, body weight, sex, and comorbidities including hy- vs.92.45%, p � 0.054). )ere was no significant difference in pertension, diabetes mellitus, hyperlipidemia, chronic kid- the 3-year all-cause death (free of the 3-year total death; ney disease, end-stage renal disease on hemodialysis, or 76.02% vs 83.35%, p � 0.16), with 14 patients in the group history of vascular events. )ere were 13.6% patients in the “without RCA intervention” and 27 patients in the group group“withoutRCAintervention”and10.2%patientsinthe “with RCA intervention” dead at the end of three years (Figures 1(c) and 1(d)). )ere was no increase in the 3-year group“withRCAintervention”andhadLVejectionfraction less than 40% (p � 0.477); 24.6% patients in the group new myocardial infarction rate of patients in the “without RCA intervention” group at index hospitalization (free of “withoutRCAintervention”and32.2%patientsinthegroup “withRCAintervention”receivedPCIbecauseofacutenon- new myocardial infarction; 87.14% vs 90.36%, p � 0.63) (Figure 1(e)). But patients without RCA intervention had ST-elevation myocardial infarction (p � 0.266). )ere was no difference between the two groups in ventricular ar- extremely high risk to receive RCA revascularization within rhythmia, respiratory failure, IABP, and temporary pace- thenext3yearsascomparedtothosewithRCAintervention maker use. )e mean hospital stay was 13.07 ±22.67 days (free ofthe 3-yearRCA revascularization;61.02%vs 89.38%, (median,6days;interquartilerange(IQR), 3–14 days)inthe p<0.0001) (Figure 1(f)). A total of 19 patients in the group group “without RCA intervention” and 9.74±12.63 days “without RCA intervention” will receive RCA PCI in the (median, 6 days; interquartile range (IQR), 4–9 days) in the next 3years,and14 of themwillreceivePCI during thenext first year. group “with RCA intervention” (Table 1). Table 2 showed the angiographic and procedure out- )e univariate analysis showed that “without RCA in- tervention,” female, IABP use, temporary pacemaker use, comes between the two groups. )ere was no significant differenceofthenumberofdiseasedvesselsandsyntaxscore respiratory failure, and implanted bare-metal stent at left main lesion were the risk factors of the 30-day cardiovas- betweenthetwogroups.Mostpatientsinthetwogroupshad triple-vessel CAD (79.7% vs 84.7%, p � 0.369). )ere were cular death. )e multivariate analysis showed that “without 44.3%patientsinthegroup“withoutRCAintervention”and RCA intervention” was still the independent risk factor for 50% patients in the group “with RCA intervention” and had the 30-day cardiovascular death (HR �9.37, 95% CI a high syntax score >33 (p � 0.440). )ere were 26.2% 1.34–65.39. p � 0.024). Other independent risk factors in- patientsinthegroup“withoutRCAintervention”and20.1% clude IABP and temporary pacemaker use, respiratory patientsinthegroup“withRCAintervention”andhadbare- failure, andbare-metal stent implantation at left main lesion (Table 3). metal stent deployed at left main lesion, and the others had drug-eluting stent deployed. Most of the patients between )e univariate analysis showed that without RCA in- tervention, body weight, chronic kidney disease, end-stage the two groups had IVUS-guided PCI for left main lesion (62.3% vs 72.4%, p � 0.139) and stenting with single-stent- renal disease on hemodialysis, history of myocardial in- only strategy at the left main lesion (68.9% vs 73.6% farction, PAOD, and LVEF <40% were the risk factors for p � 0.479). )ere was no significant difference between the the 3-year RCA revascularization. But only “without RCA two stent techniques, including simultaneous kiss-stent, intervention” and end-stage renal diseases were the inde- crushed, T-stent,andculotte’stechniques.)ere were36.1% pendent risk factors in the multivariate analysis (Table 