PCI in Patients With Heart Failure: Current Evidence, Impact of Complete Revascularization, and Contemporary Techniques to Improve Outcomes

Abstract

Coronary artery disease (CAD) is the most common cause of left ventricular systolic dysfunction (LVSD) and heart failure (HF). Revascularization with coronary artery bypass grafting (CABG) reduces all-cause mortality compared with medical therapy alone for these patients. Despite this, CABG is performed in a minority of patients with HF, partly due to patient unwillingness or inability to undergo major cardiac surgery and partly due to physician reluctance to refer for surgery due to high operative risk. Percutaneous coronary intervention (PCI) is a less-invasive method of revascularization that has the potential to reduce periprocedural complications compared with CABG in patients with HF. Recent advances in PCI technology and technique have made it realistic to achieve more complete revascularization with PCI in high-risk patients with HF, although no randomized controlled clinical trials (RCTs) of PCI in HF compared with either medical therapy or CABG have been performed. In this review, we discuss the currently available evidence for PCI in HF and the association between the extent of revascularization and clinical outcomes in HF. We also review recent advances in PCI technology and techniques with the potential to improve clinical outcomes in HF. Finally, we discuss emerging clinical trial evidence of revascularization in HF and the large, persistent evidence gaps that should be addressed with future clinical trials of revascularization in HF.

Keywords: Heart failure; coronary artery bypass grafting; percutaneous coronary intervention; revascularization.

Graphical abstract

Figure 1

All-cause mortality after treatment of 2126 propensity-matched patients with an LVEF ≤35% with everolimus-eluting stents or CABG from the New York State Registries. CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction.

Figure 2

Patient risk for percutaneous coronary intervention is determined by these 3 potentially overlapping and additive domains.

Central Illustration

Summary of Recent Advances in Both Technology and Technique for Percutaneous Coronary Intervention. With these advances, it is now realistic to safely achieve complete revascularization with PCI in many complex lesion subsets and high-risk patients with heart failure. These approaches require dedicated evaluation in patients with heart failure to establish whether they lead to improved outcomes. CTO, chronic total occlusion; PCI, percutaneous coronary intervention.