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27 May 2024: Clinical Research  

Percutaneous Coronary Intervention as a Non-Surgical Treatment for Ischemic Mitral Regurgitation in Patients with Multi-Vessel Coronary Artery Disease

Xiaoyan Wang ORCID logo1ABCE*, Zhihong Liu ORCID logo1ABCDE, Aoyun Rong ORCID logo1ABDE, Bofei Ma ORCID logo1BCDE, Ruixing Mo ORCID logo1BCEG

DOI: 10.12659/MSM.943122

Med Sci Monit 2024; 30:e943122

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Abstract

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BACKGROUND: Multi-vessel coronary artery disease (MVD) represents a severe type of coronary artery disease (CAD). Ischemic mitral regurgitation (IMR) is a common mechanical complication in patients with CAD. This study aimed to retrospectively investigate the efficacy of percutaneous coronary intervention (PCI) on moderate/severe IMR in patients with MVD.

MATERIAL AND METHODS: Clinical data were collected from 15 patients who underwent successful treatment for MVD combined with moderate/severe IMR through the PCI procedure and achieved complete revascularization between January 2014 and December 2022. Cardiac structural and functional parameters were assessed through echocardiographic evaluations. Color flow recordings of MR jets were obtained through an enlarged view of the 4-chamber cut, and the diagnosis of MR was categorized into mild (<4 cm²), moderate (4-8 cm²), and severe (>8 cm²), based on the MR area.

RESULTS: The common features of the selected cases were advanced age, low body weight, and renal insufficiency. Cardiac echocardiography revealed an augmentation in the left atrial anteroposterior diameter and left ventricular internal diameter at end-systole after PCI, while the left ventricle internal diameter in diastole, left ventricular ejection fraction, and left ventricular fractional shortening were comparable to preoperative values. All patients had moderate/severe MR preoperatively, and MR improved at 1 month (2.73±0.69) and 12 months (2.26±0.58) after PCI.

CONCLUSIONS: In cases of MVD accompanied by moderate/severe IMR, undergoing PCI can spare certain elderly patients with low body weight and renal insufficiency from high-risk surgery, alleviating the severity of MR without undergoing mitral valve intervention.

Keywords: Barlow Syndrome, Coronary Artery Disease, percutaneous coronary intervention

Introduction

Coronary atherosclerotic heart disease, also known as coronary artery disease (CAD), is one of the most common conditions affecting human well-being [1], being first in terms of mortality among various maladies [2]. Multi-vessel coronary artery disease (MVD) represents a more severe and intricate type of CAD and is defined as a diameter of stenosis exceeding 50% of a major vessel [3]. MVD accounts for nearly 50% of total CAD cases, and patients with this condition face a considerably elevated mortality risk [4]. Additionally, CAD can induce left ventricular (LV) dilation and tethering of the papillary muscles, resulting in inadequate coaptation of the mitral valve (MV) leaflets and subsequent ischemic mitral regurgitation (IMR) [5]. Clinically, approximately 35% of patients with acute myocardial infarction (AMI) develop moderate to severe IMR, leading to a 2-fold increase in mortality rates [6,7]. IMR is a common mechanical complication in patients with CAD; if the IMR cannot be effectively corrected, LV remodeling and heart failure will further progress. Regardless of whether IMR occurs in the acute or chronic phase of CAD, the mortality rate of patients will increase, and the prognosis will be poor [8,9].

At present, pharmacotherapy, percutaneous coronary intervention (PCI), and coronary artery bypass surgery (CABG) constitute the 3 primary modalities for managing CAD clinically. However, for patients with complex coronary artery lesions, pharmacological interventions often prove insufficient in effectively managing clinical symptoms [10]. Moreover, the surgical risk associated with combined CABG and mitral valve surgery (CABG+MVS) has been reported, and CABG itself poses risks, such as general anesthesia, endotracheal intubation, sternotomy, cardiopulmonary bypass, and prolonged recovery time [11]. Since the introduction of PCI as a method for coronary revascularization in 1977 to replace CABG, PCI has demonstrated a distinct advantage in the treatment of severe CAD due to its ability to open the blocked blood vessels and restore blood flow [12]. Consequently, opting for PCI can alleviate symptoms, improve cardiac function, achieve the objective of myocardial revascularization, reduce the necessity for subsequent CABG, and enhance quality of life [13], making it a favorable choice for individuals with MVD.

