Acute coronary syndrome in patients with prior coronary artery bypass grafting. Literature review

Invasive management of patients with ST- segment elevation acute coronary syndrome (ST-ACS) and non-ST-elevation acute coronary syndrome (NSTE-ACS) is a priority and reflected in the current guidelines for management of this category of patients with a high evidence level (class I, level of evidence A). One of the limitations in invasive strategy is prior coronary artery bypass grafting in patients with multivessel artery coronary disease. This analytical review reflects modern ideas about the features of diagnosis and management of patients with acute coronary syndrome and previous coronary artery bypass surgery, approaches to revascularization from the standpoint of efficiency and safety

МЕДИКАМЕНТОЗНОЕ СОПРОВОЖДЕНИЕ ЧРЕСКОЖНЫХ КОРОНАРНЫХ ВМЕШАТЕЛЬСТВ С ИСПОЛЬЗОВАНИЕМ БИВАЛИРУДИНА: ОБЗОР СОВРЕМЕННЫХ РЕКОМЕНДАЦИЙ

Purpose. The purpose of this article was a review of contemporary international guidelines for the analysis of the evidence base for bivalirudin use as a medical support of percutaneous coronary intervention (PCI) in patients with different forms of coronary artery disease.Materials and methods. Based on a review of European and American guidelines for management and revascularization in patients with different forms of coronary artery disease of 2013, 2014 and 2015, the evidence base of bivalirudin use as a medical support for PCI in patients with different forms of coronary artery disease was analyzed.Results. The current evidence base for anticoagulant PCI support in patients with different forms of coronary artery disease means choosing safe and effective anticoagulant accordance to the profiles of ischemic and hemorrhagic risk. The direct thrombin inhibitor bivalirudin has a short half-life, predictable anticoagulant profile and has indications for use it in any form of coronary artery disease (Stable coronary artery disease, Non-STEMI and STEMI), based on a large number of randomized clinical trials.Conclusions. There is no doubt that bivalirudin for patients with stable coronary artery disease and heparin-induced thrombocytopenia and for a cohort of patients with a high risk of bleeding complications has benefits and efficacy. Bivalirudin as the anticoagulant support for PCI in non-STEMI patients has the highest class and level of evidence. Class and level of evidence for the use of bivalirudin as PCI support in STEMI patients in 2014 decreased to class IIa, level A however increased risk of acute stent thrombosis associated with the bivalirudin using in this group of patients does not lead to an increased risk of death compared with unfractionated heparin.Цель. Обзор современных международных рекомендаций для анализа доказательной базы применения бивалирудина в качестве медикаментозного сопровождения чрескожных коронарных вмешательств (ЧКВ) у пациентов с различными формами ИБС.Материалы и методы. На основании обзора рекомендаций Европейского общества кардиологов по реваскуляризации миокарда от 2014 г., Американского кардиологического колледжа по лечению пациентов с инфарктом миокарда с элевацией сегмента ST (ИМпST) от 2013 г., Европейского общества кардиологов по реваскуляризации миокарда у пациентов с острым коронарным синдромом без подъема сегмента ST (ОКСбпST) от 2015 г. выполнен анализ доказательной базы применения бивалирудина в качестве медикаментозного сопровождения ЧКВ у пациентов с различными формами ИБС.Результаты. Существующая доказательная база антикоагулянтного сопровождения ЧКВ у пациентов с различными формами ИБС подразумевает выбор безопасного и эффективного препарата в соответствии с профилями ишемического и геморрагического риска. Прямой ингибитор тромбина бивалирудин обладает коротким периодом полувыведения, предсказуемым антикоагулянтным профилем и имеет показания к применению для обеспечения ЧКВ при любой форме ИБС (стабильной, ОКСбпST и ОКСпST), основанные на большом количестве рандомизированных клинических исследований.Заключение. Не вызывает сомнений польза и эффективность бивалирудина у пациентов со стабильной ИБС и гепарининдуцированной тромбоцитопенией (ГИТ), также целесообразно его использование в когорте пациентов с высоким риском геморрагических осложнений. При ОКСбпST применение бивалирудина в качестве антикоагулянтного сопровождения ЧКВ имеет наивысший класс рекомендаций и уровень доказательной базы 1А. Класс и уровень доказательности для применения бивалирудина в качестве сопровождения первичного ЧКВ у пациентов с ОКСпST к 2014 г. уменьшился до класса IIa, уровня А и уступает НФГ, имеющему I класс рекомендаций, тем не менее повышение риска острого тромбоза стента, ассоциированное с назначением бивалирудина в данной группе пациентов, не приводит к возрастанию риска смерти по сравнению с НФГ. Действующие Европейские рекомендации по лечению пациентов с ОКСбпST и ОКСпST предписывают продление инфузии бивалирудина до четырех часов после окончания ЧКВ