4). patientsinthegroup“withoutRCAintervention”and47.1% patients in the group “with RCA intervention” and had only 4. Discussion single lesion in the RCA (p � 0.134). Others were multiple lesions, and the median lesion number was two. Only 23% )is study provides evidence that PCI for concomitant RCA patientsinthegroup“withoutRCAintervention”and15.5% stenosis with LM intervention during the same hospitali- patients in the group “with RCA intervention” had focal zation significantly lowers the 30-day cardiovascular death lesions only in the RCA (p � 0.188). )ere were 68.9% and3-yearsRCArevascularizationratecomparedtopatients patients in the group “without RCA intervention” and 69% who do not receive PCI for RCA stenosis. Most of the patients in the group “with RCA intervention” and had patients without RCA intervention at the index hospitali- diffuse lesions in the RCA (p � 0.987). )e lesion location zation would receive RCA intervention for any reason between the two groups was similar. within 3 years. Patient without receiving RCA intervention Six patients in the group “without RCA intervention” during the same hospitalization will not increase the 30-day and three patients in the group “with RCA intervention” total death, 3-year total death, and 3-year new myocardial died becauseof cardiovascular causes within 30 days(free of infarction rate. the 30-day cardiovascular death; 90.11% vs. 98.23%, A previous study had reported that a patient with un- p � 0.005). Seven patients in the group “without RCA in- protected LM disease and concomitant RCA disease (RCA tervention” and nine patients in the group “with RCA in- stenosis more than 50%) had a worse 30-day survival rate, tervention” died from any cause within 30 days (free of the and the RCA disease was the independent predictor of total 30-day total death; 76.02% vs. 83.35%, p � 0.096) death [7]. Our study further demonstrated that the RCA (Figures 1(a) and 1(b)). Nine patients in the group “without intervention in those concomitant LM and RCA diseased 4 Journal of Interventional Cardiology Table 1: Baseline characteristics and clinical status between the two groups. Without RCA intervention N �61 (%) With RCA intervention N �174 (%) p value Age (years), mean 69.39±9.68 67.10±10.58 0.138 Body weight (kg), mean 63.93±9.85 66.17±11.55 0.178 Male 46 (75.4%) 132 (75.9%) 0.943 Diabetes mellitus 42 (68.9%) 100 (57.5%) 0.118 Hypertension 46 (75.4%) 148 (85.1%) 0.088 Current smokers 10 (16.4%) 42 (24.1%) 0.210 Hyperlipidemia 35 (57.4%) 111 (63.8%) 0.374 Chronic kidney disease 40 (65.6%) 94 (54%) 0.117 Hemodialysis 5 (8.2%) 13 (7.5%) 0.787 Previous stroke 15 (24.6%) 24 (13.8%) 0.051 Previous myocardial infarction 14 (23.0%) 27 (15.5%) 0.188 Previous coronary artery disease 25 (41.0%) 64 (36.8%) 0.560 Peripheral artery disease 8 (13.1%) 11 (6.3%) 0.094 LVEF <40% 8 (13.6%) 17 (10.2%) 0.477 Atrial fibrillation history 1 (1.6%) 8 (4.6%) 0.453 Warfarin or NOAC use 0 (0%) 2 (1.1%) 1.0 Acute NSTEMI 15 (24.6%) 56 (32.2%) 0.266 Respiratory failure 6 (9.8%) 12 (6.9%) 0.458 Ventricular arrhythmia 3 (4.9%) 4 (2.3%) 0.380 IABP 10 (16.4%) 26 (14.9%) 0.787 Temporary pacemaker 1 (1.6%) 5 (2.9%) 1.000 UGI bleeding 4 (6.6%) 6 (3.4%) 0.290 Hospital stay (mean) 13.07±22.67 9.74±12.63 0.280 Hospital stay (median) 6 (3–14) 6 (4–9) 0.528 Dataarepresentedasthemean±standarddeviation, n(%),andmedian(IQR). Fisher’sexacttest.IABP �intra-aorticballoonpump;LVEF �leftventricular ejection fraction; RCA �right coronary artery; NOAC �novel oral anticoagulants; NSTEMI �non-ST-elevation myocardial infarction; and UGI �upper gastrointestinal bleeding. revascularization in all diseased segments with a diameter patients at the index hospitalization would improve the 30- day cardiovascular death. After adjusting other risk factors, ≧2.5mm had