Outcome of Percutaneous Coronary Intervention Utilizing Drug-Eluting Stents in Patients With Reduced Left Ventricular Ejection Fraction

doi:10.1016/j.amjcard.2011.09.016

The American Journal of Cardiology

Volume 109, Issue 3, 1 February 2012, Pages 344-351

https://doi.org/10.1016/j.amjcard.2011.09.016 Get rights and content

Ischemic cardiomyopathy with depressed left ventricular ejection fraction (LVEF) is predictive of death after percutaneous coronary intervention (PCI), but its association with stent thrombosis (ST) and the need for repeat revascularization is less clearly defined. In total 5,377 patients undergoing PCI were retrospectively evaluated. Multivariable Cox proportional hazards regression and competitive outcome analysis were employed. The primary end point was 1-year major adverse cardiac events (all-cause death, Q-wave myocardial infarction, ST, and target lesion revascularization [TLR]). Individual end points of ST and of TLR were also evaluated. Patients with normal LVEF (>50%) were compared to those with mild (41% to 50%), moderate (25% to 40%), and severe (<25%) decreases in LVEF. Patients with abnormal LVEF were older and more commonly diabetic and had renal insufficiency and heart failure syndrome (p <0.001 for all variables). These patients demonstrated more angiographically complex lesions and less frequently received a drug-eluting stent. The primary end point was significantly increased in patients with lower LVEF (9.7% for normal LVEF vs 20.6% for severely decreased LVEF, p <0.001). ST occurred more frequently in these patients (1.4% for normal LVEF vs 6% for severely decreased LVEF, p <0.001), but clinically driven TLR did not significantly change across LVEF categories. After adjustment, only moderate and severe LVEF decreases (i.e., LVEF ≤40%) demonstrated an association with major adverse cardiac events and with the individual outcome of ST. Subgroup analysis of patients receiving only a drug-eluting stent or a bare-metal stent demonstrated no statistically significant differences for the probability of ST. In conclusion, decreased LVEF is not associated with clinically driven TLR but does increase the risk of ST. Patients with LVEF ≤40% appear to be at significantly higher risk for ST and therefore might benefit from interventional and pharmacologic strategies aimed at minimizing this risk.

Section snippets

Methods

Clinical, procedural, and follow-up data for consecutive patients undergoing PCI with stenting from January 2000 through December 2009 were retrospectively analyzed from an ongoing registry of catheter-based coronary procedures maintained at our institution. Given the focus of this study on LV function, patients presenting with cardiogenic shock or with acute myocardial infarction were excluded because systolic dysfunction in such settings may be transient.

Preprocedure LVEF was visually

Results

In total 6,382 patients underwent PCI with stenting and had LVEF data available; of these 281 were excluded for presentation with cardiogenic shock and 764 patients for presentation with acute myocardial infarction. The study population (n = 5,377) had an average age of 66 ± 11.5 years and was predominantly men (66%). Seventy percent of patients were European-American and 21% were African-American.

In the entire cohort, a normal LVEF (estimated LVEF >50%) was identified in 3,443 patients

Discussion

The main findings of the present study are as follows: (1) LV systolic dysfunction is associated with a stepwise increase in MACEs with an inflection point at an estimated LVEF ≤40%; (2) risk of ST after PCI increases stepwise as LV function worsens, (3) at least moderate systolic dysfunction (i.e., LVEF ≤40%) is independently associated with MACEs and ST, (4) TLR is not associated with LVEF, and (5) drug-eluting stent use did not appreciably increase the risk of ST.

