10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification

Hideyuki Kawashima; Patrick W Serruys; Hironori Hara; Masafumi Ono; Chao Gao; Rutao Wang; Scot Garg; Faisal Sharif; Robbert J de Winter; Michael J Mack; David R Holmes; Marie-Claude Morice; Arie Pieter Kappetein; Daniel J F M Thuijs; Milan Milojevic; Thilo Noack; Friedrich-Wilhelm Mohr; Piroze M Davierwala; Yoshinobu Onuma; SYNTAX Extended Survival Investigators

doi:10.1016/j.jcin.2021.10.026

10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification

JACC Cardiovasc Interv. 2022 Jan 24;15(2):193-204. doi: 10.1016/j.jcin.2021.10.026. Epub 2021 Dec 29.

Authors

Hideyuki Kawashima¹, Patrick W Serruys², Hironori Hara¹, Masafumi Ono¹, Chao Gao³, Rutao Wang³, Scot Garg⁴, Faisal Sharif⁵, Robbert J de Winter⁶, Michael J Mack⁷, David R Holmes⁸, Marie-Claude Morice⁹, Arie Pieter Kappetein¹⁰, Daniel J F M Thuijs¹⁰, Milan Milojevic¹¹, Thilo Noack¹², Friedrich-Wilhelm Mohr¹², Piroze M Davierwala¹³, Yoshinobu Onuma⁵; SYNTAX Extended Survival Investigators

Affiliations

¹ Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
² Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, United Kingdom. Electronic address: patrick.serruys@nuigalway.ie.
³ Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Radboud University, Nijmegen, the Netherlands.
⁴ Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom.
⁵ Department of Cardiology, National University of Ireland, Galway, Galway, Ireland.
⁶ Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
⁷ Baylor Scott & White Health, Dallas, Texas, USA.
⁸ Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁹ Département of Cardiologie, Hôpital privé Jacques Cartier, Générale de Santé Massy, Massy, France.
¹⁰ Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
¹¹ Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.
¹² University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.
¹³ Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Canada.

PMID: 34973904
DOI: 10.1016/j.jcin.2021.10.026

Abstract

Objectives: The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Background: Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization.

Methods: This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG).

Results: The 532 patients with ≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P < 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95% CI: 1.09-1.69; P = 0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (P_interaction = 0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95% CI: 0.97-1.41; P = 0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95% CI: 0.64-1.13; P = 0.264).

Conclusions: At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Keywords: SYNTAX; calcification; coronary artery bypass grafting; long-term mortality; percutaneous coronary intervention.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Coronary Artery Bypass / adverse effects
Coronary Artery Disease* / diagnostic imaging
Coronary Artery Disease* / surgery
Drug-Eluting Stents*
Humans
Percutaneous Coronary Intervention* / adverse effects
Treatment Outcome

Associated data

ClinicalTrials.gov/NCT03417050
ClinicalTrials.gov/NCT00114972