Clinical Outcomes of Percutaneous Intervention in Triple-Vessel and Left Main Coronary Artery Diseases

Mailing Address: Samuel Cargnin Cunha Instituto de Cardiologia de Santa Catarina Rua Dr Otto Feuerschuette, 177, Vila Moema, Ed Berlise apto 302, Tubarão. Postal Code: 88705020, São José, SC – Brazil E-mail: samuelccunha@gmail.com Clinical Outcomes of Percutaneous Intervention in Triple-Vessel and Left Main Coronary Artery Diseases Samuel Cargnin Cunha1, Luiz Eduardo Koenig São Thiago2, Evelim de Medeiros Sartor3 Instituto de Cardiologia de Santa Catarina1; Serviço de Hemodinâmica e Cardiologia Intervencionista – Hospital SOS Cardio – Florianópolis, Instituto de Cardiologia de Santa Catarina2; Universidade do Sul de Santa Catarina (UNISUL)3 – Palhoça, SC – Brazil


Introduction
Coronary artery disease (CAD) remains one of the most important diseases because of its high morbidity and mortality. 1However, preventive measures such as lifestyle changes, modification of risk factors, improvements in medical therapy, and advances in coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have resulted in a reduction in mortality related to cardiovascular diseases. 2e optimal revascularization strategy in patients with CAD remains a subject of debate among interventional cardiologists and surgeons.4][5][6] Myocardial revascularization should be considered in patients with evidence of Percutaneous intervention in coronary artery disease Int J Cardiovasc Sci.2016;29 (4): 262-269   Original Article moderate to severe ischemia, which in turn is associated with an annual rate of 4-6% of risk of cardiovascular death or nonfatal acute myocardial infarction, as well as the development of heart failure, sudden cardiac death, or arrhythmias. 7,8I was first introduced in 1977.Since then, its use has increased in recent decades in the various manifestations of CAD. 9,10[17] The SYNTAX study showed, in this group of patients, that PCI treatment with a drug-eluting stent (DES) was associated with mortality equivalent to treatment with CABG, despite a greater risk of a repeat bypass, but with a reduced risk of stroke. 10e success of complete revascularization by PCI is often hampered by the presentation of the disease with a complex coronary anatomy, chronic occlusions, plus additional risks such as age, renal failure, and extracardiac arteriopathy.[20] The aim of this study was to evaluate the safety of PCI with DES in patients with triple-vessel CAD and/or lesion in the LMCA in a hospital environment and their clinical outcomes during a 1-year period.

Methodology
Observational, nonrandomized, cohort study conducted at the Hemodynamic and Interventional Cardiology Department of the Hospital SOS Cardio in Florianópolis, Santa Catarina.The patients were selected from the hemodynamic department's database.Initially, 86 patients were included from both sexes, any age range, with triplevessel CAD and/or LMCA lesion, undergoing PCI in the period from June 2013 to May 2015.The decision to perform PCI was considered when the patient had a favorable anatomy and refused surgery, or when he or she had a high risk of surgical mortality, assessed by the EuroSCORE. 21Patients with previous treatment by CABG or those who missed out on the clinical follow-up were excluded, resulting in a total of 46 cases.All procedures were performed by the same interventional cardiologist at the institution.Latest generation DESs (PROMUS, XIENCE, Resolute Integrity, Nobori) were used, chosen at the time of the procedure according to the coronary anatomy.Intracoronary ultrasound was used in cases where a better definition of the atheromatous plaque characteristics was deemed necessary, in order to provide a better result.
Data collection was performed using electronic medical records from the TASY system and printed medical records.The researcher contacted all patients by phone within a minimum period of 1 year after the procedure.The interview was conducted with the patient or a family member in charge of the patient using a spreadsheet containing the variables.For analysis of clinical outcomes, questions were asked in the interview about symptoms and complications during the period after the procedure.If there were reports of new angioplasty, CABG, or death, the data were recorded in the records of the aforementioned hospital or by a medical assistant, with a prior consent by the patient.All deaths were considered of cardiac origin unless a noncardiac cause was clearly identified.
The diagnosis of myocardial infarction was defined according to the universal definition of myocardial infarction. 22The left ventricular systolic function was classified as normal, when the ejection fraction was above 55%; mild dysfunction, when between 45 and 54%; moderate dysfunction, when between 30 and 44%; and significant dysfunction, when < 30%.The PCI success was determined by a TIMI-3 flow and a residual stenosis lower than 30% by visual assessment.
The data were analyzed by the SPSS 22.0 program.The statistical analysis began with the description of the study variables.Association tests between the dependent and independent variables were carried out using Fisher's exact test, with statistical significance at p < 0.05.
As this study involved data collected from the patients' medical records, due to the difficulty of obtaining individual consent, the researchers committed to respecting the confidentiality of the data and preserving anonymity.The Hospital SOS Cardio authorized the collection of data from medical records, and the project was approved by the Research Ethics Committee under the number 50334715.7.0000.0113.