Impact of the COVID-19 Pandemic on Myocardial Revascularization in Patients with Acute Coronary Syndrome in the Russian Federation

Aim. To compare and analyze the results of myocardial revascularization in the Russian Federation (RF) with acute coronary syndrome (ACS) before the onset (2018-2019) and during the novel coronavirus infection (COVID-19) pandemic (2020-2021).Material and methods. The analysis included the number of cases of ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), the number of cases of myocardial revascularization in the above forms of ACS, the number of deaths depending on the form of ACS and the method performed revascularization. The period of time before the start of the coronavirus pandemic corresponded to the annual data received in the Russian Federation for 2018-2019. The period of the coronavirus disease pandemic corresponded to the annual data received in the country for 2020-2021. Absolute, relative, estimated values of patient hospitalization, myocardial revascularization procedures, and mortality in ACS were compared between time periods before and during the COVID-19 pandemic. The data for analysis were obtained from the monitoring of the Ministry of Health of Russia.Results. In 2018 and 2019 in the RF, 531,019 and 501,238 patients were hospitalized with a diagnosis of ACS, and during the pandemic (2020-2021) - 403,931 and 397,930 patients, respectively. Reduction in the number of patients diagnosed with ACS admitted to hospitals in Russia by 22.32% in 2020-2021 years was mainly due to a significant decrease in hospitalizations of patients with a diagnosis of NSTE-ACS (by 29.03%). At the same time, admission to clinics of patients with STEMI decreased only by 6.02%. During the COVID-19 pandemic, mortality increased significantly in PPCI (by 9.6%) and in the general STEMI group (by 12.3%); significantly increased mortality both in the general group (by 48%) and during PCI in patients with NSTE-ACS (by 28.6%); there was an increase in the average annual number of PPCI (by 12.6%), which was accompanied by an increased average annual number of PPCI per 1 million of population (up to 451 per 1 million of population); a slight increase in the average time "symptom-balloon" (by 2 minutes) was recorded; there was an absolute slight decrease and a relative increase in the number of PCIs in NSTE-ACS (by 2.7% and 37.1%, respectively). In 2021, in the Russian Federation, primary PCI was performed in 50.2%, thrombolytic therapy - in 23.1%, and 26.7% of patients remained without reperfusion. Pharmacoinphasive strategy was applied in 60%, and isolated thrombolysis - in 40% of patients.Conclusion. During the COVID-19 pandemic, revascularization in patients with ACS in Russia corresponded to the following trends recorded in the literature: increased hospital mortality in PPCI and in the general STEMI group; hospital mortality both in the general group and during PCI in patients with NSTE-ACS. The indicators of myocardial revascularization in ACS in the RF during the pandemic were fundamentally different from the data of Western countries: there was an increase in the average annual number of PPCI and the average annual number of PPCI per 1 million population; a slight increase in the average symptom-balloon time was recorded; revealed an absolute slight decrease and a relative increase in the number of PCIs in NSTE-ACS

