Author + information
- Ayaka Endo, MD∗ (, )
- Atsushi Mizuno, MD,
- Shun Kohsaka, MD and
- Kentaro Ejiri, MD
- ↵∗Division of Cardiology, Department of Internal Medicine, Saiseikai Central Hospital, 1-4-7 Mita Minato-ku, Tokyo 108-0073, Japan
We read with great interest the paper by Mylotte et al. (1) in JACC: Cardiovascular Interventions, which reports the efficacy of multivessel primary percutaneous coronary intervention (MV-PCI) and compares it with that of culprit-only PCI in patients with ST-segment elevation myocardial infarction presenting with cardiogenic shock and resuscitated cardiac arrest. The investigators suggested that complete up-front revascularization with MV-PCI has the potential to improve outcomes in critically ill patients. However, a few issues regarding the interpretation of their data come to mind.
The study is limited by an obvious patient selection bias. Because the study was a retrospective analysis of prospectively collected data, all decisions regarding the PCI were solely at the discretion of the treating physician. The lesional and procedural factors such as lesion difficulty (included the infarct-related artery [IRA] and non-IRA), expected procedure time, and operator's skill level have the potential to influence the results. For example, anatomically, the MV-PCI group may have included “PCI-favorable” cases, and this may have led to a better patient outcome compared with that for the culprit-only PCI group. Obviously, the patients with complex “PCI-unfavorable” lesions have a worse prognosis compared with that of patients with simple lesions (2). In the present study, the lesion complexity of the IRA and non-IRA between the 2 groups was not clear. Adjustment with variables that reflect lesion complexity (e.g., the prevalence of type-C or chronic total occlusion lesions) might be helpful (3). Additionally, the differences in the devices that were used for intervention during the more than 10-year period (1998 to 2010) may have affected the outcomes. These differences may have occurred because of various factors, including improvements in guidewire flexibility and the stent delivery system. It may be helpful to determine whether the favorable outcome in the MV-PCI group compared with that in the culprit-only PCI group was consistent during the time of the study. We believe that the clarification of these 2 points would further assist in validating this important study.
- American College of Cardiology Foundation