Thus, when considering PCI

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Cited by (24)

Influence of left ventricular ejection fraction in patients undergoing contemporary pLVAD-supported high-risk PCI
2024, American Heart Journal
Left ventricular (LV) systolic dysfunction worsens outcomes in patients undergoing percutaneous coronary intervention (PCI). The objective of this study, therefore, was to evaluate outcomes of pLVAD-supported high-risk PCI (HRPCI) patients according to LV ejection fraction (LVEF).
Patients from the PROTECT III study undergoing pLVAD-supported HRPCI were stratified according to baseline LVEF: severe LV dysfunction (LVEF <30%), mild and moderate LV dysfunction (LVEF ≥30% to <50%), or preserved LV function (LVEF ≥50%). Major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization), and PCI-related complications were assessed at 90 days and mortality was assessed at 1-year.
From March 2017 to March 2020, 940 patients had evaluable baseline LVEF recorded in the study database. Patients with preserved LV function were older, more frequently presented with myocardial infarction, and underwent more left main PCI and atherectomy. Immediate PCI-related coronary complications were infrequent (2.7%, overall), similar between groups (P = 0.98), and not associated with LVEF. Unadjusted 90-day MACCE rates were similar among LVEF groups; however, as a continuous variable, LVEF was associated with both 90-day MACCE (adj.HR per 5% 0.89, 95% CI [0.80, 0.98], P = 0.018) and 1-year mortality (adj.HR per 5% 0.84 [0.78, 0.90], P <0.0001).
Patients who underwent pLVAD-supported HRPCI exhibited low incidence of PCI-related complications, regardless of baseline LVEF. However, LVEF was associated with 90-day MACCE and 1-year mortality.
Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention of the Left Anterior Descending Artery
2023, American Journal of Cardiology
The left anterior descending artery (LAD) subtends a large myocardial territory. The outcomes of LAD chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. We performed a retrospective analysis of all patients who underwent LAD CTO PCI at a high-volume single center. Outcomes included in-hospital and long-term major adverse cardiovascular events (MACEs) and changes in left ventricular ejection fraction (LVEF). We performed a subgroup analysis of patients with ischemic cardiomyopathy, defined as an LVEF of 40% or less. From December 2014 to February 2021, 237 patients underwent LAD CTO PCI. The technical success rate was 97.4%, and the in-hospital MACE rate was 5.4%, A landmark analysis after hospital discharge showed an overall survival of 92% and 85% MACE-free survival at 2 years. There was no difference in overall survival or MACE-free survival between those who had ischemic cardiomyopathy versus those who did not. In patients with ischemic cardiomyopathy, LAD CTO PCI was associated with significant improvement in LVEF (10.9% at 9 months), which was further pronounced when these patients had a proximal LAD CTO and were on optimal medical therapy (14% at 6 months). In a single high-volume center, LAD CTO PCI was associated with 92% overall survival at 2 years, with no difference in survival between patients with or without ischemic cardiomyopathy. LAD CTO PCI was associated with an absolute 10% increase in LVEF at 9 months in patients with ischemic cardiomyopathy.
Impact of Left Ventricular Ejection Fraction on Procedural and Long-Term Outcomes of Bifurcation Percutaneous Coronary Intervention
2022, American Journal of Cardiology
Citation Excerpt :
Similarly to EXCEL,19 outcomes in patients with BIFmEF were similar to those of patients with BIFpEF. Interestingly, not only patient-oriented but also device-oriented outcomes at long-term follow-up were more frequently observed in patients with BIFrEF, as also previously reported.26 Specifically, patients with BIFrEF experienced a significant 2.6-fold higher adjusted-risk of TVR than patients with BIFmEF and a significant 2.5-fold higher adjusted-risk of ST than patients with BIFpEF.