Furthermore, evidence indicates that PCI revascularization surgery can alleviate IMR [5,14]. In the study by Rayan et al, more than one-third of the patients with IMR had improvement in severity of IMR [5]. In addition, the mortality benefit associated with PCI treatment in patients with moderate to severe functional mitral regurgitation was consistent regardless of the age, sex, reason for admission, presence of diabetes mellitus, left ventricular ejection fraction (LVEF) value, and left main and 3-vessels disease [14]. With the continuous development and maturation of PCI procedures, the perioperative and postoperative clinical outcomes of PCI have been further enhanced. PCI treatment has been demonstrated to be associated with a reduction in all-cause mortality. Thus, there is an increasing number of patients, and clinicians are considering PCI as the primary choice for revascularization [15]. Nevertheless, in rare cases of MVD combined with moderate to severe IMR, there have been no reports on the improvement of IMR following PCI.

Therefore, in this study, we retrospectively analyzed data from patients with concomitant multi-vessel CAD and moderate to severe IMR who underwent only PCI, aiming to elucidate the clinical characteristics of such cases, as well as the impact of PCI on MR areas, cardiac function improvement, and its influence on survival rates among enrolled patients.

Material and Methods

PATIENT SELECTION:

This retrospective analysis was conducted using the clinical data of 15 patients with MVD combined with moderate to severe IMR at the Third Hospital of Shijiazhuang from January 2014 to December 2022. The patients were successfully treated through the PCI procedure, achieving complete revascularization, without experiencing clinical symptoms, such as chest tightness or pain, and the MR in all cases reduced to mild reflux. This study was approved by the Ethics Committee of the Third Hospital of Shijiazhuang City (No. 2023083), and all patients included in our study provided verbal informed consent. The clinical data were obtained by the retrospective review of the medical records of all the patients.

The inclusion criteria were as follows. Included patients received a diagnosis of moderate to severe IMR through transthoracic echocardiography and MVD via coronary angiography and were successfully treated with the PCI procedure. IMR is an insufficiency of the MV secondary to myocardial ischemia and CAD and occurs in the absence of structural or primary MVD [16]. The diagnosis of MR was categorized into mild (<4 cm2), moderate (4–8 cm2), and severe (>8 cm2), based on the MR area. The exclusion criteria were (1) patients in whom PCI procedures failed to open target vessels (guidewire failed to cross the lesion) or did not achieve complete revascularization of the coronary arteries; (2) patients who underwent PCI procedures and subsequently received MVS in cardiac surgery; (3) patients with CAD combined with organic lesions; (4) patients with CAD combined with valve stenosis; (5) LVEF < 0.4; and (6) patients with other severe comorbidities, including those with significant pulmonary, hepatic, or renal dysfunction, as well as malignancy, were excluded from the study.

DATA COLLECTION AND INTERVENTION:

A standard 12-lead electrocardiogram (ECG) was conducted by an experienced resident using the MAC5500 (General Electric Co) for all enrolled patients upon admission, during symptom occurrence, and after PCI procedures. Moreover, experienced cardiologists conducted coronary angiography with the Siemens angiography X-ray system, displaying the blood flow in the coronary arteries in standard positions. In addition, 2-dimensional quantitative coronary angiography was conducted for preoperative assessment of coronary artery stenosis severity. Furthermore, all transthoracic echocardiography examinations were performed by experienced physicians specializing in ultrasound imaging in the Department of Ultrasound and using the Acuson Sequoia 512 echocardiography system (Siemens, USA). The color flow recordings of MR jets were obtained through an enlarged view of the 4-chamber cut.