higher all-cause mortality and a composite of RCA intervention is still the independent risk factor of the cardiac death, myocardial infarction, and repeat revascu- 30-day cardiovascular death. Without RCA intervention, larization [17]. A meta-analysis which included 38 publi- these patients will result in more than a nine-fold risk of 30- cations and a total of 156,240 patients concluded that day cardiovascular death (HR �9.37, 95% CI: 1.34–65.39. incomplete revascularization in multiple vessel disease, p � 0.024). anatomically or functionally, increased the risk of death, OurstudyalsoshowedthatresidualRCAstenosishadan myocardial infarction, and repeated revascularization. And influence on the 3-year cardiovascular death. Although our the degree of incomplete revascularization is strongly as- sociated to the odds ratio of mortality [18]. Our study was study failed to achieve the statistical difference, it showed that residual RCA stenosis had a trend of increasing the 3- consistent with previous studies in the 3-year revasculari- zation rate. Without RCA intervention at the same hospi- year cardiovascular death. Capodanno et al. reported that a patient with residual RCA stenosis had a more than four talization will significantly increase the risk of RCA times higher cardiac death (HR 4.41, 95% CI 1.55–12.51, revascularization in the next 3years (HR �3.629, 95% p � 0.005) at the 3-year follow-up [4]. )e number of pa- CI �1.82–7.22, p<0.001). )e multivariate analysis in our tients in our study is relatively small, and a large portion of studydemonstratedthatonlywithoutRCAinterventionand these patients in the group of “without RCA intervention” hemodialysis are the independent risk factors of RCA re- received RCA intervention in the first year after discharge vascularization. However, our study showed that the 30-day and may interfere in the outcome of the 3-year cardiovas- total death, 3-year total death, and 3-year new myocardial cular death in our study. infarction showed no difference whether patient received RCA PCI or not at the same hospitalization for LM inter- In patients with left main and multiple vessel disease, most of the patients can achieve complete revascularization vention.Apossibleexplanationofnodifferenceinthe3-year new myocardial infarction is that there were 14 over 61 after CABG intervention. But if they receive PCI to the left main disease, the interventionists may not treat the RCA patientswhoreceivedRCAinterventionduringthenextfirst stenosis at the index hospitalization. )e importance of year, and it prevented further new cardiovascular events. “complete revascularization” regardless of PCI or CABG in )ere are several limitations in this study. First, it is a complex coronary artery disease was demonstrated by retrospective study, and all data were collected from a previously studies [14–18]. Zhang et al. reported a patient single medical center. Second, patient with or without with unprotected left main disease who did not achieve RCA intervention is dependent on the decision of a Journal of Interventional Cardiology 5 Table 2: Angiographic and procedure outcome between the two groups. Without RCA intervention (n �61) With RCA intervention (n �174) p value SYNTAX score values 33.96±11.52 33.26±9.65 0.523 ≤22 7 (11.5%) 14 (8%) 0.419 23–32 27 (44.3%) 73 (42.0%) 0.754 ≥33 27 (44.3%) 87 (50.0%) 0.440 Number of diseased vessels 2.80±0.40 2.83±0.42 0.626 LM with single vessel 0 (0%) 3 (1.8%) 0.571 LM with two vessels 12 (20.3%) 23 (13.5%) 0.223 LM with triple vessels 49 (80.3%) 148 (85.1%) 0.388 PCI procedure BMS at LM 16 (26.2%) 35 (20.1%) 0.319 IVUS-guided 38 (62.3%) 126 (72.4%) 0.139 Total stent number in LM 1.31±0.47 1.28±0.49 0.681 Single stent 42 (68.9%) 128 (73.6%) 0.479 Two stents 19 (31.1%) 43 (24.7%) 0.326 )ree stents 