HFSA 2021: Identifying Patients Who Would Benefit from Complete Revascularization

Cindy Grines, MD, FACC, MSCAI, addresses the question, ‘Which patients benefit from complete revascularization?’ Dr. Grines is chief scientific officer at Northside Hospital Cardiovascular Institute in Atlanta, Georgia, and immediate past president of the Society for Cardiovascular Angiography & Interventions (SCAI). She gave this presentation virtually at the 2021 Heart Failure Society of America (HFSA) scientific meeting.

To answer the question, Dr. Grines reviews data from randomized trials, meta-analyses, and clinical registries. “Some patients just have really complex disease, and some patients have really severe LV dysfunction. And as an interventionalist you might just want to get in and get out. ‘First, do no harm,’ right? That’s what we’ve been taught. But perhaps Impella® can make this a little bit better.”

Dr. Grines shows data from the R-IMP-IT study (Revascularization extent in IMPella ITalian registry) and Roma-Verona registry, both showing that more complete revascularization with Impella is linked to increased survival. In the Roma-Verona registry, she emphasizes, “what was found in this study of multivessel disease treated with PCI with Impella support is that there’s a threefold increase in patients who had ejection fractions that improved beyond 35%. So that’s a testament to revascularization being able to treat these patients, being able to reduce the stunning that one often sees with tight lesions contributing to severe heart failure and LV dysfunction.”

She also presents data from the SCAI position statement on optimal coronary interventional therapy for complex coronary artery disease, highlighting, “If one can achieve complete revascularization, then there is potentially a 71% reduction in death, 27% reduction in MACE, and 41% reduction in risk of MI. And these benefits were also present in high-risk STEMI patients as well as patients with acute coronary syndrome.”

“So, all the evidence that we have suggests that if you have acute coronary syndrome, regardless of whether it’s a STEMI, a non-STEMI, or unstable angina, those patients do better with complete revascularization.”

Dr. Grines also mentions data from the CULPRIT SHOCK trial—demonstrating higher 30-day mortality or renal replacement therapy in the immediate multivessel PCI group compared to culprit-lesion-only PCI—explaining that there are some high-risk patients who may not benefit from complete revascularization, especially if multivessel PCI is performed acutely. While this study led many societies to change guidelines for performing multivessel PCI acutely in patients with cardiogenic shock, Dr. Grines presents her own clinical approach when determining the extent of revascularization: “What I like to do is ask how tight the lesion is and how much myocardium does it supply.”

Returning to the initial question: ‘Which patients benefit from complete revascularization?’, Dr. Grines concludes, “I think, perhaps, all patients, as long as they have significant multivessel disease—I’m talking about, you know, 80 to 90 percent lesions, not 50% stenoses—but you always keep in mind that you want to be safe. And so you can perform multivessel PCI if it can be safely performed, and it appears that if one uses mechanical circulatory support, we can more likely, more readily, achieve complete revascularization.”