The association of left ventricular ejection fraction (LVEF) with procedural and long-term outcomes after state-of-the-art percutaneous coronary intervention (PCI) of bifurcation lesions remains unsettled. A total of 5,333 patients who underwent contemporary coronary bifurcation PCI were included in the intercontinental retrospective combined insights from the unified RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) and COBIS (COronary BIfurcation Stenting) III bifurcation registries. Of 5,003 patients (93.8%) with known baseline LVEF, 244 (4.9%) had LVEF <40% (bifurcation with reduced ejection fraction [BIFrEF] group), 430 (8.6%) had LVEF 40% to 49% (bifurcation with mildly reduced ejection fraction [BIFmEF] group) and 4,329 (86.5%) had ejection fraction (EF) ≥50% (bifurcation with preserved ejection fraction [BIFpEF] group). The primary end point was the Kaplan-Meier estimate of major adverse cardiac events (MACEs) (a composite of all-cause death, myocardial infarction, and target vessel revascularization). Patients with BIFrEF had a more complex clinical profile and coronary anatomy. No difference in procedural (30 days) MACE was observed across EF categories, also after adjustment for in-study outcome predictors (BIFrEF vs BIFmEF: adjusted hazard ratio [adj-HR] 1.39, 95% confidence interval [CI] 0.37 to 5.21, p = 0.626; BIFrEF vs BIFpEF: adj-HR 1.11, 95% CI 0.25 to 2.87, p = 0.883; BIFmEF vs BIFpEF: adj-HR 0.81, 95% CI 0.29 to 2.27, p = 0.683). BIFrEF was independently associated with long-term MACE (median follow-up 21 months, interquartile range 10 to 21 months) than both BIFmEF (adj-HR 2.20, 95% CI 1.41 to 3.41, p <0.001) and BIFpEF (adj-HR 1.91, 95% CI 1.41 to 2.60, p <0.001) groups, although no difference was observed between BIFmEF and BIFpEF groups (adj-HR 0.87, 95% CI 0.61 to 1.24, p = 0.449). In conclusion, in patients who underwent PCI of a coronary bifurcation lesion according to contemporary clinical practice, reduced LVEF (<40%), although a strong predictor of long-term MACEs, does not affect procedural outcomes.
Impact of Percutaneous Coronary Intervention on Outcomes in Patients With Heart Failure: JACC State-of-the-Art Review
2021, Journal of the American College of Cardiology
Citation Excerpt :
Advanced age, female sex, diabetes mellitus, multivessel disease, number of vessels treated, new acute MI, LVEF <35%, and symptoms of HF have been independently associated with higher mortality (59,64). Although PCI has demonstrated feasibility in patients with LVSD, severe LVSD has been associated with nearly 4-fold higher rates of stent thrombosis and 2-fold higher rates of major adverse cardiovascular events (MACE) (all-cause death, Q-wave myocardial infarction, stent thrombosis, and target lesion revascularization) at 1 year following PCI (65). The currently ongoing REVIVED-BCIS2 (REVascularisation for Ischaemic Ventricular Dysfunction) trial (NCT01920048) is a prospective, multicenter, open-label, randomized controlled trial funded by the National Institute for Health Research in the United Kingdom.
Coronary artery disease (CAD) is highly prevalent in patients with heart failure (HF) and accounts for nearly two-thirds of cases. The use of percutaneous coronary intervention (PCI) in HF patients with CAD has markedly increased and has been suggested to be associated with improved outcomes in numerous observational studies. Randomized data comparing the impact of PCI with that of coronary artery bypass graft (CABG) or contemporary guideline-directed medical therapy alone on clinical outcomes and myocardial recovery in patients with HF are lacking. The purpose of this review is to describe the available evidence regarding the impact of PCI in acute HF (in the presence and absence of an acute coronary syndrome), chronic HF with reduced ejection fraction, and HF with preserved ejection fraction. Adequately-powered randomized clinical trials examining the outcomes with PCI in these distinct HF populations are warranted.
Independent and cumulative association of clinical and morphological heart failure with long-term outcome after percutaneous coronary intervention
2021, Journal of Cardiology
Citation Excerpt :
Heart failure (HF) is associated with high rates of mortality, morbidity, and readmission; it puts an increased economic burden on the healthcare system [1]. It is also an established risk factor for adverse post-procedural outcomes after revascularization [2–6]. Patients with HF typically present with signs and symptoms of congestion, which require therapeutic interventions.
Heart failure (HF) is a risk factor for adverse post-procedural outcome after revascularization; however, it is unclear how left ventricular systolic dysfunction (LVSD) and clinical HF symptoms affect percutaneous coronary intervention (PCI) outcomes. We investigated the characteristics and long-term outcomes of patients with clinical HF or LVSD after PCI.