ОПРЕДЕЛЕНИЕ ОПТИМАЛЬНОЙ СТРАТЕГИИ РЕВАСКУЛЯРИЗАЦИИ У БОЛЬНЫХ С ИНФАРКТОМ МИОКАРДА С ЭЛЕВАЦИЕЙ СЕГМЕНТА ST ПРИ МНОГОСОСУДИСТОМ ПОРАЖЕНИИ КОРОНАРНОГО РУСЛА ПРИ ПОМОЩИ ИНТЕРАКТИВНОГО КАЛЬКУЛЯТОРА

Purpose. The purpose of this study was to create a model and interactive calculator for a differentiated choice of revascularization strategy in patients with ST-elevation myocardial infarction (STEMI) and coronary artery multivessel disease (MVD).Material and methods. The study included 327 patients with STEMI and MVD undergoing primary percutaneous coronary intervention (PCI). Patients were divided into two groups: 1) Multivessel stenting (MS) (n=91); 2) Staged PCI (SP) (n=236). Study endpoints over 12 months were significant adverse cardiovascular events. Relative frequency of occurrence of an adverse outcome was evaluated and prognostic value for each of 12 demographic, clinical and angiographic factor was calculated for each revascularization strategy.Results. The negative predictive value for adverse outcome in patients undergoing MS strategy had the following factors: myocardial infarction in past; severe coronary atherosclerosis (SYNTAX Score≥23); Age ≥65 years; female. Negative predictive value for SP strategy had the following factors: stroke in past; myocardial infarction in past; polyvascular atherosclerosis; three-vessel coronary artery disease; using of bare metal stents. The main result of this study was creation of interactive calculator for determine the optimal revascularization strategy for STEMI patients with MVD.Conclusion. Using the developed model of differentiated choice of the optimal revascularization strategy and created calculator can improve treatment outcomes for STEMI patients with MVD.Цель. Целью настоящего исследования являлось создание модели дифференцированного выбора стратегии реваскуляризации у больных с инфарктом миокарда с подъемом сегмента ST (ИМпST) и многососудистым поражением (МП) коронарного русла и создание интерактивного калькулятора.Материалы и методы. В исследование было включено 327 пациентов с ИМпST и МП коронарного русла, подвергающихся первичному чрескожному коронарному вмешательству (ЧКВ). Больные были распределены в две группы: 1) многососудистое стентирование (МС) в рамках первичного ЧКВ (n=91); 2) поэтапная реваскуляризация (ПР) (n=236). Конечными точками исследования на протяжении 12 месяцев наблюдения были значимые неблагоприятные кардиоваскулярные события. Внутри каждой группы была оценена относительная частота наступления неблагоприятного исхода и рассчитан прогностический коэффициент, позволяющий определить значимость каждого учитываемого клинико-демографического и ангиографического показателя в развитии неблагоприятного исхода.Результаты. Наибольшей негативной прогностической значимостью для неблагоприятного исхода у пациентов, подвергающихся стратегии МС в рамках первичного ЧКВ, обладали следующие факторы: наличие постинфактного кардиосклероза (ПИКС); тяжелый коронарный атеросклероз (SYNTAX≥23 балла); пожилой возраст (≥65 лет); женский пол. В отношении же ПР отмечены наличие в анамнезе инсульта; ПИКС; мультифокальный атеросклероз; трехсосудистое поражение коронарного русла и применение стентов без лекарственного покрытия. Основным результатом настоящего исследования стало создание интерактивного калькулятора, при помощи которого становится возможным определять оптимальную стратегию реваскуляризации для пациентов с ИМпST и МП. Приводятся примеры использования калькулятора.Заключение. Учет комплекса клинико-демографических и анатомо-ангиографических факторов при помощи разработанного калькулятора может способствовать улучшению результатов лечения при ИМпST посредством определения оптимальной стратегии реваскуляризации

ИНТЕРВЕНЦИОННАЯ КАРДИОЛОГИЯ – НОВОСТИ, СОБЫТИЯ И ТЕНДЕНЦИИ (по материалам on-line издания Cardiac Interventions Today)

In the review of publications in the «Cardiac Interventions Today» on-line edition (2015; Vol. 9) have been discussed such topical issues in interventional cardiology as treatment of acute myocardial infarction complicated by cardiogenic shock and the strategy of antiplatelet therapy after percutaneous coronary intervention.В обзоре материалов, опубликованных в on-line издании «Cardiac Interventions Today» за 2015 год (Vol. 9), рассматриваются такие актуальные вопросы интервенционной кардиологии, как оказание помощи при остром инфаркте миокарда, осложненном кардиогенным шоком, и стратегия антитромбоцитарной терапии после чрескожного коронарного вмешательства

What is changing in the treatment of acute coronary syndrome in the Russian Federation?

