BACKGROUND: Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking. METHODS: In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed. RESULTS: A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.4±1.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P = 0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group. CONCLUSIONS: In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and Abbott Vascular; FAME 3 ClinicalTrials.gov number, NCT02100722.).
- MeSH
- délka operace MeSH
- délka pobytu MeSH
- frakční průtoková rezerva myokardu * MeSH
- Kaplanův-Meierův odhad MeSH
- kardiovaskulární nemoci epidemiologie MeSH
- koronární angioplastika škodlivé účinky metody MeSH
- koronární bypass * škodlivé účinky MeSH
- koronární stenóza mortalita chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- reoperace MeSH
- senioři MeSH
- stenty MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- hodnocení ekvivalence MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
- MeSH
- adherence k farmakoterapii * MeSH
- akutní koronární syndrom diagnostické zobrazování mortalita terapie MeSH
- balónková koronární angioplastika škodlivé účinky metody MeSH
- hodnocení rizik MeSH
- inhibitory agregace trombocytů terapeutické užití MeSH
- koronární stenóza diagnostické zobrazování mortalita terapie MeSH
- lidé MeSH
- míra přežití MeSH
- prognóza MeSH
- selhání zařízení * MeSH
- stupeň závažnosti nemoci MeSH
- trombóza diagnostické zobrazování farmakoterapie etiologie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
BACKGROUND: Percutaneous coronary intervention (PCI) performed within 12 h from symptom onset enables complete blood flow restoration in infarct-related artery in 90% of patients. Nevertheless, even with complete restoration of epicardial blood flow in culprit vessel (postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3), myocardial perfusion at tissue level may be insufficient. We hypothesized that the outcome of patients with STEMI/bundle branch block (BBB)-myocardial infarction and post-PCI TIMI 3 flow is related to the time to reperfusion. METHODS: Observational study based on a retrospective analysis of population of 635 consecutive patients with STEMI/BBB-MI and post-PCI TIMI 3 flow from January 2009 to December 2011 (mean age 63 years, 69.6% males). Mortality of patients was evaluated in relation to the time from symptom onset to reperfusion. RESULTS: A total of 83 patients (13.07%) with postprocedural TIMI 3 flow after PCI had died at 1-year follow-up. Median TD in patients who survived was 3.92 h (iqr 5.43), in patients who died 6.0 h (iqr 11.42), P = 0.004. Multiple logistic regression analysis identified time delay ≥ 9 h as significantly related to 1-year mortality of patients with STEMI/BBB-MI and post-PCI TIMI 3 flow (OR 1.958, P = 0.026). Other significant variables associated with mortality in multivariate regression analysis were: left ventricle ejection fraction < 30% (P = 0.006), age > 65 years (P < 0.001), Killip class >2 (P <0.001), female gender (P = 0.019), and creatinine clearance < 30 mL/min (P < 0.001). CONCLUSION: Time delay to reperfusion is significantly related to 1-year mortality of patients with STEMI/BBB-MI and complete restoration of epicardial blood flow in culprit vessel after PCI.
- MeSH
- blokáda Tawarova raménka mortalita chirurgie MeSH
- čas zasáhnout při rozvinutí nemoci MeSH
- infarkt myokardu mortalita chirurgie MeSH
- Kaplanův-Meierův odhad MeSH
- koronární angioplastika mortalita MeSH
- koronární stenóza mortalita chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mikrocirkulace fyziologie MeSH
- pooperační komplikace mortalita MeSH
- reperfuze myokardu mortalita MeSH
- retrospektivní studie MeSH
- senioři MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
- Geografické názvy
- Česká republika epidemiologie MeSH
Background Primary angioplasty improves outcomes of acute myocardial infarction (AMI). However, in the highest risk subgroups, the mortality remains high despite modern catheter-based reperfusion therapy. This study analyzed patients with AMI caused by the left main coronary artery unstable lesion, a subgroup considered to be associated with very high early mortality. Methods A multicenter registry enrolled 6742 consecutive patients with AMI. Ninety-seven patients (1,4% of the entire study population) had left main as the infarct related artery. Baseline clinical characteristics, ECG patterns, coronary angiographic and echocardiographic data were correlated with the revascularization therapies used and with in-hospital outcomes. Results Twenty-five patients (25,8%) died during the hospital stay. The deceased patients were older, had more freqently bundle branch block on the admission ECG, had higher Killip class on presentation, more frequently had TIMI flow <3 and PCI success rate was 72% (vs. 100% among survivors). Left main coronary artery (LMCA) lesion impaired distal flow (TIMI flow 0–2 on presentation) in 35 patients: the most frequent ECG presentation pattern for these LMCA occlusions was ST segment elevation (n=17), followed by RBBB (n=9; with LAH 6 and without LAH 3), LBBB (n=6) and ST segment depression (n=3). In other words: acute LMCA occlusion presents in 51% with ECG changes other than ST segment elevations. Patients with TIMI flow 0–2 had higher Killip class on admission, lower ejection fraction and higher in-hospital mortality (37% vs. 20%), when compared to those with TIMI flow 3 on the initial angiogram. Conclusions Despite modern interventional therapy, acute myocardial infarction caused by the left main coronary artery obstruction bears high early mortality. The presence of bundle branch block, diminished TIMI flow on the initial angiogram, higher age and Killip class are related with increased mortality.