0 (0%) 3 (1.7%) 0.570 Two stent technique SKS 1 (1.6%) 2 (1.1%) 1.000 Crushed 3 (4.9%) 4 (2.3%) 0.380 T-stent 6 (9.8%) 23 (13.2%) 0.489 Culottes 9 (14.8%) 17 (9.8%) 0.286 RCA vessel classification Multiple lesions 39 (63.9%) 92 (52.9%) 0.134 Lesion numbers (median) 2 (1–2.5) 2 (1-2) 0.055 Focal disease 14 (23.0%) 27 (15.5%) 0.188 Tubular disease 5 (8.2%) 27 (15.5%) 0.151 Diffuse disease 42 (68.9%) 120 (69.0%) 0.987 RCA lesion locations Primary 29 (47.5%) 94 (54.0%) 0.383 Mid 31 (50.8%) 83 (47.7%) 0.675 Distal 27 (44.3%) 71 (40.8%) 0.637 Dataarepresentedasthemean±standarddeviation, n(%),andmedian(IQR). Fisher’sexacttest.BMS �bare-metalstent;IVUS �intravascularultrasound; LM �left main; PCI �percutaneous coronary intervention; RCA �right coronary artery; and SKS �simultaneous kissing-stents. 30-day CV death 30-day total death 100 100 98.23% 94.79% 90.11% 90 90 88.53% 80 80 Log test p = 0.005 Log test p = 0.096 0 10 20 30 0 10 20 30 Days Days Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 58 56 54 No intervention 61 58 55 54 No intervention Intervention 174 168 164 162 Intervention 174 168 164 162 (a) (b) Figure 1: Continued. Percent survival (%) Percent survival (%) 6 Journal of Interventional Cardiology 3-years CV death 3-year total death 92.45% 84.09% 83.35% 76.02% 60 60 Log test p = 0.16 Log test p = 0.054 50 50 0 12 24 36 0 12 24 36 Months Months Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 47 44 39 No intervention 61 47 44 39 No intervention Intervention 174 151 137 118 Intervention 174 151 137 118 (c) (d) 3-year new MI 3-year RCA revascularization 100 100 90.36% 90 90 89.38% 87.14% 80 80 61.02% Log test p < 0.0001 Log test p = 0.63 0 12 24 36 0 12 24 36 Months Months Without RCA intervention Without RCA intervention With RCA intervention With RCA intervention Number at risk Number at risk 61 44 40 35 No intervention 61 35 30 23 No intervention Intervention 174 143 124 107 Intervention 174 145 131 114 (e) (f) Figure1:Kaplan–Meiercurvesforevent-freesurvival.Solidline—patientswithconcomitantleftmaindiseaseandRCAsignificantstenosis (>70% stenosis) and received PCI to left main disease and right coronary artery at the same hospitalization; dotted line—patients with concomitant left maindisease and RCA significantstenosis (>70% stenosis) onlyreceived PCI to left main diseaseand wasdischarged with residualRCAsignificantstenosis.(a)30-daycardiovasculardeath-freesurvival.(b)30-daytotaldeath-freesurvival.(c)3-yearcardiovascular death-freesurvival.(d)3-yeartotaldeath-freesurvival.(e)3-yearnewmyocardialinfarction-freesurvival.(f)3-yearRCArevascularization- free survival. Table 3: Cox regression for the 30-day cardiovascular death. Univariate analysis Multivariate analysis 30 day CV death HR 95% CI p HR 95% CI p Without RCA intervention 4.548 2.334–8.862 <0.001 9.370 1.343–65.387 0.024 Female 4.188 1.124–15.599 0.033 IABP 12.988 3.243–52.021 <0.001 7.480 1.463–38.252 0.016 Temporary pacemaker 29.095 7.416–118.459 <0.001 28.628 3.242–252.778 0.003 Respiratory failure 6.800 1.697–27.258 0.007 LM BMS 4.623 1.241–17.217 0.022 4.766 1.108–20.510 0.036 CI �confidence interval; CV �cardiovascular; HR �hazard ratio; IABP �intra-aortic balloon pump; LM �left main; and RCA �right coronary artery. Percent survival (%) Percent survival (%) Percent survival (%) Percent survival (%) Journal of Interventional Cardiology 7 Table 4: Cox regression for the 3-year RCA revascularization. Univariate analysis Multivariate analysis 3-year RCA revascularization HR 95% CI p HR 95% CI p Without RCA intervention 5.756 1.439–23.014 0.013 3.629 1.816–7.216 <0.001 Body weight 0.964 0.935–0.993 0.017 Diabetes mellitus 2.026 0.973–4.222 0.059 Chronic kidney disease 3.555 1.552–8.143 0.003 Hemodialysis 4.706 2.037–10.872 <0.001 3.421 1.379–8.488 0.008 Previous MI 2.251 1.080–4.693 0.030 PAOD 4.367 1.803–10.576 0.001 LVEF <40% 3.182 1.387–7.299 0.006 CI �confidence interval; HR �hazard ratio; IABP �intra-aortic balloon pump; LM �left main; LVEF �left ventricular ejection fraction; MI �myocardial infarction; PAOD �peripheral arterial occlusive disease; and RCA �right coronary artery. physician and is therefore not randomized. Although References neither groups had significance in clinical presentation [1] P. W. Serruys, M.