Se Hun Kang

Coronary Artery Bypass Grafting vs. Drug-Eluting Stent Implantation for Multivessel Disease in Patients with Chronic Kidney Disease

Background and Objectives There is currently a limited amount of data that demonstrate the optimal revascularization strategy for chronic kidney disease (CKD) patients with multivessel coronary artery disease (CAD). We compared the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass graft surgery (CABG) for multivessel CAD in patients with CKD. Subjects and Methods We analyzed 2108 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m2) with multivessel CAD that were treated with PCI with DES (n=1165) or CABG (n=943). The primary outcome was a composite of all causes of mortality, myocardial infarction, or stroke. The mean age was 66.9±9.1 years. Results Median follow-up duration was 41.4 (interquartile range 12.1-75.5) months. The primary outcome occurred in 307 (26.4%) patients in the PCI group compared with 304 (32.2%) patients in the CABG group (adjusted hazard ratio [HR], 0.941; 95% confidence interval [CI], 0.79–1.12; p=0.493). The two groups exhibited similar rates of all-cause mortality (adjusted HR, 0.91; 95% CI, 0.77–1.09; p=0.295), myocardial infarction (adjusted HR, 1.86; 95% CI, 0.85–4.07; p=0.120) and stroke (3.2% vs. 4.8%; HR, 0.93; 95% CI, 0.57–1.61; p=0.758). However, PCI was associated with significantly increased rates of repeat revascularization (adjusted HR, 4.72; 95% CI, 3.20–6.96; p<0.001). Conclusion Among patients with CKD and multivessel CAD, PCI with DES when compared with CABG resulted in similar rates of composite outcome of mortality from any cause, MI, or stroke; however, a higher risk of repeat revascularization was observed.

Trends and Outcomes of Transcatheter Aortic Valve Implantation (TAVI) in Korea: the Results of the First Cohort of Korean TAVI Registry

Background and Objectives There has been no nation-wide data on the outcomes of transcatheter aortic valve implantation (TAVI) after commercialization of TAVI in Korea. We report clinical features and outcomes of the first cohort of TAVI performed from Jun 2015 to Jun 2017 in Korea. Methods The first cohort of Korean-TAVI (K-TAVI) registry includes 576 consecutive patients with severe symptomatic aortic stenosis who underwent TAVI from 17 Korean hospitals for 2 years. Results Most of TAVI procedures were performed for septuagenarians and octogenarians (90.8%) through transfemoral approach (98.3%). The rate of device success was 92.5% and permanent pacemaker was implanted in 5.6%. In successive years, incidences of paravalvular leakage (PVL) and major bleeding declined. Society of Thoracic Surgeons (STS) score was 5.2 (3.0 to 9.0) and 34.7% of patients had high surgical risk (STS ≥8). One-year all-cause death occurred in 8.9% and was significantly lower in low to intermediate risk one than in high risk (5.4% vs. 15.5%, p<0.001). The independent predictors of 1-year mortality were age (hazard ratio [HR], 1.087; 95% confidence interval [CI], 1.036–1.141; p=0.001), moderate or severe PVL (HR, 4.631; 95% CI, 1.624–13.203; p=0.004) and end-stage renal disease (HR, 5.785; 95% CI, 2.717–12.316; p<0.001). Conclusions K-TAVI registry showed favorable 1-year outcomes with decreasing complication rate over time in real-world Korean patients. Two-thirds of patients were low to intermediate surgical risk and showed a significantly lower mortality than the high-risk patients, suggesting the promising future on the expanded indications of TAVI.

Generalizability of Excel and Noble results to a large registry population with unprotected left main coronary artery disease

Objective The aim of this study was to determine how trial-based findings of EXCEL and NOBLE might be interpreted and generalizable in ‘real-world’ settings with comparison of data from the large-scaled, all-comer Interventional Research Incorporation Society−Left MAIN Revascularization (IRIS–MAIN) registry. Patients and methods We compared baseline clinical and procedural characteristics and also determined how the relative treatment effect of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) was different in EXCEL and NOBLE, compared with those of the multicenter, IRIS–MAIN registry (n=2481). The primary outcome for between-study comparison was a composite of death, myocardial infarction (MI), or stroke. Results There were between-study differences in patient risk profiles (age, BMI, diabetes, and clinical presentation), lesion complexities, and procedural characteristics (stent type, the use of off-pump surgery, and radial artery); the proportion of diabetes and acute coronary syndrome was particularly lower in NOBLE than in other studies. Although there was interstudy heterogeneity for the protocol definition of MI, the risks for serious composite outcome of death, MI, or stroke were similar between PCI and CABG in EXCEL [hazard ratio (HR): 1.00; 95% confidence interval (CI): 0.79–1.26; P=0.98] and in the matched cohort of IRIS–MAIN (HR: 1.08; 95%CI: 0.85–1.38; P=0.53), whereas it was significantly higher after PCI than after CABG in NOBLE (HR: 1.47; 95%CI: 1.06–2.05; P=0.02), which was driven by more common MI and stroke after PCI. Conclusion In the comparison of a large-sized, all-comer registry, the EXCEL trial might represent better generalizability with respect to baseline characteristics and observed clinical outcomes compared with the NOBLE trial.

