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Validation of the SYNTAX Revascularization Index to Quantify Reasonable Level of Incomplete Revascularization After Percutaneous Coronary Intervention

      Incomplete revascularization is common after percutaneous coronary intervention (PCI). Whether a “reasonable” degree of incomplete revascularization is associated with a similar favorable long-term prognosis compared with complete revascularization remains unknown. We sought to quantify the proportion of coronary artery disease burden treated by PCI and evaluate its impact on outcomes using a new prognostic instrument—the Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) Revascularization Index (SRI). The baseline SYNTAX score (bSS), the residual SYNTAX score, and the delta SYNTAX score (ΔSS) were determined from 888 angiograms of patients enrolled in the prospective SYNTAX trial. The SRI was then calculated for each patient using the following formula: SRI = (ΔSS/bSS]) × 100. Outcomes were examined according to the proportion of revascularized myocardium (SRI = 100% [complete revascularization], 50% to <100%, and <50%). The Youden index for the SRI was computed to identify the best cutoff for 5-year all-cause mortality. The mean bSS was 28.4 ± 11.5, and after PCI, the mean ΔSS was 23.8 ± 10.9 and the mean residual SYNTAX score was 4.5 ± 6.9. The mean SRI was 85.3 ± 21.2% and was 100% in 385 patients (43.5%), <100% to 50% in 454 patients (51.1%), and <50% in 48 patients (5.4%). Five-year adverse outcomes, including death, were inversely proportional to the SRI. An SRI cutoff of <70% (present in 142 patients [16.0%] after PCI) had the best prognostic accuracy for prediction of death and, by multivariable analysis, was an independent predictor of 5-year mortality (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.79 to 6.11, p <0.0001). In conclusion, the SRI is a newly described method for quantifying the proportion of coronary artery disease burden treated by PCI. The SRI is a useful tool in assessing the degree of revascularization after PCI, with SRI ≥70% representing a “reasonable” goal for patients with complex coronary artery disease.
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      References

        • Sianos G.
        • Morel M.A.
        • Kappetein A.P.
        • Morice M.C.
        • Colombo A.
        • Dawkins K.
        • van den Brand M.
        • Van Dyck N.
        • Russell M.E.
        • Mohr F.W.
        • Serruys P.W.
        The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease.
        EuroIntervention. 2005; 1: 219-227
        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • Colombo A.
        • Holmes D.R.
        • Mack M.J.
        • Stahle E.
        • Feldman T.E.
        • van den Brand M.
        • Bass E.J.
        • Van Dyck N.
        • Leadley K.
        • Dawkins K.D.
        • Mohr F.W.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        • Capodanno D.
        • Capranzano P.
        • Di Salvo M.E.
        • Caggegi A.
        • Tomasello D.
        • Cincotta G.
        • Miano M.
        • Patane M.
        • Tamburino C.
        • Tolaro S.
        • Patane L.
        • Calafiore A.M.
        • Tamburino C.
        Usefulness of SYNTAX score to select patients with left main coronary artery disease to be treated with coronary artery bypass graft.
        JACC Cardiovasc Interv. 2009; 2: 731-738
        • Palmerini T.
        • Genereux P.
        • Caixeta A.
        • Cristea E.
        • Lansky A.
        • Mehran R.
        • Dangas G.
        • Lazar D.
        • Sanchez R.
        • Fahy M.
        • Xu K.
        • Stone G.W.
        Prognostic value of the SYNTAX score in patients with acute coronary syndromes undergoing percutaneous coronary intervention: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) trial.
        J Am Coll Cardiol. 2011; 57: 2389-2397
        • Yadav M.
        • Palmerini T.
        • Caixeta A.
        • Madhavan M.V.
        • Sanidas E.
        • Kirtane A.J.
        • Stone G.W.
        • Genereux P.
        Prediction of coronary risk by SYNTAX and derived scores: synergy between percutaneous coronary intervention with taxus and cardiac surgery.
        J Am Coll Cardiol. 2013; 62: 1219-1230
        • Genereux P.
        • Palmerini T.
        • Caixeta A.
        • Rosner G.
        • Green P.
        • Dressler O.
        • Xu K.
        • Parise H.
        • Mehran R.
        • Serruys P.W.
        • Stone G.W.
        Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score.
        J Am Coll Cardiol. 2012; 59: 2165-2174
        • Farooq V.
        • Serruys P.W.
        • Bourantas C.V.
        • Zhang Y.
        • Muramatsu T.
        • Feldman T.
        • Holmes D.R.
        • Mack M.
        • Morice M.C.
        • Stahle E.
        • Colombo A.
        • de Vries T.
        • Morel M.A.
        • Dawkins K.D.
        • Kappetein A.P.
        • Mohr F.W.
        Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score.
        Circulation. 2013; 128: 141-151
        • Capodanno D.
        • Chisari A.
        • Giacoppo D.
        • Bonura S.
        • Lavanco V.
        • Capranzano P.
        • Caggegi A.
        • Ministeri M.
