Emergency surgical and endovascular revascularization in high-surgical risk patients with non-ST segment elevation acute coronary syndrome

• Nishonov A.B.
• Tarasov R.S.
• Kozirin K.A.
• Ivanov S.V.
• Ganykov V.I.

Abstract

Background. There is a limited number of studies concerning the results of urgent coronary artery bypass grafting (CABG) in high-surgical risk patients with non-ST elevation acute coronary syndrome. Deficit of an evidence-supported base is related to peculiarities of organization and availability of emergency CABG, the process of decision-making, and a series of tactical and technical aspects of performing this type of intervention within the first 24 hours in high-surgical risk patients with manifest symptoms of ischemia and myocardial lesion in severe multivessel coronary atherosclerosis and involvement of the left coronary artery trunk.

Objective. The purpose of this study was to carry out a comparative analysis of the in-hospital outcomes of emergency surgical and endovascular revascularization (CABG and percutaneous coronary intervention) in high-surgical risk patients with non-ST elevation acute coronary syndrome.

Patients and methods. In our retrospective study with propensity score matching, we analyzed the in-hospital results of CABG (n=67) and percutaneous coronary intervention (n=67) in high-surgical risk patients with non-ST-segment elevation acute coronary syndrome within the first 24 hours after admission. The patients had severe lesions of coronary arteries with a median of the SYNTAX score of 24 points. The endpoints of the study were all-cause mortality, cardiac mortality, myocardial infarction, repeat non-elective revascularizations, and a composite endpoint combining all the above enumerated events. Besides, we evaluated completeness of the scope of myocardial revascularization in the groups.

Results. The patients in the groups were comparable by the main clinical and anamnestic data which was ensured by propensity score matching. The majority of CABGs were performed in conditions of artificial circulation. In the group of percutaneous coronary intervention, the strategy of multivessel and staged stenting was used approximately in a similar proportion (47.8 and 52.2%, respectively). There were no significant differences between the groups of CABG and percutaneous coronary intervention by the endpoints. Mortality from cardiac causes in the groups turned out to be similar, each amounting to 4.5%. CABG was characterized by significantly higher frequency of complete myocardial revascularization as compared with percutaneous coronary intervention: n=62 (92.5%) vs n=48 (71.6%), respectively, p=0.001.

Conclusion. Urgently performed CABG demonstrated comparable with percutaneous coronary intervention in-hospital results of revascularization in high-surgical risk patients with severe multivessel lesions with non-ST elevation-acute coronary syndrome, ensuring fuller scope of myocardial revascularization as compared with percutaneous coronary intervention.

Keywords:emergency myocardial revascularization; non-ST segment elevation acute coronary syndrome; multivessel lesion; coronary artery bypass grafting; percutaneous coronary intervention

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