Impact of left ventricular dysfunction on the outcome of patients undergoing microaxial flow pump-supported high-risk percutaneous coronary intervention

https://doi.org/10.1007/s00392-024-02526-y

Alexander Laupp (Dresden)1, F. Woitek (Dresden)1, A. Conrad (Dresden)1, S. Haussig (Dresden)1, D. Obradovic (Dresden)1, J. Mierke (Dresden)1, J. Vogel (Dresden)1, E. B. Winzer (Dresden)1, R. Höllriegel (Dresden)1, S. Jellinghaus (Dresden)1, A. Linke (Dresden)1, N. Mangner (Dresden)1

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.

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