Comparative determinants of 5-year cardiovascular event rates in patients with unprotected left main coronary artery disease

Background Diabetes mellitus (DM), low ejection fraction (EF), and the extent of coronary artery disease (CAD) have all been identified as predictors of cardiovascular events in multivessel disease, but their comparative contributions to future risk remain unclear in patients with unprotected left main coronary artery (ULMCA) disease. Through this study we aimed to categorize the risk for cardiovascular events in patients with ULMCA disease using simple clinical descriptors. Patients and methods Our study included a total of 5975 patients with ULMCA disease from the Interventional Research Incorporation Society-Left MAIN Revascularization registry who were treated with percutaneous coronary intervention (n=2850), coronary artery bypass grafting (n=2337), or medical therapy alone (n=608). We categorized the risk for cardiovascular events using simple clinical descriptors (DM, low EF, and the extent of CAD). The primary outcome was a major adverse cardiac or cerebrovascular event (MACCE) (i.e. death from any cause, stroke, myocardial infarction, or repeat revascularization). Results Overall, the 5-year rate of MACCE was highest in the medical group, lower in the percutaneous coronary intervention group, and lowest in the coronary artery bypass grafting group (42.5, 25.7, and 19.9%, respectively; P<0.001). In multivariable modeling, the presence of DM [hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.12–1.40; P<0.001], low EF of 40% or less (HR: 1.83; 95% CI: 1.56–2.15; P<0.001), and the extent of CAD (HR: 1.14; 95% CI: 1.08–1.21; P<0.001) were independent predictors of MACCE; in addition, these factors were consistently associated with a significantly higher risk for MACCE, regardless of index treatment strategies. Conclusion Simple clinical descriptors can assist clinicians in identifying high-risk patients and in predicting future cardiovascular events within the broad range of risk factors for ULMCA disease.

Differential Event Rates and Independent Predictors of Long-Term Major Cardiovascular Events and Death in 5795 Patients With Unprotected Left Main Coronary Artery Disease Treated With Stents, Bypass Surgery, or Medication: Insights From a Large International Multicenter Registry

Background— Identifying predictive factors for major cardiovascular events and death in patients with unprotected left main coronary artery disease is of great clinical value for risk stratification and possible guidance for tailored preventive strategies. Methods and Results— The Interventional Research Incorporation Society-Left MAIN Revascularization registry included 5795 patients with unprotected left main coronary artery disease (percutaneous coronary intervention, n=2850; coronary-artery bypass grafting, n=2337; medication alone, n=608). We analyzed the incidence and independent predictors of major adverse cardiac and cerebrovascular events (MACCE; a composite of death, MI, stroke, or repeat revascularization) and all-cause mortality in each treatment stratum. During follow-up (median, 4.3 years), the rates of MACCE and death were substantially higher in the medical group than in the percutaneous coronary intervention and coronary-artery bypass grafting groups (P<0.001). In the percutaneous coronary intervention group, the 3 strongest predictors for MACCE were chronic renal failure, old age (≥65 years), and previous heart failure; those for all-cause mortality were chronic renal failure, old age, and low ejection fraction. In the coronary-artery bypass grafting group, old age, chronic renal failure, and low ejection fraction were the 3 strongest predictors of MACCE and death. In the medication group, old age, low ejection fraction, and diabetes mellitus were the 3 strongest predictors of MACCE and death. Conclusions— Among patients with unprotected left main coronary artery disease, the key clinical predictors for MACCE and death were generally similar regardless of index treatment. This study provides effect estimates for clinically relevant predictors of long-term clinical outcomes in real-world left main coronary artery patients, providing possible guidance for tailored preventive strategies. Clinical Trial Registration— URL: https://clinicaltrials.gov. Unique identifier: NCT01341327.

TCT-534 Fractional Flow Reserve and Cardiac Events In Coronary Artery Disease: Data From Prospective Registry

Abstract Background -We evaluated the prognosis of deferred and revascularized coronary stenoses after FFR measurement to assess its revascularization threshold in clinical practice. Methods -The IRIS-FFR registry prospectively enrolled 5846 patients with at least one coronary lesion with FFR measurement. Revascularization was deferred in 6468 lesions and performed in 2165 lesions after FFR assessment. The primary endpoint was major adverse cardiac events (MACE; cardiac death, myocardial infarction, and repeat revascularization) at a median follow-up of 1.9 years and analyzed on a per-lesion basis. A marginal Cox model accounted for correlated data in patients with multiple lesions, and a model to predict per-lesion outcomes was adjusted for confounding factors. Results -For deferred lesions, the risk of MACE demonstrated a significant, inverse relationship with FFR (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.05-1.08; P < 0.001). However, this relationship was not observed in revascularized lesions (aHR, 1.00; 95% CI, 0.98-1.02; P = 0.70). For lesions with FFR ≥ 0.76, the risk of MACE was not significantly different between deferred and revascularized lesions. Conversely, in lesions with FFR ≤ 0.75, the risk of MACE was significantly lower in revascularized lesions than in deferred lesions (for FFR 0.71-0.75, aHR, 0.47; 95% CI, 0.24-0.89; P = 0.021, and for FFR ≤ 0.70, aHR 0.47; 95% CI, 0.26-0.84; P = 0.012). Conclusions -This large, prospective registry showed that the FFR value was linearly associated with the risk of cardiac events in deferred lesions. In addition, revascularization for coronary artery stenosis with a low FFR (≤ 0.75) was associated with better outcomes than the deferral, while for a stenosis with a high FFR (≥ 0.76), medical treatment would be a reasonable and safe treatment strategy. Clinical Trial Registration -clinicaltrials.gov Identifier: NCT01366404.