-C. Morice, A. P. Kappetein et al., “Per- status and syntax score, there will still be some selection cutaneous coronary intervention versus coronary artery by- bias in this study. )ird, this study had a small patient pass grafting for severe coronary artery disease,” ,e New population, and many patients in the group of “without England Journal of Medicine, vol. 360, no. 10, pp. 961–972, RCAintervention”receivedRCArevascularizationduring the observation period. )is may interfere in the long- [2] W. Wijns, P. Kolh, N. Danchin et al., “Guidelines on myo- term outcome of our study and underestimate the risk of cardial revascularization: )e Task Force on Myocardial residual RCA critical stenosis after LM revascularization. Revascularization of the European Society of Cardiology Fourth, we excluded the patients with either chronic total (ESC) and the European Association for Cardio-)oracic occlusion or RCA lesion under 70% stenosis, so our result Surgery (EACTS),” European Heart Journal, vol. 31, no. 20, cannot be applied in these groups. Last, we adopted the pp. 2501–2555, 2010. angiographic definition of the RCA critical stenosis, and [3] S. J. Head, M. Milojevic, J. Daemen et al., “Mortality after not all of patients in this study received the PCI procedure coronary arterybypass graftingversus percutaneous coronary under IVUS-guide. Accordingly, some patients with intervention with stenting for coronary artery disease: a physiological ischemia of RCA territory were possibly pooled analysis of individual patient data,” ,e Lancet, vol. 391, no. 10124, pp. 939–948, 2018. excluded in our study. Despite the limitations mentioned [4] D. Capodanno,M.-E. D.Salvo, and C. Tamburino, “Impactof above, giventhepaucityof reports regarding thebenefitof right coronary artery disease on mortality in patients un- concomitant PCI for RCA lesions in patients with LMCA dergoing percutaneous coronary intervention of unprotected diseaseandRCAstenosis,thisstudystillprovidesvaluable left main coronary artery disease,” EuroIntervention, vol. 6, information for clinical practice. no. 4, pp. 454–460, 2010. [5] A. Migliorini, R. Valenti, G. Parodi et al., “)e impact of right 5. Conclusions coronaryarterychronictotalocclusiononclinicaloutcomeof patients undergoing percutaneous coronary intervention for Rightcoronaryarteryinterventionforconcomitantleftmain unprotected left main disease,” Journal of the American andrightcoronaryarterystenosisatthesamehospitalization College of Cardiology, vol. 58, no. 2, pp. 125–130, 2011. will reduce the 30-day cardiovascular death and the 3-year [6] K. Takagi, A. Ielasi, A. Chieffo et al., “Impact of residual RCA revascularization rate compared to those without RCA chronic total occlusion of right coronary artery on the long- intervention. Without RCA intervention is both the inde- term outcome in patients treated for unprotected left main pendent risk factor for the 30-day cardiovascular death and disease: the Milan and New-Tokyo registry,” Circulation: the3-yearRCArevascularization.Itisreasonabletoperform Cardiovascular Interventions, vol. 6, no. 2, pp.154–160, 2013. [7] T.-M. Lu, Y.-L. Jou, Y.