key: cord-0732143-in4mdxgj
authors: Mohamed, Mohamed O.; Curzen, Nick; de Belder, Mark; Goodwin, Andrew T.; Spratt, James C; Balacumaraswami, Lognathen; Deanfield, John; Martin, Glen P.; Rashid, Muhammad; Shoaib, Ahmad; Gale, Chris P; Kinnaird, Tim; Mamas, Mamas A.
title: Revascularisation strategies in patients with significant left main coronary disease during the COVID‐19 pandemic
date: 2021-03-25
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.29663
sha: 0ee86200f7e85bd53c28f318e8e25537eb321e9e
doc_id: 732143
cord_uid: in4mdxgj

BACKGROUND: There are limited data on the impact of the COVID‐19 pandemic on left main (LM) coronary revascularisation activity, choice of revascularisation strategy, and post‐procedural outcomes. METHODS: All patients with LM disease (≥50% stenosis) undergoing coronary revascularisation in England between January 1, 2017 and August 19, 2020 were included (n = 22,235), stratified by time‐period (pre‐COVID: 01/01/2017–29/2/2020; COVID: 1/3/2020–19/8/2020) and revascularisation strategy (percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). Logistic regression models were performed to examine odds ratio (OR) of 1) receipt of CABG (vs. PCI) and 2) in‐hospital and 30‐day postprocedural mortality, in the COVID‐19 period (vs. pre‐COVID). RESULTS: There was a decline of 1,354 LM revascularisation procedures between March 1, 2020 and July 31, 2020 compared with previous years' (2017–2019) averages (−48.8%). An increased utilization of PCI over CABG was observed in the COVID period (receipt of CABG vs. PCI: OR 0.46 [0.39, 0.53] compared with 2017), consistent across all age groups. No difference in adjusted in‐hospital or 30‐day mortality was observed between pre‐COVID and COVID periods for both PCI (odds ratio (OR): 0.72 [0.51. 1.02] and 0.83 [0.62, 1.11], respectively) and CABG (OR 0.98 [0.45, 2.14] and 1.51 [0.77, 2.98], respectively) groups. CONCLUSION: LM revascularisation activity has significantly declined during the COVID period, with a shift towards PCI as the preferred strategy. Postprocedural mortality within each revascularisation group was similar in the pre‐COVID and COVID periods, reflecting maintenance in quality of outcomes during the pandemic. Future measures are required to safely restore LM revascularisation activity to pre‐COVID levels.

Significant left main (LM) coronary artery disease is a Class 1 indication for revascularisation, given its prognostic importance and the large myocardial territory it supplies. 1 While there have been recent debates about the optimal revascularisation strategy for LM disease, both percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are viewed as acceptable revascularisation strategies, based on patient comorbidities and overall anatomical complexity. [2] [3] [4] [5] [6] [7] [8] The coronavirus pandemic has led to a significant strain on healthcare services, with previous reports demonstrating a substantial reduction in cardiac procedural activity since the start of the pandemic. [9] [10] [11] [12] [13] [14] This is particularly relevant for procedures requiring admission to an intensive care unit (ICU) and prolonged hospitalization (such as CABG surgery), at a time when such resources were prioritized for critically unwell patients with COVID-19. Moreover, patients with cardiac conditions are at a higher risk of COVID-19 related mortality than the general population and, in the United Kingdom, were advised to shield meaning that significant numbers of elective cardiac procedures were canceled. 15, 16 Little is known about the impact these national policy level and excluded CABG patients who received PCI in the preceding 30 days (n = 222) (flow diagram: Figure S1 ). Patients were stratified according to revascularisation modality (CABG surgery and PCI) as well as the period during which the procedure was undertaken (pre-COVID: January 1, 2017-February 29, 2020; COVID: March 1, 2020-August 19, 2020). Procedural risk was assessed using the Logistic EuroSCORE and British Cardiovascular Intervention Society (BCIS) 30-day mortality score for CABG and PCI cases, respectively, using coefficients previously described for both scoring systems. 21,22

The primary outcomes were (a) the receipt of CABG or PCI for significant LM disease and (b) in-hospital and 30-day mortality from the date of the procedure.

