Editor’s 2024 Top 10: Complex Percutaneous Coronary Intervention in Patients Unable to Undergo Coronary Artery Bypass Grafting During the COVID-19 Pandemic: Insights From the UK-ReVasc Registry

Dr Deepak L. Bhatt, editor-in-chief of the Journal of Invasive Cardiology, catches up with Dr Andrew Ladwiniec about his Editor’s 2024 Top 10 article, “Complex Percutaneous Coronary Intervention in Patients Unable to Undergo Coronary Artery Bypass Grafting During the COVID-19 Pandemic: Insights From the UK-ReVasc Registry”.

Transcript:

Dr Bhatt: Hello, I'm Dr Deepak Bhatt, editor-in-chief of the Journal of Invasive Cardiology. I'm really fortunate to be here today with Dr Andrew Ladwiniec; he is an interventional cardiologist and honorary senior lecturer in the Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Center at Glenfield Hospital, University of Leicester, and University Hospitals of Leicester, NHS Trust in Leicester. Welcome.

Dr Ladwiniec: Thanks very much.

Dr Bhatt: We're here today to discuss an article that made the top 10 list for the Journal of Invasive Cardiology on complex percutaneous coronary intervention in patients unable to undergo CABG during the COVID-19 pandemic; these are some insights from the UK-ReVasc registry. I found the study to be very interesting—as I mentioned, it made the top 10. Perhaps you could just tell us why you did the study and what the goals were.

Dr Ladwiniec: So, this all came about at the beginning of the first wave of the COVID-19 pandemic in 2020. And we suddenly found that these patients we were discussing in the MDT that would either be considered for bypass surgery or PCI or offered both—we lost the option of bypass surgery at that time. And so, with Professor Tony Gershlick, as well as Dr Tom Kite, who's the first author on the paper, we got to talking about-

Dr Bhatt: Tony’s a great guy, I just have to say, parenthetically.

Dr Ladwiniec: Well, so, what I was going to get on to, we talked about the fact that this was a pretty unprecedented period in that these patients who, the evidence would suggest should have bypass surgery, suddenly don't have access to it and we should try and capture that. Now I think conversations like that happen in MDTs, in multidisciplinary meetings and cath labs all the time, but with Tony, it would always drive things such that you actually get going and do something about it. And so really, Tony was the main driver for us setting up a registry with the help of the Centre for Biostatistics in the University of Glasgow. We ran a webinar to talk about the registry, we got 45 centers in the UK involved to look at patients who were either on the waiting list for bypass surgery and needed prompt revascularization, couldn't wait, or had presented during the pandemic with a pattern of disease which would be best suited to bypass surgery, but that wasn't available. Then try and capture that moment in time and look at the outcomes and look at the practice.

And so, you can see from the study there were 215 patients originally recruited and we had 12-month follow-up for 209 of them. If you look at the measures of complexity, the syntax scores, it's pretty complex disease and the PCI that was carried out was pretty complex. What we found was—I should also say that there was a high proportion of non-ST-elevation MI, as you might expect, given that a lot of these are acute presentations, than you would see in a lot of trials comparing PCI or bypass surgery, which I think probably drives the outcomes that we saw. What we saw at 12 months is, I think, pretty acceptable long-term or at least medium-term outcomes for these patients, higher than you might see in some of the randomized trials that had a high proportion of stable coronary disease, but these are patients with acute presentations with complex disease. We saw, notably, a very low proportion of mechanical circulatory support; there were just 2 patients who had intra-aortic balloon pumps, which is interesting. I think if this had been elsewhere, we may have seen a higher proportion of those. There were only 209 patients at follow-up. So, it was small to demonstrate subgroup differences, but what we did see is that we didn't see a difference whether patients had complete vs incomplete revascularization; maybe, if it had been a larger cohort, we would have seen that. We did see a difference in outcomes between those treated with intracoronary imaging and, obviously, that may be confounded, but that fits with a lot of the observational data we see of subgroup analyses from randomized trials.

Dr Bhatt: Absolutely, really intriguing data. I thought the study was fascinating and you know it's a lesson that we learned in the pandemic in many areas of medicine, that things that we thought were one way could be another. That is, you know, even discharging patients sometimes same-day after TAVR or other procedures which seemed like a totally outlandish idea pre-pandemic. You sort of have to do what you have to do during the pandemic; I was really surprised how many things that I thought weren't great ideas actually seemed feasible. So yeah, wonderful study. It'd be interesting to see the longer-term follow-up here too, because, of course, some of the differences between CABG and PCI emerge at longer follow-up. But shortly, the follow-up that you had out to 12 months, the rates looked, as you said, pretty acceptable for a complex coronary population.  

What do you think the implications are for your study? I mean, hopefully there won't be another pandemic—or maybe there will be, I've heard a lot about bird flu lately—but you know, if there's another pandemic, sure, again, we'll have to go back into crisis mode and do what we have to do. But short of that, do you think there are implications just in terms of fundamental assumptions we're making that might not be true, such as which patients really need CABG?

Dr Ladwiniec: I think if you look at the outcomes, then certainly the outcomes appear to be acceptable if some of these patients that we would have said must have bypass surgery can have PCI. It’s obviously limited by the fact that there isn’t another arm; we don’t know if that same cohort, or at least a cohort with identical risk, if they were treated surgically would have significantly better outcomes; in fact, I wouldn't be surprised if they would. But we're not seeing terrible numbers in terms of the outcomes at 12 months, particularly bearing in mind a lot of these patients had acute presentations. So, if you look at the outcomes at 12 months for patients in trials including NSTEMI, these patients, most of whom would have more complex disease than a lot of them, don't really stand out as having worse outcomes than them.

Dr Bhatt: Really great points. In terms of next steps, you could, of course, do longer follow-up. Is that planned?

Dr Ladwiniec: It's not at the moment. I don't think we'll go beyond 1 year, more because of feasibility than anything else. I don't think it would add a great deal. I think if you had a comparative group, I think it would be more valuable. But going out to 5 years or something with just a single arm with a relatively small group, I don't think it would add a great deal.

Dr Bhatt: That does make a lot of sense. Well, any final points you want to make to the audience about this interesting study?

Dr Ladwiniec: Like I said earlier, I think the really interesting thing about it is, and what struck me the most was really what we got from Tony Gershlick when we were setting it up in the sense that if you've got a question and you've got the drive, then really, I mean, it was a case of we had a conversation one day and then within a few weeks we're up and running with the registry, it was really that rapid. So, it shows what you can do if you have the drive and the know-how to get things going.

Dr Bhatt: Tony was just an incredible doctor, incredible human being. Any other work that we should expect coming out of the UK-ReVasc registry?

Dr Ladwiniec: Not from the UK Registry no, I think that's it, and hopefully we won't be in a similar situation any time soon.

Dr Bhatt: I hope not. Well, really interesting study and wonderful insights from you today. I enjoyed the conversation. Thank you so much.

Dr Ladwiniec: Thanks very much for having me.

The transcript has been edited for clarity.