The work of the national network of vascular centers of the Russian Federation (RF), based on the Clinical recommendations of the Russian Society of Cardiology and the procedure for providing medical care to patients with cardiovascular diseases, has led to significant positive results in the treatment of patients with acute coronary syndrome (ACS) in the country, although a number of targets have not yet been reached. The purpose of the publication is to demonstrate the trend in therapeutic approaches to the management of patients with ACS in 2020-2022. in Russia and analysis of their effectiveness. Quantitative and qualitative indicators of the treatment of patients with ACS for the presented analysis were obtained on the basis of monitoring data from the Russian Ministry of Health for 2018-2021. presented: Monitoring of measures to reduce mortality from coronary heart disease, letters of the Ministry of Health of Russia dated March 13, 2015 No. 17-6 / 10 / 1-177 and dated July 24, 2015 No. 17-9 / 10 / 2-4128, within which data collection carried out monthly, on the portal of the Federal State Budgetary Institution "TsNIIOIZ" of the Ministry of Health of Russia - Automated system for monitoring medical statistics and the register REGION-IM (Russian Register of Acute Myocardial Infarction) - a multicenter prospective observational cohort study for 2020-2022, organized by the Federal State Budgetary Institution "National Medical Research Center of Cardiology named after Academician E.I. Chazov" of the Ministry of Health of Russia. In Russia with a diagnosis of ACS in 2020 and 2021 403,931 and 397,930 patients were hospitalized, respectively. The decrease in the number of patients diagnosed with ACS admitted to Russian hospitals by 22.32% was mainly due to a significant decrease in hospital admissions of patients diagnosed with non-ST elevation ACS (non-STE-ACS) (by 29.03%). At the same time, the admission of patients with ST elevation myocardial infarction (STEMI) decreased only by 6.02%. Compared to 2018-2019, in 2020-2022. increased mortality in primary percutaneous coronary intervention (PCI) (by 9.6%) and in the general STEMI group (by 12.3%); significantly increased mortality both in the general group of NSTE-ACS (by 48%) and during PCI for patients with non-STE-ACS (by 28.6%); there was an increase in the average annual number of primary PCI (by 12.6%); an absolute and relative increase in the number of PCI in non-STE-ACS was revealed (by 2.7 and 37.1%, respectively). In the country's hospitals, by the time of discharge, 95% of patients receive statins, beta-blockers – 87%, ACE inhibitors – 80%, acetylsalicylic acid – 82%, P2Y12 inhibitors – 98% of patients, regardless of the type of ACS. In Russia in 2020-2022 unfavorable tendencies in the provision of care to patients with ACS include: increased mortality in primary PCI and in the general STEMI group; increased mortality both in the general group of non-STE-ACS and during PCI for patients with non-STE-ACS. The positive results of the work of the national network of vascular centers include: absolute, relative and estimated increase in the number of primary PCI; absolute and relative increase in the number of PCI in non-STE-ACS; a high level of prescribing drugs with a proven positive effect on the prognosis

Рандомизированное исследование превентивной реваскуляризации нестабильных бляшек коронарных артерий у больных хронической ишемической болезнью сердца

