Elsevier

The American Journal of Cardiology

Volume 158, 1 November 2021, Pages 37-44
The American Journal of Cardiology

High-Risk Percutaneous Coronary Intervention of Native Coronary Arteries Without Mechanical Circulatory Support in Acute Coronary Syndrome Without Cardiogenic Shock

https://doi.org/10.1016/j.amjcard.2021.07.014Get rights and content

Widespread utilization of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) remains controversial, with a lack of randomized supporting evidence and associated risk of device-related complications. We investigated whether high-risk PCI of native coronary arteries without elective MCS in patients with acute coronary syndrome (ACS) is safe and feasible. We performed a single-center, retrospective analysis for ACS patients meeting American College of Cardiology high-risk criteria: unprotected left main disease, last remaining conduit, ejection fraction <35%, 3-vessel coronary artery disease, severe aortic stenosis, or severe mitral regurgitation. Patients with cardiogenic shock and those undergoing PCI of the bypass grafts were excluded. Major in-hospital and 30-day cardiovascular outcomes were assessed. From 2003 through 2018, 499 patients (847 lesions) with unstable angina pectoris (UAP), 1218 patients (1807 lesions) with non-ST-elevation myocardial infarction (NSTEMI), and 868 patients (1260 lesions) with ST-segment elevation myocardial infarction (STEMI) underwent high-risk PCI. Procedural success was achieved in 97.2% of UAP, 98.3% of NSTEMI, and 96.6% of STEMI patients. In-hospital and 30-day all-cause mortality were as follows: UAP, 2%; NSTEMI, 2.1%; and STEMI 4.7%. Bailout intra-aortic balloon pump was required in 1.6% of UAP, 3.1% of NSTEMI, and 10.3% of STEMI patients. Major complications for UAP, NSTEMI, and STEMI were, respectively: target lesion revascularization (2.3%, 1.4%, and 1.5%), stroke or transient ischemic attack (0.8%, 0.6%, and 1.3%), acute renal failure (8.2%, 7.2%, and 10.2%), major bleeding (1.6%, 3.1%, and 8.5%). In conclusion, our results show that high-risk PCI without elective MCS is safe and feasible in most ACS patients, challenging professional societies’ current recommendations. A randomized trial comparing unprotected versus protected high-risk PCI for non-shock ACS patients is warranted.

Section snippets

Methods

All patients with ACS – unstable angina pectoris (UAP), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) – undergoing high-risk PCI at MedStar Washington Hospital Center, Washington, District of Columbia, United States (US), from 2003 through 2018 were included in this analysis. High-risk PCI was defined as patients meeting 1 or more of the contemporary criteria described by the Interventional Scientific Council of the ACC:1 unprotected LMCA

Results

A total of 499 patients (847 lesions) with UAP, 1218 patients (1807 lesions) with NSTEMI, and 868 patients (1260 lesions) with STEMI who met the predefined high-risk PCI criteria were included in the analysis. Patients meeting eligibility criteria but presenting with stable ischemic heart disease or cardiogenic shock or undergoing PCI of bypass grafts were excluded. Additionally, 13 patients presenting with UAP, 58 with NSTEMI, and 101 with STEMI received elective IABP before PCI and were also

Discussion

Our analysis demonstrates that in patients presenting with ACS meeting high-risk criteria, the strategy of PCI without elective MCS is: a) Feasible and safe in the majority of patients presenting with UAP and NSTEMI, with a low rate of bailout MCS; b) Associated with a higher number of bailout MCS in patients presenting with STEMI; c) Associated with higher mortality in STEMI patients in comparison with the other groups; and d) Associated with a low incidence of major complications (except for

Disclosures

Toby Rogers – Proctor and Consultant: Medtronic, Edwards Lifesciences; Advisory Board: Medtronic; Equity interest: Transmural Systems.

Ron Waksman – Advisory Board: Abbott Vascular, Amgen, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd.; Consultant: Abbott Vascular, Amgen, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd., Transmural Systems; Grant Support: AstraZeneca, Biotronik, Boston

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Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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