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Left ventricular dysfunction (LVD) is associated with increased risk of adverse clinical events after percutaneous coronary intervention (PCI). Severe coronary artery calcification (CAC) increases the complexity and risk of PCI. Orbital atherectomy (OAS) is effective in plaque modification with CAC, however its safety and efficacy in patients with LVD are unknown. We evaluated the angiographic and clinical outcomes in patients with severe CAC and LVD who underwent OAS.
438 consecutive patients undergoing OAS at 3 centers from 2013- 2016, were identified, 69 of whom had EF ≤ 40%. The primary safety endpoint was the incidence of angiographic procedural complications including dissection, perforation and no reflow. The secondary endpoint was the rate of major adverse cardiac and cerebrovascular events (MACCE) at 30 days.
The primary safety end point showed no significant differences between patients with preserved vs. reduced systolic function with dissections (0.9% vs. 1.6 %, p=0.51), perforation (0.3% vs. 3.2%., p=0.07) or no reflow (0.3% v. 3.2%, p=0.07). The composite rate of 30-day MACCE and individual end points of death, and MI, were significantly higher in patients with reduced systolic function. The rates of TVR, stroke, and stent thrombosis were low in both groups and did not differ.
|30-day Clinical Event Rates||EF>40% (n=369)||EF<40% (n=69)||p-value|
|Major adverse cardiac and cerebrovascular events||4(1.1)||6 (8.7)||0.002|
|Death||1 (0.3)||5 (7.2)||<0.001|
|Myocardial infarction||2 (0.5)||3 (4.3)||0.03|
|Target vessel revascularization||0 (0)||0 (0)||1|
|Stroke||1 (0.3)||0 (0)||>0.9|
|Stent thrombosis||3 (0.8)||1 (1.4)||0.50|
|Emergent coronary artery bypass grafting||3 (0.8)||0 (0)||>0.9|
Plaque modification with OAS was well tolerated in patients with systolic dysfunction and CAC. However, patients with LVD had higher 30-day all cause mortality and MI outcomes compared with patients with preserved left ventricular function. This demonstrates a need for further investigation into the optimal approach in these high risk patients with CAC.