Background. Today, a number of unresolved issues remain regarding vulnerable coronary plaques, one of which is the need for preventive revascularization.Aim. Evaluation of the appropriateness of preventive revascularization of functionally insignificant lesions of the coronary arteries with signs of vulnerability according to the virtual histology of intravascular ultrasound in patients with stable coronary artery disease.Methods. The prospective randomized study includes patients with stable coronary artery disease and isolated intermediate-grade coronary stenosis. The first step in patients is measured fractional flow reserve to confirm the hemodynamic insignificance of stenosis. Then an intravascular ultrasound is performed to verify signs of plaque vulnerability: a thin-cap fibroatheroma and / or minimum lumen area <4 mm2 and/or plaque burden >70%. After that, patients are randomized into two groups: preventive revascularization or optimal medical therapy. After 12 months, patients undergo repeated intravascular ultrasound and end-point analysis.Results. So far, 10 patients have been included in the study (6 in the preventive revascularization group and 4 in the optimal medical therapy group). No endpoints and complications were recorded in both groups in 30-days follow-up.Conclusion. Intravascular imaging methods can identify vulnerable coronary plaques, which allows you to use a personalized approach in determining treatment tactics, one of which can be preventive revascularization.Актуальность. На сегодняшний день остается ряд нерешенных вопросов касательно нестабильных коронарных бляшек, одним из которых является необходимости их превентивной реваскуляризации.Цель. Оценка целесообразности превентивной реваскуляризации гемодинамически незначимых поражений коронарных артерий с признаками нестабильности по данным виртуальной гистологии внутрисосудистого ультразвука у больных хронической ишемической болезнью сердца.Материалы и методы. Исследование носит проспективный рандомизированный характер с включением пациентов с изолированным пограничным поражением коронарного русла. Первым этапом пациентам измеряется фракционный резерв кровотока для подтверждения функциональной незначимости стеноза. Затем выполняется внутрисосудистое ультразвуковое исследование для верификации признаков нестабильности бляшки: тонкокапсульная фиброатерома и/или минимальная площадь просвета <4 мм2 и/или площадь бляшки >70%. После этого пациенты рандомизируются в две группы: превентивной реваскуляризации или оптимальной медикаментозной терапии. Через 12 месяцев пациентам выполняется повторное внутрисосудистое ультразвуковое исследование и анализ конечных точек.Результаты. Пока в исследование включено 10 пациентов (6 в группе реваскуляризации и 4 в группе оптимальной медикаментозной терапии). За 30-дневный период наблюдения в обеих группах исследования конечных точек и осложнений не зарегистрировано.Заключение. Внутрисосудистые методы визуализации позволяют выявить нестабильные коронарные бляшки, что позволяет использовать персонифицированный подход в определении тактики лечения, одной из опций которой может стать превентивная реваскуляризация

ПРОГНОСТИЧЕСКАЯ РОЛЬ ИСХОДНОЙ И РЕЗИДУАЛЬНОЙ ВЫРАЖЕННОСТИ КОРОНАРНОГО АТЕРОСКЛЕРОЗА У ПАЦИЕНТОВ С ИНФАРКТОМ МИОКАРДА ПОСЛЕ ПЕРВИЧНОГО ЧРЕСКОЖНОГО КОРОНАРНОГО ВМЕШАТЕЛЬСТВА

