Key result
Atherectomy in patients with severely reduced LVEF was associated with a significantly higher risk of in-hospital all-cause mortality compared to those with moderate or preserved LVEF (RR 5.28).
Why the study?
Data were limited examining the safety and efficacy of atherectomy without hemodynamic support for severely calcified coronary lesions in patients with reduced LVEF.
Does atherectomy in patients with severely reduced LVEF compared to moderately reduced or preserved LVEF increase the risk of mortality and adverse cardiac events?
Systematic Review (n=2,238)
Does atherectomy in patients with severely reduced LVEF compared to moderately reduced or preserved LVEF increase the risk of mortality and adverse cardiac events?
Atherectomy in patients with severely calcified coronary lesions and severely reduced LVEF is associated with significantly higher in-hospital and long-term mortality compared to those with preserved or moderately reduced LVEF.
Atherectomy in severely reduced LVEF associated with higher adverse events; leaves open optimal strategies and need for RCTs.
Background 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). Objective To evaluate the clinical outcomes of atherectomy in patient with reduced LVEF. Methods 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). Results 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; P = 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; P = 0.02]. In-hospital TVR risk was 2.0 vs. 0.6% (RR: 4.15; 95% CI 4.15–15.67; P = 0.04) and long-term TVR was [6.0 vs. 9.9%; RR of 0.75; 95% CI 0.39–1.42; P = 0.37]. In-hospital MI was [7.1 vs. 5.4%; RR 1.63; 95% CI 0.91–2.93; P = 0.10], long-term MI was [7.5 vs. 5.7; RR 1.74; 95%CI 0.95–3.18; P = 0.07). Conclusion 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.
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Abusnina et al. (2022) conducted a systematic review in Severely calcified coronary lesions with reduced left ventricular ejection fraction (n=2,238). Severely reduced LVEF (during atherectomy) vs. Moderate or preserved LVEF (during atherectomy) was evaluated on In-hospital all-cause mortality (RR 5.28, 95% CI 1.65-16.84, p=0.005). Atherectomy in patients with severely reduced LVEF was associated with a significantly higher risk of in-hospital all-cause mortality compared to those with moderate or preserved LVEF (RR 5.28).
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