-H. Chen et al., “)e clinical signifi- RCA intervention for those patients with concomitant left cance of right coronary artery stenosis on the prognosis of main and right coronary artery disease during the same patients with unprotected left main disease undergoing per- hospitalization for left main percutaneous coronary cutaneous coronary intervention,” Acta Cardiologica Sinica, intervention. vol. 27, pp. 14–20, 2011. [8] G. N. Levine, E. R. Bates, J. C. Blankenship et al., “2015 ACC/ Data Availability AHA/SCAI focused update on primary percutaneous coro- nary intervention for patients with ST-elevation myocardial )e data used to support the findings of this study are infarction: an update of the 2011 ACCF/AHA/SCAI guideline available from the corresponding author upon request. for percutaneous coronary intervention and the 2013 ACCF/ AHA guideline for the management of ST-elevation myo- cardial infarction: a report of the American college of car- Conflicts of Interest diology/American heart association task force on clinical All authors declare that they have no conflicts of interest. practice guidelines and the society for cardiovascular 8 Journal of Interventional Cardiology angiography and interventions,” Catheterization and Car- diovascular Interventions, vol. 87, no. 6, pp. 1001–1019, 2016. [9] B. Ibanez, S. James, S. Agewall et al., “2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients pre- senting with ST-segment elevation of the European Society of Cardiology (ESC),” European Heart Journal, vol. 39, no. 2, pp. 119–177, 2018. [10] A. Chieffo, N. Morici, F. Maisano et al., “Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience,” Circulation,vol.113,no.21,pp.2542–2547,2006. [11] C.-I. Cheng,C.-J. Wu, C.-Y.Fang et al., “Feasibility and safety of transradial stenting for unprotected left main coronary artery stenoses,” Circulation Journal, vol. 71, no. 6, pp. 855–861, 2007. [12] C.-I. Cheng, F.-Y. Lee, J.-P. Chang et al., “Long-term out- comes of intervention for unprotected left main coronary artery stenosis: coronary stenting vs coronary artery bypass grafting,” Circulation Journal, vol. 73, no. 4, pp. 705–712, [13] D.-W. Park, K. B. Seung, Y.-H. Kim et al., “Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (revascularization for unprotectedleftmaincoronaryarterystenosis:comparisonof percutaneous coronary angioplasty versus surgical revascu- larization) registry,” Journal of the American College of Car- diology, vol. 56, no. 2, pp. 117–124, 2010. [14] B.Xu,N.Bettinger,C.Guanetal.,“Impactofcompletenessof revascularization in complex coronary artery disease as measured with the SYNTAX revascularization index: an SEEDS substudy,” Catheterization and Cardiovascular In- terventions, vol. 89, no. S1, pp. 541–548, 2017. [15] T. A. Schwann, M. B. Yammine, A.-K. M. El-Hage-Sleiman, M. C. Engoren, M. R. Bonnell, and R. H. Habib, “)e effect of completeness of revascularization during CABG with single versus multiple arterial grafts,” Journal of Cardiac Surgery, vol. 33, no. 10, pp. 620–628, 2018. [16] G.Sarno,S.Garg,Y.Onumaetal.,“Impactofcompletenessof revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft pa- tients (from the ARTS-II study),” ,e American Journal of Cardiology, vol. 106, no. 10, pp. 1369–1375, 2010. [17] Y.-J. Zhang, J. Iqbal, B. Xu et al., “Clinical outcomes of “complete, partially complete, and incomplete” revascular- isation at the five-year follow-up after percutaneous inter- vention of unprotected left main coronary artery disease with drug-eluting stents,” EuroIntervention, vol. 12, no. 8, pp. e957–e963, 2016. [18] V. Nagaraja, S.-Y. Ooi, J. Nolan et al., “Impact of incomplete percutaneous revascularization in patients with multivessel coronary artery disease: a systematic review and meta-anal- ysis,” Journal of the American Heart Association,vol.5,no.12,

Journal

Journal of Interventional Cardiology – Hindawi Publishing Corporation

Published: Jun 15, 2020

There are no references for this article.