The aim of this study was to investigate the prognostic role of initial and residual severity of coronary atherosclerosis by SYNTAX SCORE among ST segment elevation myocardial infarction patients (STEMI) undergoing primary percutaneous coronary intervention (PCI).Materials and methods. The study included 327 STEMI patients with multivessel coronary atherosclerosis who underwent primary PCI. Two groups were formed to study the prognostic value of initial coronary atherosclerosis severity: SYNTAX ≤22 points (n=213) and SYNTAX ≥23 points (n=114). 317 patients included in the second sub-analysis (the study of the prognostic role of residual severity of coronary atherosclerosis). The patients were divided into two groups, depending on the residual SYNTAX SCORE after primary PCI: ≤8 points (n=243) and ≥9 points (n=74). The endpoints of the study were adverse cardiovascular events over 12 months.Results. The initial value of SYNTAX ≥23 points led to a significant increase in the rate of death, myocardial infarction (MI) and stent thrombosis (ST) as well as the combined endpoint. The most significant adverse events during the 12 months of observation, associated with the severity of coronary lesions on the SYNTAX ≥23 are: 1) death from any cause – OR 4.9 (95 % CI, p=0.004); 2) cardiac death – OR 5.6 (95 % CI, p=0.004); 3) MI – OR 3.5 (95 % CI, p=0.01); 4) The combined endpoint – OR 2.4 (95 % CI, p=0.05); 5) ST – 5 OR (95 % CI, p=0.007). The group of residual SYNTAX ≥9 in comparison with the group SYNTAX ≤8 characterized by less favorable prognosis, which was reflected in a higher frequency of death from all causes – 13.5 % vs. 2.9 % (p=0.001), OR 3.4 (1,5–7,9 95 % CI) (p=0.004), MI – 10.8 % versus 4.1 % (p=0.05), OR 2.7 (1.2–6.1; 95 % CI) (p=0.01), non-target vessel revascularization – 9.5 % versus 2.5 % (p=0.02), OR 2.6 (1.2–5.5; 95 % CI) (p=0.01). Conclusions. It was demonstrated the high predictive value of initial and residual severity of coronary lesions by SYNTAX SCORE to influence the risk of adverse cardiovascular events in patients undergoing primary PCI. The results obtained may find application in the development of predictive models aimed at determining the optimal strategies revascularization for patients with STEMI in multiple coronary atherosclerosis.Цель. Изучить прогностическую роль исходной и резидуальной выраженности коронарного атеросклероза по шкале SYNTAX среди пациентов с инфарктом миокарда и элевацией сегмента ST (ИМпST), подвергшихся первичным чрескожным коронарным вмешательствам (ЧКВ).Материалы и методы. В исследование включено 327 пациентов с ИМпST, имеющих многососудистый коронарный атеросклероз, которым выполнялось первичное ЧКВ. Для изучения прогностической значимости исходной выраженности коронарного атеросклероза были сформированы две группы: SYNTAX ≤22 баллам (n=213) и SYNTAX ≥23 баллам (n=114). Во второй субанализ (изучение прогностической роли резидуальной выраженности коронарного атеросклероза) вошло 317 пациентов. Больные были разделены на две группы в зависимости от остаточной после первичного ЧКВ тяжести поражения коронарного русла по шкале SYNTAX: ≤8 баллам (n=243) и ≥9 баллам (n=74). На протяжении 12 месяцев производился учет неблагоприятных кардиоваскулярных событий.Результаты. Исходное значение показателя SYNTAX ≥23 баллам приводило к значимому возрастанию частоты смерти, инфаркта миокарда (ИМ) и тромбоза стента (ТС), равно как и комбинированной конечной точки. Наиболее значимыми неблагоприятными событиями на протяжении 12 месяцев наблюдения, ассоциированными с тяжестью поражения коронарного русла по шкале SYNTAX ≥23 баллам, стали: 1) смерть от любой причины – ОШ 4,9 (95 % ДИ, р=0,004); 2) кардиальная смерть – ОШ 5,6 (95 % ДИ, р=0,004); 3) ИМ – ОШ 3,5 (95 % ДИ, р=0,01); 4) комбинированная конечная точка – ОШ 2,4 (95 % ДИ, р=0,05); 5) ТС – ОШ 5 (95 % ДИ, р=0,007). Группа резидуального SYNTAX ≥9 баллам в сравнении с группой SYNTAX ≤8 баллам характеризовалась менее благоприятным прогнозом, что выражалось в большей частоте смерти от всех причин – 13,5 % против 2,9 % (р=0,001), отношение шансов (ОШ) 3,4 (1,5–7,9; 95 % ДИ), (р=0,004), повторного ИМ – 10,8 % против 4,1 % (р=0,05), ОШ 2,7 (1,2–6,1; 95 % ДИ), (р=0,01), повторной реваскуляризации нецелевых сосудов – 9,5 % против 2,5 % (р=0,02), ОШ 2,6 (1,2–5,5; 95 % ДИ), (р=0,01).Заключение. Таким образом, была показана высокая прогностическая ценность исходной и резидуальной тяжести поражения коронарного русла по шкале SYNTAX по влиянию на риск неблагоприятных кардиоваскулярных событий у пациентов после первичного ЧКВ. Полученные результаты могут найти свое применение при разработке прогностических моделей, направленных на определение оптимальных стратегий реваскуляризации миокарда для пациентов с ИМпST при множественном коронарном атеросклерозе

