Key result
Surgical turndown for CABG linked to ~3-fold higher 90-day MACCE after high-risk PCI.
Why the study?
Limited data exist on patient characteristics, reasons for surgical turndown, and outcomes among CABG-ineligible patients undergoing Impella-supported HRPCI.
Does surgical ineligibility (turndown by a cardiothoracic surgeon) predict worse short-term outcomes compared to patient declination of surgery among patients undergoing Impella-supported high-risk PCI?
Observational (n=791)
Yes
Does surgical ineligibility (turndown by a cardiothoracic surgeon) predict worse short-term outcomes compared to patient declination of surgery among patients undergoing Impella-supported high-risk PCI?
Answers are grounded in this paper and cite their sources.
Among patients requiring Impella-supported high-risk PCI, those deemed surgically ineligible represent a distinctly sicker population with worse short-term clinical outcomes than those who simply decline CABG, and standard surgical risk models significantly underestimate their 30-day mortality.
Background Impella-supported high-risk percutaneous coronary intervention (HRPCI) is an alternative for patients ineligible for coronary artery bypass grafting (CABG). However, limited data exist on patient characteristics, reasons for surgical turndown, and patient outcomes. This study aimed to characterize the baseline characteristics and short-term and intermediate-term outcomes of patients evaluated for CABG in the PROTECT III study. Methods Patients enrolled in the PROTECT III study (NCT04136392), who underwent Impella-supported HRPCI, with an evaluable chart who were assessed by a cardiothoracic surgeon (CTS) for CABG were studied. Reasons for surgical turndown were derived from medical records. Baseline characteristics and major adverse cardiovascular and cerebrovascular events (composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 30 and 90 days and all-cause mortality at 1 year were assessed. Observed to expected 30-day mortality ratios were calculated using the Society of Thoracic Surgeons (STS) risk score. Results Of 791 patients evaluated for CABG, 680 (86.0%) were turned down by a CTS, and 111 (14.0%) declined surgery. The most common reasons for surgical turndown were comorbidities (40%) and anatomical factors (25%). Compared with patients who declined surgery, patients turned down (deemed ineligible) by CTS had higher rates of major adverse cardiovascular and cerebrovascular event at 30 days (9.2% vs 4.6%; P = .12) and 90 days (14.1% vs 4.6%; P = .02). The observed to expected mortality ratio, based on the STS risk score, was 1.43 (95% CI, 1.08-1.83). Conclusions Impella-supported HRPCI is a viable alternative for high-risk patients deemed ineligible for CABG. Patients turned down by a CTS had worse clinical outcomes than those who declined surgery. The underestimation of 30-day mortality by the STS risk score suggests the need for improved risk prediction models in this high-risk cohort.
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Falah et al. (2025) conducted an observational in Complex coronary artery disease requiring high-risk PCI (n=791). Surgical turndown (deemed ineligible for CABG by a cardiothoracic surgeon) vs. Patient declination of CABG surgery was evaluated on 90-day major adverse cardiovascular and cerebrovascular events (MACCE) (p=.02). Patients deemed ineligible for CABG by a cardiothoracic surgeon who underwent Impella-supported high-risk PCI had significantly higher 90-day MACCE rates compared to those who declined surgery (14.1% vs 4.6%, p=0.02).
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