Abusnina Waiel, Mostafa Mostafa Reda, Al-Abdouh Ahmad, Radaideh Qais, Ismayl Mahmoud, Alam Mahboob, Shah Jaffer, Yousfi Noraldeen El, Paul Timir K, Ben-Dor Itsik, Dahal Khagendra
Department of Cardiology, Creighton University School of Medicine, Omaha, NE, United States.
Department of Medicine, Rochester Regional/Unity Hospital, Rochester, NY, United States.
Front Cardiovasc Med. 2022 Sep 20;9:946027. doi: 10.3389/fcvm.2022.946027. eCollection 2022.
Severely calcified coronary lesions with reduced left ventricular (LV) function result in worse outcomes. Atherectomy is used in treating such lesions when technically feasible. However, there is limited data examining the safety and efficacy of atherectomy without hemodynamic support in treating severely calcified coronary lesions in patients with reduced left ventricular ejection fraction (LVEF).
To evaluate the clinical outcomes of atherectomy in patient with reduced LVEF.
We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 21, 2021) for studies evaluating the outcomes of atherectomy in patients with severe LV dysfunction. We used random-effect model to calculate risk ratio (RR) with 95% confidence interval (CI). The endpoints were in-hospital and long term all-cause mortality, cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR).
A total of 7 studies consisting of 2,238 unique patients were included in the analysis. The median follow-up duration was 22.4 months. The risk of in-hospital all-cause mortality using atherectomy in patients with severely reduced LVEF compared to the patients with moderate reduced or preserved LVEF was [2.4vs.0.5%; RR:5.28; 95%CI 1.65-16.84; = 0.005], the risk of long term all-cause mortality was [21 vs. 8.8%; RR of 2.84; 95% CI 1.16-6.95; = 0.02]. In-hospital TVR risk was 2.0 vs. 0.6% (RR: 4.15; 95% CI 4.15-15.67; = 0.04) and long-term TVR was [6.0 vs. 9.9%; RR of 0.75; 95% CI 0.39-1.42; = 0.37]. In-hospital MI was [7.1 vs. 5.4%; RR 1.63; 95% CI 0.91-2.93; = 0.10], long-term MI was [7.5 vs. 5.7; RR 1.74; 95%CI 0.95-3.18; = 0.07).
Our meta-analysis suggested that the patients with severely reduced LVEF when using atherectomy devices experienced higher risk of clinical outcomes in the terms of all-cause mortality and cardiac mortality. As we know that the patients with severely reduced LVEF are inherently at increased risk of adverse clinical outcomes, this information should be considered hypothesis generating and utilized while discussing the risks and benefits of atherectomy in such high risk patients. Future studies should focus on the comparison of outcomes of different atherectomy devices in such patients. Adjusting for the inherent mortality risk posed by left ventricular dysfunction may be a strategy while designing a study.
严重钙化的冠状动脉病变且左心室（LV）功能降低会导致更差的预后。在技术可行时，旋切术用于治疗此类病变。然而，关于在没有血流动力学支持的情况下旋切术治疗左心室射血分数（LVEF）降低患者的严重钙化冠状动脉病变的安全性和有效性的数据有限。
评估LVEF降低患者旋切术的临床结局。
我们检索了PubMed、Cochrane中央对照试验注册库和ClinicalTrials.gov（从创建至2021年7月21日），以查找评估严重左心室功能障碍患者旋切术结局的研究。我们使用随机效应模型计算风险比（RR）及95%置信区间（CI）。终点指标为住院期间和长期的全因死亡率、心源性死亡、心肌梗死（MI）和靶血管血运重建（TVR）。
分析共纳入7项研究，包含2238例独特患者。中位随访时间为22.4个月。与LVEF中度降低或保留的患者相比，LVEF严重降低的患者使用旋切术的住院期间全因死亡风险为[2.4%对0.5%；RR：5.28；95%CI 1.65 - 16.84；P = 0.005]，长期全因死亡风险为[21%对8.8%；RR为2.84；95%CI 1.16 - 6.95；P = 0.02]。住院期间TVR风险为2.0%对0.6%（RR：4.15；95%CI 4.15 - 15.67；P = 0.04），长期TVR为[6.0%对9.9%；RR为0.75；95%CI 0.39 - 1.42；P = 0.37]。住院期间MI为[7.1%对5.4%；RR 1.63；95%CI 0.91 - 2.93；P = 0.10]，长期MI为[7.5%对5.7%；RR 1.74；95%CI 0.95 - 3.18；P = 0.07]。
我们的荟萃分析表明，使用旋切术器械时，LVEF严重降低的患者在全因死亡率和心源性死亡率方面经历更高的临床结局风险。由于我们知道LVEF严重降低的患者本身不良临床结局风险增加，在讨论此类高危患者旋切术的风险和益处时，该信息应被视为产生假设并加以利用。未来研究应聚焦于比较此类患者中不同旋切术器械的结局。在设计研究时，调整左心室功能障碍带来的固有死亡风险可能是一种策略。
