Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

Background: SYNTAX score II [SS II] integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality

Aims: We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes [ACS] population with severe coronary artery disease [CAD] undergoing percutaneous coronary intervention [PCI]

Methods: From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 [13.6%] showed severe CAD [three-vessel disease and/or left main involvement]. Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events [MACCE] were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization

Results: The median SS II was 29 [range, 14-59]. Overall, MACCE occurred in 25% of patients [cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%]. The 1-year MACCE-free survival was significantly lower in patients with SS [>/=29], than in those with SS II [<29] [64.2% vs. 87.2%, respectively; p=0.007]. In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval [CI]: 1.02-5.85; p=0.031] and SS II >/=29 [hazard ratio 2.74, 95% CI: 1.30-8.21; p=0.011] were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 [95% CI: 0.58-0.81]. For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 [p=0.09]

Conclusion: SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization

Invasive assessment modalities of unprotected left main stenosis

Among all coronary lesions, the decision-making process for the treatment of unprotected left main [ULM] stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention [PCI] performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment