https://doi.org/10.1007/s00392-024-02526-y
1Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin, Kardiologie und Intensivmedizin Dresden, Deutschland
Background: Patients receiving high-risk percutaneous coronary interventions (HRPCI) are characterized by complex coronary artery disease, severe comorbidities and adverse hemodynamics including severely reduced left-ventricular ejection fraction (LV-EF). We investigated the optimal cut-off for LV-EF in patients undergoing microaxial flow pump (mAFP)-supported HRPCI to predict survival and aimed to evaluate the impact of complete revascularization on patients with low (low-EF) compared to preserved LV-EF (pres-EF).
Methods: We used a prospective single-center registry to examine 229 patients undergoing mAFP-supported HRPCI. We performed receiver operating curve analysis to determine the optimal cut-off for LV-EF to predict 3-year survival. The primary outcomes were 30-day and 3-year survival and safety was assessed according to ARC-2 and VARC-3 definitions. The interaction between complete revascularization and LV-EF with regard to 3-year survival was evaluated.
Results: According to Youden-Index, the optimal cut-off for LV-EF to predict 3-year survival was 35.5% and the cohort was divided into low-EF (≤35.5%, n=99 (43.2%)) and pres-EF (>35.5%, n=130 (56.8%)). Compared to pres-EF, low-EF patients were younger and had more severe heart failure symptoms (all p<0.05). The STS score was significantly higher in low-EF (7.4% (IQR 4.4; 13.0) vs 4.7% (IQR 2.7; 9.4), p<0.001). The rate of 3-vessel disease (~80%), median baseline Syntax- (32 (IQR 24; 41) and BCIS Myocardial Jeopardy Score (12 (IQR 8; 12) were high but not significantly different between groups. However, low-EF had a significantly higher rate of any CTO and a lower rate of left main disease compared to pres-EF.
Complete revascularization defined by a residual BCIS Myocardial Jeopardy Score <4 compared to ≥4 was less often achieved in low-EF compared to pres-EF (63.8% vs 79.1%, p=0.012). The time of mAFP-support was not different between groups. There was a numerically higher rate of SCAI myocardial infarction and stent thrombosis in low-EF (each 3.1% vs 0%, p=0.077). VARC-defined vascular access site complications, bleeding, stroke and acute kidney injury were not different between groups.
The Kaplan-Meier estimated 30-day (70.7% (95%-CI 61.7; 81.0) vs. 92.7% (95%-CI 88.3; 97.3), p<0.001) and 3-year survival (35.6% (95%-CI 25.6; 49.5) vs. 59.4% (95%-CI 49.7; 71.0), p<0.001) was significantly worse in low-EF compared to pres-EF. In a multivariate Cox regression analysis, low-EF was independently associated with early (HR 3.04 (95%-CI 1.36; 6.76)) and late mortality (HR 1.70 (95%-CI 1.07; 2.69)).
Complete revascularization (residual BCIS Myocardial Jeopardy Score <4 vs ≥4) had no impact on 3-year survival in pres-EF (58% (95%-CI 47.4; 71.0) vs 66.1% (95%-CI 46.6; 93.8), p=0.653), whereas complete revascularization was associated with higher 3-year survival in low-EF (45.3% (95%-CI 31.9; 64.3) vs 23.5% (95%-CI 11.5; 48.2), p=0.037) (p-value for interaction <0.001).
Conclusion: In patients undergoing mAFP-supported HRPCI, a LV-EF <35.5% was associated with poor 30-day and 3-year survival. Complete revascularization led to a higher 3-year survival in patients with low-EF, but had no impact on patients with pres-EF. The low-EF population seems suitable to study the effects of a mAFP-guided HRPCI strategy aiming at complete revascularization in randomized controlled trials.