        • Tamburino C.
        Objectifying the impact of incomplete revascularization by repeat angiographic risk assessment with the residual SYNTAX score after left main coronary artery percutaneous coronary intervention.
        Catheter Cardiovasc Interv. 2013; 82: 333-340
        • Genereux P.
        • Campos C.M.
        • Yadav M.
        • Palmerini T.
        • Caixeta A.
        • Xu K.
        • Francese D.P.
        • Dangas G.D.
        • Mehran R.
        • Leon M.B.
        • Serruys P.W.
        • Stone G.W.
        Reasonable incomplete revascularisation after percutaneous coronary intervention: the SYNTAX Revascularisation Index.
        EuroIntervention. 2014; ([Epub ahead of print])
        • Mohr F.W.
        • Morice M.C.
        • Kappetein A.P.
        • Feldman T.E.
        • Stahle E.
        • Colombo A.
        • Mack M.J.
        • Holmes Jr., D.R.
        • Morel M.A.
        • Van Dyck N.
        • Houle V.M.
        • Dawkins K.D.
        • Serruys P.W.
        Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
        Lancet. 2013; 381: 629-638
        • Serruys P.W.
        • Onuma Y.
        • Garg S.
        • Sarno G.
        • van den Brand M.
        • Kappetein A.P.
        • Van Dyck N.
        • Mack M.
        • Holmes D.
        • Feldman T.
        • Morice M.C.
        • Colombo A.
        • Bass E.
        • Leadley K.
        • Dawkins K.D.
        • van Es G.A.
        • Morel M.A.
        • Mohr F.W.
        Assessment of the SYNTAX score in the Syntax study.
        EuroIntervention. 2009; 5: 50-56
        • Genereux P.
        • Palmerini T.
        • Caixeta A.
        • Cristea E.
        • Mehran R.
        • Sanchez R.
        • Lazar D.
        • Jankovic I.
        • Corral M.D.
        • Dressler O.
        • Fahy M.P.
        • Parise H.
        • Lansky A.J.
        • Stone G.W.
        SYNTAX score reproducibility and variability between interventional cardiologists, core laboratory technicians, and quantitative coronary measurements.
        Circ Cardiovasc Interv. 2011; 4: 553-561
        • Cutlip D.E.
        • Windecker S.
        • Mehran R.
        • Boam A.
        • Cohen D.J.
        • van Es G.A.
        • Steg P.G.
        • Morel M.A.
        • Mauri L.
        • Vranckx P.
        • McFadden E.
        • Lansky A.
        • Hamon M.
        • Krucoff M.W.
        • Serruys P.W.
        • Academic Research Consortium
        Clinical end points in coronary stent trials: a case for standardized definitions.
        Circulation. 2007; 115: 2344-2351
        • Ong A.T.
        • Serruys P.W.
        • Mohr F.W.
        • Morice M.C.
        • Kappetein A.P.
        • Holmes Jr., D.R.
        • Mack M.J.
        • van den Brand M.
        • Morel M.A.
        • van Es G.A.
        • Kleijne J.
        • Koglin J.
        • Russell M.E.
        The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase.
        Am Heart J. 2006; 151: 1194-1204
        • Farooq V.
        • Serruys P.W.
        • Bourantas C.
        • Vranckx P.
        • Diletti R.
        • Garcia Garcia H.M.
        • Holmes D.R.
        • Kappetein A.P.
        • Mack M.
        • Feldman T.
        • Morice M.C.
        • Colombo A.
        • Morel M.A.
        • de Vries T.
        • van Es G.A.
        • Steyerberg E.W.
        • Dawkins K.D.
        • Mohr F.W.
        • James S.
        • Stahle E.
        Incidence and multivariable correlates of long-term mortality in patients treated with surgical or percutaneous revascularization in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial.
        Eur Heart J. 2012; 33: 3105-3113
        • Youden W.J.
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • van den Brand M.J.
        • Rensing B.J.
        • Morel M.A.
        • Foley D.P.
        • de Valk V.
        • Breeman A.
        • Suryapranata H.
        • Haalebos M.M.
        • Wijns W.
        • Wellens F.
        • Balcon R.
        • Magee P.
        • Ribeiro E.
        • Buffolo E.
        • Unger F.
        • Serruys P.W.
        The effect of completeness of revascularization on event-free survival at one year in the ARTS trial.
        J Am Coll Cardiol. 2002; 39: 559-564
        • Hannan E.L.
        • Racz M.
        • Holmes D.R.
        • King III, S.B.
        • Walford G.
        • Ambrose J.A.
        • Sharma S.
        • Katz S.
        • Clark L.T.
        • Jones R.H.
        Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era.
        Circulation. 2006; 113: 2406-2412
        • Sarno G.
        • Garg S.
        • Onuma Y.
        • Gutierrez-Chico J.L.
        • van den Brand M.J.
        • Rensing B.J.
        • Morel M.A.
        • Serruys P.W.