We examined rates and patient and procedural characteristics of patients undergoing PCI and CABG, as well as in-hospital and 30-day mortality before and during the COVID pandemic (pre-COVID: January 1, 2017-February 29, 2020; COVID: March 1, 2020-August 19, 2020). Similar comparisons were performed for each calendar

year. The number of PCI and CABG surgery procedures for each of the months January-July were compared between the 2017-2019 average and 2020 to estimate the percentage change (Δ) in procedural activity and, in turn, the projected deficit in cases in 2020 as a result of the pandemic. Data between August 1, 2020 and August 19, 2020 was not used to calculate procedural activity as there may have been a lag between data submission by participating hospitals and availability in the NHS Digital database. Continuous variables were summarized using median and interquartile range (IQR) and compared using the Kruskal-Wallis test. Categorical variables were summarized as percentages and analyzed using the Chi squared (X 2 ) test.

Multiple imputation with chained equations was performed for variables with missing data prior to model fitting, with a total of 10 imputations and model estimates combined using Rubin's rules. 23 The frequency of missing data prior to imputation is provided in Table S1 .

Multivariable logistic regression models were fitted to examine (a) the likelihood of receipt of CABG compared with PCI and (b) associated in-hospital and 30-day mortality in the COVID-19 period (with pre-COVID as reference), adjusting for the variables summarized in Appendix A. We report the association of COVID-19 period with the outcomes using odds ratios (OR) with corresponding 95% confidence intervals (CI). In order to estimate the adjusted probability of death in the CABG and PCI groups in both the pre-COVID and COVID time periods, multivariable logistic regression models were performed with an interaction term between revascularisation strategy (PCI vs. CABG) and time period (pre-COVID vs. COVID), adjusting for the variables in Appendix A, followed by the margins command to generate adjusted probabilities of mortality in each group. Statistical analyses were performed using Stata 16 MP (College Station, TX). and by NHS England, which oversees commissioning decisions in the NHS, and NHS Improvement, which is responsible for overseeing quality of care in NHS hospitals.

A total of 22,235 cases of revascularisation involving significant LM disease were recorded between January 1, 2017 and August 19, 2020, of which 62.9% (n = 13,994) were PCI and 37.1% (n = 8,241) were CABG.

Overall, there was a decline in procedural activity for LM revascularisation during the pandemic, with an estimated total deficit of 1,354 cases between March 1, 2020 and July 31, 2020 compared with previous years' (2017-2019) averages (Δ −48.8%), with the greatest decline observed in July 2020 (Δ-60.6%). (Table S2 ) This was evident in both PCI and CABG groups, with a significant decline in the 7-day rolling average number of procedures beginning at the start of UK-wide lockdown (March 23, 2020). (Figure 1 ).

Pre-COVID, PCI accounted for 61.9% of all left main revascularisation procedures, whereas during the COVID period, this has risen to 77.6%. (Table 1 Table S3 ).

Overall, patients undergoing PCI were older, more frequently male, more likely to be admitted electively and to receive PCI for an ACS indication compared with those undergoing CABG. (Table 1 ) Patients undergoing PCI also had a higher prevalence of left ventricular (LV) impairment (moderate or severely impaired) compared with CABG. However, all these differences were similar in the pre-COVID and COVID time periods (Table 1) , as well as in individual year subgroups of the pre-COVID period (Table S4) 

The unadjusted rates of in-hospital and 30-day mortality were higher in PCI than CABG in the pre-COVID period (6.5% vs. 2.2% and 8.4% vs. 2.5%, respectively) (Table 3) , a pattern that was consistent in individual years of the pre-COVID period (Table S5) . However, only 30-day mortality was higher in PCI than CABG in the COVID period (6.5% vs. 3.0%) with no difference in in-hospital mortality between PCI and CABG (4.4% vs. 2.1%, p = .062). (Table 3) .