- Klíčová slova
- perkutánní koronární intervence,
- MeSH
- analýza přežití MeSH
- angioplastika metody využití MeSH
- blokáda Tawarova raménka diagnóza komplikace MeSH
- elektrokardiografie metody využití MeSH
- financování organizované MeSH
- infarkt myokardu diagnóza etiologie terapie MeSH
- koronární angiografie využití MeSH
- koronární stenóza diagnóza mortalita terapie MeSH
- lidé MeSH
- mortalita v nemocnicích MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- senioři MeSH
- Publikační typ
- multicentrická studie MeSH
This study was designed to compare the long-term clinical outcome of coronary artery bypass grafting (CABG) with intracoronary stenting of patients with isolated proximal left anterior descending coronary artery. BACKGROUND: Although numerous trials have compared coronary angioplasty with bypass surgery, none assessed the clinical evaluation in the long term. METHODS: We evaluated the 10-year clinical outcome in the SIMA (Stent versus Internal Mammary Artery grafting) trial. Patients were randomly assigned to stent implantation versus CABG. RESULTS: Of 123 randomized patients, 59 underwent CABG and 62 received a stent (2 patients were excluded). Follow-up after 10 years was obtained for 98% of the randomized patients. Twenty-six patients (42%) in the percutaneous coronary intervention group and 10 patients (17%) in the CABG group reached an end point (p < 0.001). This difference was due to a higher need for additional revascularization. The incidences of death and myocardial infarction were identical at 10%. Progression of the disease requiring additional revascularization was rare (5%) and was similar for the 2 groups. Stent thrombosis occurred in 2 patients (3%). Angina functional class showed no significant differences between the 2 groups. CONCLUSIONS: Both stent implantation and CABG are safe and highly effective in relieving symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Stenting with bare-metal stents is associated with a higher need for repeat interventions. The long-term prognosis for these patients is excellent with either mode of revascularization.
- MeSH
- arteria thoracica interna-arteria coronaria - anastomóza MeSH
- balónková koronární angioplastika MeSH
- časové faktory MeSH
- koronární cévy patologie MeSH
- koronární stenóza chirurgie mortalita terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- progrese nemoci MeSH
- prospektivní studie MeSH
- senioři MeSH
- stenty MeSH
- tepový objem MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
AIMS: To determine whether repeat revascularisation (RR) in diabetic patients treated with prior drug-eluting stents (DES) is the result of either DES restenosis or native progression of atherosclerotic disease in the coronary vasculature, and to evaluate the impact of atherosclerotic disease progression on the midterm clinical outcome.