IN-HOSPITAL AND LONG TERM RESULTS OF PERCUTANEOUS CORONARY INTERVENTION WITH BIVENTRICULAR SUPPORT AND EXTRACORPOREAL MEMBRANE OXYGENATION

Patients, due to various reasons not indicated for coronary bypass (CABG), usually have extremely high risk of complications in percutaneous intervention (PCI) as well. Recently it was shown that extracorporeal membrane oxygenation (ECMO) might provide a necessary support in the case of high risk PCI. ECMO can be effective in PCI in patients with refractory cardiogenic shock too, however evidence base for the technological approach in high risk PCI remains underdeveloped.Aim. To evaluate in-hospital and long-term results of high risk PCI with biventricular bypass and ECMO in patients not fitted for CABG.Material and methods. We conducted a retrospective analysis of the treatment of 12 patients having extremely high risk of complications in CABG. In all cases PCI was done in conditions of biventricular bypass and ECMO. Stable angina and non-STelevation acute coronary syndrome occurred in 42 and 58% cases, respectively. Clinical picture of cardiogenic shock was the criteria of exclusion. All patients had severe comorbidity with high score by “EuroScore” — 6,3±4,9%. In all cases there was multivessel disease with high level of coronary lesion involvement by “Syntax Score” (30,1±10,1). Mean level of left ventricle ejection fraction was satisfactory — 51±12,6%. Ten patients (83%) had significant (≥50 %) lesion of unprotected stem of the left coronary artery (SLCA).Results. All procedures were successful. As a success of PCI we meant the opened artery with the flow rate not worse than TIMI 3 and absent of significant cardiovascular complications. Mean quantity of the implanted drug-eluting stents was 2,4±1. Full revascularization was reached in 42% cases. Residual value of “Syntax Score” was at the level about 6,33±6,88. Significant adverse cardiovascular complications (death, myocardial infarction, repeated non-planned revascularization) during inhospital phase were not registered. In one case there was an iliac artery dissection, that did not lead to necessity of surgery. Hemorrhagic complications were found just in one patients (8%, 2nd type by “BARC”). All patients were discharged. There were no any fatal cases or myocardial infarction (MI) in 6 months after observation. Two patients required another revascularization (17%). In long-term period there were no and signs of “definite” or “probable” stent thrombosis.Conclusion. PCI in the conditions of biventricular bypass and ECMO might be effective alternative strategy of revascularization in a cohort of patients not indicated for CABG due to high complications risk

Impact of Smoking Status on Mortality in STEMI Patients Undergoing Mechanical Reperfusion for STEMI: Insights from the ISACS-STEMI COVID-19 Registry

The so-called \"smoking paradox\", conditioning lower mortality in smokers among STEMI patients, has seldom been addressed in the settings of modern primary PCI protocols. The ISACS-STEMI COVID-19 is a large-scale retrospective multicenter registry addressing in-hospital mortality, reperfusion, and 30-day mortality among primary PCI patients in the era of the COVID-19 pandemic. Among the 16,083 STEMI patients, 6819 (42.3%) patients were active smokers, 2099 (13.1%) previous smokers, and 7165 (44.6%) non-smokers. Despite the impaired preprocedural recanalization (p < 0.001), active smokers had a significantly better postprocedural TIMI flow compared with non-smokers (p < 0.001); this was confirmed after adjustment for all baseline and procedural confounders, and the propensity score. Active smokers had a significantly lower in-hospital (p < 0.001) and 30-day (p < 0.001) mortality compared with non-smokers and previous smokers; this was confirmed after adjustment for all baseline and procedural confounders, and the propensity score. In conclusion, in our population, active smoking was significantly associated with improved epicardial recanalization and lower in-hospital and 30-day mortality compared with previous and non-smoking history