This was a Japanese multicenter registry study of adult patients receiving PCI. Among 4689 consecutive patients who underwent PCI at 15 hospitals from January 2009 to December 2012, we analyzed 2634 (56.2%) with documented left ventricular ejection fraction (LVEF). They were divided into four groups based on clinical HF (symptoms or HF hospitalization) and LVEF [≥35% and <35% (HF due to LVSD)]. The primary outcome was major adverse cardiovascular events (MACE), comprising all-cause death, acute coronary syndrome, HF hospitalization, performance of coronary artery bypass grafting, and stroke within 2 years after the initial PCI.
Our findings revealed 354 patients (13.4%) with HF (clinical HF, n = 173, 48.9%; LVSD, n = 132, 37.3%; both, n = 49; 13.8%). The incidence of MACE was higher in patients with clinical HF or LVSD, and was largely due to higher non-cardiac death and HF hospitalization. After adjustment, clinical HF (hazard ratio 2.16, 95% confidence interval; 1.49−3.14) and lower LVEF (per 10%, hazard ratio 0.89, 95% confidence interval; 0.81−0.99) were independently associated with higher MACE risk.
Clinical HF and LVSD were independently associated with adverse long-term clinical outcomes, particularly with non-cardiac death and HF readmission, in patients treated with PCI.
Comparison of Benefit of Successful Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients With Versus Without Reduced (≤40%) Left Ventricular Ejection Fraction
2017, American Journal of Cardiology
Citation Excerpt :
Although the increased risk of MACE associated with LV dysfunction was largely driven by an increased risk of mortality, TVR was the predominant determinant of MACE in patients with preserved LV function. Similar observations have previously been reported in unselected patients undergoing PCI.17 In this registry, successful CTO PCI conferred a significant long-term survival advantage in both patients with impaired and patients with preserved LV function, and interaction analyses suggested similar relative revascularization benefits in both patient groups.
Successful recanalization of chronic total occlusions (CTO) has been associated with improved survival. Data on outcomes in patients with left ventricular (LV) systolic dysfunction undergoing percutaneous coronary intervention for CTO, however, are scarce. Between January 2005 and December 2013, a total of 2,002 consecutive patients undergoing elective CTO percutaneous coronary intervention at a tertiary care center were divided into patients with (LV ejection fraction ≤ 40%) and without (LV ejection fraction > 40%) LV systolic dysfunction as defined by transthoracic echocardiography. The primary end point was all-cause mortality. Median follow-up was 2.6 (1.1 to 3.1) years. A total of 348 (17.4%) patients had LV dysfunction. All-cause mortality was higher in patients with LV dysfunction (30.2%) than in those with normal LV function (8.2%, p <0.001), and associations remained significant after adjustment for baseline differences (adjusted hazard ratio [HR] 3.39, 95% confidence interval [CI] 2.57 to 4.47, p <0.001). Successful CTO recanalization was independently associated with reduced all-cause mortality, with similar relative risk reductions in both the preserved (6.6% vs 16.9%, adjusted HR 0.48, 95% CI 0.34 to 0.70, p <0.001) and the reduced LV function groups (26.2% vs 45.2%, adjusted HR 0.63, 95% CI 0.41 to 0.98, p = 0.04, interaction p = 0.28). In conclusion, irrespective of LV function, successful CTO recanalization is associated with a clear survival benefit.

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Coronary artery diseaseOutcome of Percutaneous Coronary Intervention Utilizing Drug-Eluting Stents in Patients With Reduced Left Ventricular Ejection Fraction

Section snippets

Methods

Results

Discussion

Am J Cardiol

Am J Cardiol

Cardiovasc Revasc Med

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Cardiovasc Revasc Med

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Procedural results of coronary angioplasty but not late mortality have improved in patients with depressed left ventricular function

Clin Cardiol

Percutaneous coronary stenting in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis

EuroIntervention

Coronary artery disease
Outcome of Percutaneous Coronary Intervention Utilizing Drug-Eluting Stents in Patients With Reduced Left Ventricular Ejection Fraction