Results
A total of 46 patients aged 48 to 92 years (mean 69.9 years) were studied.

Original Article
The success rate of the procedures was 100%.LMCA angioplasties were performed with only one stent in 29 cases (63%), LMCA angioplasties with more than one stent in six cases (13%), and triple-vessel angioplasty without LMCA lesion in 11 cases (23.9%).There were no deaths or emergency CABG in the procedures (Table 2).
During the in-hospital period, there were two cases (4.34%) of NSTEMI.In one of the cases, there was a distal branch occlusion of the first marginal.In the second case, there was an occlusion of a sub-branch of the diagonal artery.None of the cases required a new reintervention by PCI or CABG.There were no deaths during this phase (Table 3).
In the follow-up after hospital discharge, the outcomes were classified in the period between 0 and 6 months, and between 6 and 12 months.Among the patients, five (10.86%) had the outcome documented during follow-up.There was one death (2.2%) and one case of angioplasty (2.2%) in the first 6 months of monitoring after the procedure.In the period from 6 to 12 months, there were three deaths (6.5%), two cases of CABG (4.3%), and one case of angioplasty (2.2%) (Table 5).The overall mortality in the study was 8.7% (n = 4), and in two cases (4.35%), the deaths were due to cardiovascular causes.The two cases of noncardiovascular death occurred from complications with an infectious cause.In relation to deaths with a cardiovascular cause, one was a sudden death at home, and the other was due to myocardial infarction.Among the deaths, the mean age was 82 years.The mortality rate as a risk factor was significantly associated with left ventricular heart failure and with moderate to severe ventricular dysfunction (Table6).

Discussion
4][25][26][27][28] In spite of the small sample size, this is indicative that the population presented in this study had a high cardiovascular risk when compared with those of other randomized studies.
During the in-hospital phase, the rate of acute myocardial infarction was low (4.34%), and the episodes that occurred were related to arteries of little relevance and with no clinical significance, similar to that described in the literature. 10,29,30There were no deaths during the in-hospital period, which was lower than that found in the meta-analysis of Biondi-Zoccai et al., 31 in which 16 studies were evaluated with a total of 1,278 patients with a mortality of 1.7% in 30 days.
During the 12-month follow-up after the angioplasty, the death rate from any cause in our study (8.7%) was similar to that in other studies 29,30 and slightly higher than that of the SYNTAX study (4.4%).We attribute the cases of death in the study to an elevated age range and high cardiovascular risk.
Regarding the immediate complications and patient follow-up, an acceptable rate of repeat revascularization was found, with 6.6% of cases, which was less than the SYNTAX study, with 13.5% in the PCI group.In the present study, the repeat revascularization was performed more frequently by PCI (4.4%) than by CABG (2.2%), which was similar to the SYNTAX study, with 2.8% by CABG and 11.4% by PCI.
We consider the follow-up period satisfactory in relation to PCI and cardiovascular events, whereas, usually, with a longer follow-up of up to 5 years, the number of events and their incidence are likely to remain similar to intermediate follow-up values. 32is low number of cardiovascular events can still be explained by the better socioeconomic and knowledge status of the patients because the study was conducted in a private center, in which patients were frequently monitored by their clinical cardiologists and had their medication maintained at optimal levels.

Study limitations
The main limitation of the study is the size of the population included.One should also mention the fact that it was a single-arm, observational, and nonrandomized register.

Conclusion
We conclude from this study that treatment by PCI with DES in LMCA and triple-vessel atherosclerotic disease in clinical practice is safe and effective both in the hospital phase and in the long term, with low rates of cardiac death and stent thrombosis.This indicates that this strategy is an acceptable alternative, or possibly even preferred in selected cases.

Table 6 Characteristics relevant to mortality
*LVHF: left ventricular heart failure.

Table 5 Follow-up after angioplasty
CABG: coronary artery bypass grafting.