- MeSH
- balónková koronární angioplastika mortalita přístrojové vybavení škodlivé účinky MeSH
- časové faktory MeSH
- diabetické angiopatie mortalita terapie MeSH
- financování organizované MeSH
- hodnocení rizik MeSH
- koronární restenóza etiologie mortalita parazitologie terapie MeSH
- koronární stenóza mortalita terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- nemoci koronárních tepen mortalita terapie MeSH
- odds ratio MeSH
- progrese nemoci MeSH
- registrace MeSH
- rizikové faktory MeSH
- senioři MeSH
- stenty uvolňující léky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
The purpose of this study was to compare the early and late results of percutaneous and surgical revascularization of left main coronary artery stenosis. BACKGROUND: Unprotected left main coronary artery (ULMCA) stenting is being investigated as an alternative to bypass surgery. METHODS: We randomly assigned 105 patients with ULMCA stenosis to percutaneous coronary intervention (PCI; 52 patients) or coronary artery bypass grafting (CABG; 53 patients). The primary end point was the change in left ventricular ejection fraction (LVEF) 12 months after the intervention. Secondary end points included 30-day major adverse events (MAE), major adverse cardiac and cerebrovascular events (MACCE), length of hospitalization, target vessel failure (TVF), angina severity and exercise tolerance after 1 year, and total and MACCE-free survival. RESULTS: A significant increase in LVEF at the 12-month follow-up was noted only in the PCI group (3.3 +/- 6.7% after PCI vs. 0.5 +/- 0.8% after CABG; p = 0.047). Patients performed equally well on stress tests, and angina status improved similarly in the 2 groups. PCI was associated with a lower 30-day risk of MAE (p < 0.006) and MACCE (p = 0.03) and shorter hospitalizations (p = 0.0007). Total and MACCE-free 1-year survival was comparable. Left main TVF was similar in the 2 groups. During the 28.0 +/- 9.9-month follow-up, there were 3 deaths in the PCI group and 7 deaths in the CABG group (p = 0.08). CONCLUSIONS: Patients with ULMCA disease treated with PCI had favorable early outcomes in comparison with the CABG group. At 1 year, LVEF had improved significantly only in the PCI group. After more than 2 years, MACCE-free survival was similar in both groups with a trend toward improved survival after PCI.
- MeSH
- angina pectoris epidemiologie MeSH
- balónková koronární angioplastika MeSH
- časové faktory MeSH
- Kaplanův-Meierův odhad MeSH
- kardiovaskulární nemoci epidemiologie MeSH
- koronární bypass MeSH
- koronární stenóza chirurgie mortalita patofyziologie terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- pooperační komplikace MeSH
- stenty škodlivé účinky MeSH
- tepový objem MeSH
- výsledek terapie MeSH
- zátěžový test MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
OBJECTIVES: Changes in hemostasis after off-pump coronary artery bypass grafting are still being discussed. There is a lack of information about platelet activity and aspirin efficacy after coronary artery bypass grafting. The aim of this study was to assess and compare platelet activity and aspirin efficacy early and late after off-pump and on-pump coronary artery bypass grafting. METHODS: Eighty patients were enrolled in a prospective randomized study. Platelet activity was determined based on membrane expression of antigen CD62P (P-selectin) by means of flow cytometric analysis. Aspirin efficacy was assessed by using arachidonic acid-induced platelet aggregation. Blood samples were collected before the operation, immediately postoperatively, and on days 1, 2, 5, and 30. RESULTS: In the off-pump group expression of P-selectin was markedly increased in comparison with preoperative values, with a maximum difference observed on day 2 (+53%, P = .02), and it was significantly higher compared with that seen in the on-pump group on days 2 and 5 (+53% vs +4%, P = .004, and +20% vs -16%, P = .005). On day 30, P-selectin expression was similar both between the groups and in comparison with the preoperative values. Arachidonic acid-induced platelet aggregation was gradually decreasing until day 30, but on day 2, there was an unexpected increase in aggregation that was more expressed in the off-pump group. CONCLUSIONS: The platelet activity is higher in the early postoperative period in off-pump compared with on-pump coronary artery bypass grafting. The present aspirin strategy seems to be insufficient in the early postoperative period, irrespective of the surgical technique used.
- MeSH
- analýza přežití MeSH
- Aspirin aplikace a dávkování MeSH
- financování organizované MeSH
- hodnocení rizik MeSH
- interval spolehlivosti MeSH
- koronární bypass bez mimotělního oběhu metody škodlivé účinky MeSH
- koronární bypass metody škodlivé účinky MeSH
- koronární stenóza diagnóza chirurgie mortalita MeSH
- lidé středního věku MeSH
- lidé MeSH
- P-selektin analýza MeSH
- pooperační péče MeSH
- pravděpodobnost MeSH
- předoperační péče MeSH
- přežívání štěpu MeSH
- prognóza MeSH
- prospektivní studie MeSH
- rejekce štěpu MeSH
- rozvrh dávkování léků MeSH
- senioři MeSH
- tkáňový faktor metabolismus MeSH
- výsledek terapie MeSH
- vztah mezi dávkou a účinkem léčiva MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- randomizované kontrolované studie MeSH