After adjustment for baseline patient and procedural characteristics, 30-day mortality was higher for PCI than CABG in the pre- Abbreviations: CABG: coronary artery bypass graft surgery; PCI: percutaneous coronary intervention. Adjusted for the following: age (years), sex, smoking status, diabetes, indication for intervention (ACS vs. CCS), previous MI, PCI and CVA, LV function category (good, moderate or poor); cardiogenic shock pre-procedure, intra-aortic balloon pump; hypertension; peripheral vascular disease; creatinine clearance (ml/min-Cockcroft and Gault formula). In addition, PCI models were adjusted for CTO, type of access (femoral vs. radial), type of stent, and the use of intracoronary imaging (IVUS and OCT) while CABG models were also adjusted for on-pump bypass, total bypass and cross-clamp times as well as concomitant valve surgery.

This finding was consistent across different age groups. Although differences in patient characteristics were evident between PCI and CABG groups, these were largely similar in the pre-COVID and COVID

periods. Finally, we show that 30-day mortality after LM revascularisation remained unchanged over the years. Importantly, we find that adjusted in-hospital and 30-day mortality within each revascularisation group (PCI and CABG) was similar in the pre-COVID and COVID periods. We also show that only 30-day mortality was higher with PCI compared with CABG in the pre-COVID period, but no difference in in-hospital or 30-day mortality between PCI and CABG were observed in the COVID period.

Significant LM coronary disease of prognostic importance due to the large myocardial territory it supplies and is considered a Class which is associated with shorter length of stay and even a same day discharge, 26 to avoid further growth in CABG waiting lists. This is certainly in keeping with European Society of Cardiology guidance during the COVID-19, which recommended Heart Team discussions on hybrid revascularisation (PCI and CABG) or full PCI for patients whose interventions cannot be postponed. 27 As evidenced by our analysis, procedural activity has not recovered even after the lift of lockdown restrictions in early July 2020. While the observed change in choice of revascularisation strategy may have been prudent during the height of the pandemic, operational changes are required to restore procedural activity to pre-COVID levels, when decisions on the ideal revascularisation strategy were primarily based on patient-related and anatomical factors rather than availability of resources.

We observe a significant reduction in overall LM procedural activ- given that there is a deficit of more than 1,300 LM cases (>50% decline) between March 2020 and July 2020 compared with previous years' averages.

Firstly, while the British Cardiovascular Intervention Society NAPCI and British Cardiothoracic Society NACSA datasets capture many patient and procedural characteristics, these do not include measures of comorbidity such as Charlson or Elixhauser scores as well as frailty, which are important predictors of procedural mortality. 31, 32 It is possible that patients undergoing PCI were turned down for CABG following heart team discussions, owing to their significant frailty or comorbid burden; however, information on such discussions was not available, although this is the case in most national databases.

Secondly, information regarding the overall procedural complexity, as measured by the SYNTAX score, was not available. Furthermore, significant proximal/ostial stenoses of the left anterior descending and left circumflex arteries, which are considered LM equivalents with equal prognostic significance to LM disease stenosis, are not captured in the NACSA database, meaning that they were not included in our analysis. Thirdly, we were unable to follow up mortality for longer than 30 days post procedures so as to allow capture of all procedures up until 19th August 2020. It is possible that longer-term follow up will demonstrate more pronounced differences in mortality between revascularisation strategies.

In our national analysis of a contemporary procedural cohort, we demonstrate that LM revascularisation has significantly declined during the COVID period, with a total deficit of more than 1,300 cases compared to previous years' averages and a shift towards PCI as the preferred revascularisation strategy. Adjusted in-hospital and 30-day mortality within each revascularisation group was similar in the pre-COVID and COVID periods, reflecting a maintenance in quality of outcomes following LM revascularisation despite the significant pressure on healthcare facilities during the pandemic. However, further measures are required to safely restore LM revascularisation activity, including PCI and CABG, to pre-COVID levels and deal with growing waiting lists to prevent long-term cardiovascular morbidity and mortality.

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How to cite this article: Mohamed MO

Revascularisation strategies in patients with significant left main coronary disease during the COVID-19

The authors acknowledge Tony Burton, Chris Roebuck, and Tom Denwood from NHS digital for providing and creating the secure environment for data hosting and for analytical support.

The authors report no conflicts of interest, financial disclosures or relationship with the industry.

Our data user agreement with NHS digital does not allow us to release confidential patient-level data.