Impact of Follow-Up Ischemia on Myocardial Perfusion Single-Photon Emission Computed Tomography in Patients with Coronary Artery Disease

Purpose Few studies have reported on predicting prognosis using myocardial perfusion single-photon emission computed tomography (SPECT) during coronary artery disease (CAD) treatment. Therefore, we aimed to assess the clinical implications of myocardial perfusion SPECT during follow-up for CAD treatment. Materials and Methods We enrolled 1153 patients who had abnormal results at index SPECT and underwent follow-up SPECT at intervals ≥6 months. Major adverse cardiac events (MACE) were compared in overall and 346 patient pairs after propensity-score (PS) matching. Results Abnormal SPECT was associated with a significantly higher risk of MACE in comparison with normal SPECT over the median of 6.3 years (32.3% vs. 19.8%; unadjusted p<0.001). After PS matching, abnormal SPECT posed a higher risk of MACE [32.1% vs. 19.1%; adjusted hazard ratio (HR)=1.73; 95% confidence interval (CI)=1.27–2.34; p<0.001] than normal SPECT. After PS matching, the risk of MACE was still higher in patients with abnormal follow-up SPECT in the revascularization group (30.2% vs. 17.9%; adjusted HR=1.73; 95% CI=1.15–2.59; p=0.008). Low ejection fraction [odds ratio (OR)=5.33; 95% CI=3.39–8.37; p<0.001] and medical treatment (OR=2.68; 95% CI=1.93–3.72; p<0.001) were independent clinical predictors of having an abnormal result on follow-up SPECT. Conclusion Abnormal follow-up SPECT appears to be associated with a high risk of MACE during CAD treatment. Follow-up SPECT may play a potential role in identifying patients at high cardiovascular risk.

Early experience and favorable clinical outcomes of everolimus-eluting bioresorbable scaffolds for coronary artery disease in Korea

Background/Aims Compared with metallic drug-eluting stents (DES), bioresorbable vascular scaffolds (BVS) may further improve long-term outcomes of percutaneous coronary intervention (PCI) in patients with coronary artery disease. We report our early experience with BVS in Korea. Methods We evaluated 105 consecutive patients with BVS implanted at Asan Medical Center, Korea between October 21, 2015 and June 3, 2016. Angiographic results, and in-hospital and 6-month clinical outcomes were assessed. Results A total of 134 BVS were implanted to treat 115 lesions. The mean age was 62 ± 10.5 years; 85 patients (81%) were males, 26 patients (25%) were presented with acute coronary syndrome. Among 115 lesions treated with BVS, 76 (66.1%) were B2/C type, 27 (23.5%) were bifurcation lesions, and four (3.5%) were chronic total occlusion. Pre-dilation and post-dilation using high-pressure non-compliant balloon was performed in 104 lesions (90.4%) and 113 lesions (98.2%), respectively. During the procedure, intravascular imaging was used for all patients (100%; intravascular ultrasound 89 and optical coherence tomography 40 patients). Device success rate was 100%. In-segment and in-scaffold acute again were 1.1 ± 0.6 and 1.3 ± 0.5 mm, respectively. Periprocedural myocardial infraction occurred in four patients (3.8%). No deaths, stent thrombosis, or urgent revascularizations occurred either during hospitalization or the follow-up period. Conclusions In this single-center experience, implantation of BVS with intravascular imaging support was feasible and early clinical outcomes were excellent. Evaluation of long-term efficacy and safety of BVS and its feasibility in clinical use for a broader range of lesions is warranted.

TCT-498 Lower mortality in patients with vasospastic angina who receive statin therapy: Data from the Asan Vasospastic Angina Registry

Statin therapy is the standard treatment for atherosclerotic cardiovascular disease. However, the benefits of statin therapy in patients with vasospastic angina (VSA) remains unknown. This study investigated the long-term benefits of statin therapy in patients with VSA. Between March 1996 and

MORTALITY OF PATIENTS WITH PREVIOUS STROKE UNDERGOING DRUG-ELUTING STENT IMPLANTATION

Background: The patients with a prior history of stroke undergoing percutaneous coronary intervention (PCI) are increasing, but there are limited data about clinical outcomes. Methods: The authors pooled patients-level data from 3 registry trials investigating clinical outcomes of CAD treated PCI