        • ARTS-II Investigators
        Impact of completeness of revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft patients (from the ARTS-II study).
        Am J Cardiol. 2010; 106: 1369-1375
        • Farooq V.
        • Serruys P.W.
        • Garcia-Garcia H.M.
        • Zhang Y.
        • Bourantas C.V.
        • Holmes D.R.
        • Mack M.
        • Feldman T.
        • Morice M.C.
        • Stahle E.
        • James S.
        • Colombo A.
        • Diletti R.
        • Papafaklis M.I.
        • de Vries T.
        • Morel M.A.
        • van Es G.A.
        • Mohr F.W.
        • Dawkins K.D.
        • Kappetein A.P.
        • Sianos G.
        • Boersma E.
        The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial.
        J Am Coll Cardiol. 2013; 61: 282-294
        • Garcia S.
        • Sandoval Y.
        • Roukoz H.
        • Adabag S.
        • Canoniero M.
        • Yannopoulos D.
        • Brilakis E.S.
        Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.
        J Am Coll Cardiol. 2013; 62: 1421-1431
        • Head S.J.
        • Mack M.J.
        • Holmes Jr., D.R.
        • Mohr F.W.
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        Incidence, predictors and outcomes of incomplete revascularization after percutaneous coronary intervention and coronary artery bypass grafting: a subgroup analysis of 3-year SYNTAX data.
        Eur J Cardiothorac Surg. 2012; 41: 535-541
        • Rastan A.J.
        • Walther T.
        • Falk V.
        • Kempfert J.
        • Merk D.
        • Lehmann S.
        • Holzhey D.
        • Mohr F.W.
        Does reasonable incomplete surgical revascularization affect early or long-term survival in patients with multivessel coronary artery disease receiving left internal mammary artery bypass to left anterior descending artery?.
        Circulation. 2009; 120: S70-S77
        • Boden W.E.
        • O'Rourke R.A.
        • Teo K.K.
        • Hartigan P.M.
        • Maron D.J.
        • Kostuk W.J.
        • Knudtson M.
        • Dada M.
        • Casperson P.
        • Harris C.L.
        • Chaitman B.R.
        • Shaw L.
        • Gosselin G.
        • Nawaz S.
        • Title L.M.
        • Gau G.
        • Blaustein A.S.
        • Booth D.C.
        • Bates E.R.
        • Spertus J.A.
        • Berman D.S.
        • Mancini G.B.
        • Weintraub W.S.
        • COURAGE Trial Research Group
        Optimal medical therapy with or without PCI for stable coronary disease.
        N Engl J Med. 2007; 356: 1503-1516
        • De Bruyne B.
        • Pijls N.H.
        • Kalesan B.
        • Barbato E.
        • Tonino P.A.
        • Piroth Z.
        • Jagic N.
        • Mobius-Winkler S.
        • Rioufol G.
        • Witt N.
        • Kala P.
        • MacCarthy P.
        • Engstrom T.
        • Oldroyd K.G.
        • Mavromatis K.
        • Manoharan G.
        • Verlee P.
        • Frobert O.
        • Curzen N.
        • Johnson J.B.
        • Juni P.
        • Fearon W.F.
        • FAME 2 Trial Investigators
        Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease.
        N Engl J Med. 2012; 367: 991-1001
        • Nam C.W.
        • Mangiacapra F.
        • Entjes R.
        • Chung I.S.
        • Sels J.W.
        • Tonino P.A.
        • De Bruyne B.
        • Pijls N.H.
        • Fearon W.F.
        • Fame Study Investigators
        Functional SYNTAX score for risk assessment in multivessel coronary artery disease.
        J Am Coll Cardiol. 2011; 58: 1211-1218
        • Mancini G.B.
        • Hartigan P.M.
        • Shaw L.J.
        • Berman D.S.
        • Hayes S.W.
        • Bates E.R.
        • Maron D.J.
        • Teo K.
        • Sedlis S.P.
        • Chaitman B.R.
        • Weintraub W.S.
        • Spertus J.A.
        • Kostuk W.J.
        • Dada M.
        • Booth D.C.
        • Boden W.E.
        Predicting outcome in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation): coronary anatomy versus ischemia.
        JACC Cardiovasc Interv. 2014; 7: 195-201
        • Safley D.M.
        • House J.A.
        • Marso S.P.
        • Grantham J.A.
        • Rutherford B.D.
        Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel.
        JACC Cardiovasc Interv. 2008; 1: 295-302
        • George S.
        • Cockburn J.
        • Clayton T.C.
        • Ludman P.
        • Cotton J.
        • Spratt J.
        • Redwood S.
        • de Belder M.
        • de Belder A.
        • Hill J.
        • Hoye A.
        • Palmer N.
        • Rathore S.
        • Gershlick A.
        • Di Mario C.
        • Hildick-Smith D.
        • British Cardiovascular Intervention Society
        • National Institute for Cardiovascular Outcomes Research
        Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central cardiac audit database.
        J Am Coll Cardiol. 2014; 64: 235-243