Surgical risk assessment was conducted during the selection of the surgical approach. The risk of mortality for CABG was assessed through age, creatinine, and ejection fraction (ACEF) scores [17] and the EuroSCORE [18]. The ACEF score, calculated by age/ejection fraction (EF) +1 (if creatinine >2.0 mg/dL), was used to assess the postoperative bleeding risk for CABG. Among the total patients, 2 had ACEFlow ≤1.07; 10 had 1.09<ACEFmid ≤1.44; and 3 had ACEFhigh >1.44. The EuroSCORE was used to predict patient mortality during cardiac surgery, with low-risk group scoring 0–2 points, n=0; moderate-risk group scoring 3–5 points, n=4; and high-risk group scoring ≥6 points, n=11. PCI risk assessment was evaluated through National Cardiovascular Data Registry (NCDR CathPCI) risk scores to predict mortality among patients undergoing PCI [19]. The surgical strategy involved addressing the culprit target vessel and other diseased vessels simultaneously or exclusively treating the culprit target vessel scheduled for staged PCI. All patients were already taking aspirin 300 mg, clopidogrel 300 mg, or ticagrelor 180 mg preoperatively, and underwent anticoagulation with either normal heparin or bivalirudin for the first PCI, and with either low-molecular heparin or enoxaparine for 24 to 72 h postoperatively. The stents implanted in all patients were drug-coated stents or drug-eluting stents, including the Resolute stent, Xience Prime stent, and Firebird stent.

EVALUATION PARAMETERS:

Clinical data during the patients’ hospitalization were collected by reviewing the medical records. A follow-up at the Outpatient Department within 1 year after the PCI surgery was conducted, and cardiac ultrasound results were examined. A comparison was made between the preoperative, 1-month postoperative, and 12-month postoperative periods for left atrial anteroposterior diameter (LAAD), left ventricle internal diameter in diastole (LVIDd), left ventricular internal diameter at end-systole (LVIDs), LVEF, left ventricular fractional shortening (LVFS), and MR area. The patients were followed up for 1 year to monitor their survival status and record major cardiac events, including cardiac death, repeat revascularization, and worsening of heart function.

Results

PATIENTS’ CHARACTERISTICS:

A total of 15 patients with concomitant MVD and moderate to severe IMR were included in the study, comprising 11 cases of moderate IMR and 4 cases of severe IMR. Figure 1 shows the consort flow chart of the study. As depicted in Table 1, the average age of this cohort was 77.27±10.11 years, with 12 patients (80%) being of the male sex. Baseline data and characteristics of the 15 enrolled patients are summarized in Tables 1 and 2, respectively. The selected patients’ cohort exhibited characteristics of advanced age and low body weight, with a total of 10 patients over the age of 75, with the eldest patient being 92 years old, and the lowest BMI being 18.02. Additionally, all 15 patients had varying degrees of renal insufficiency, with the lowest glomerular filtration rate measuring only 49.04 mL/min/1.73 m2 (Table 2).

RESULTS OF CARDIAC ECHOCARDIOGRAPHY:

As shown in Table 3, for all patients in the selected cohort, the procedural mortality risk associated with PCI was consistently lower than that of undergoing CABG surgery. Consequently, patients ultimately underwent PCI as their exclusive surgical intervention. The detailed information regarding PCI and the stent types used is presented in Table 4.

Table 5 presents the findings of cardiac echocardiography in patients before and after treatment. In comparison to the preoperative values, both the LAAD and LVIDs increased at 1 month and 12 months after surgery, indicating a certain degree of myocardial remodeling in patients after PCI. Furthermore, the LVIDd, LVEF, and LVFS were comparable to preoperative values, suggesting that the patients did not experience deterioration in cardiac function postoperatively, and there was a trend of improvement. Among all enrolled patients, 4 had severe IMR preoperatively, and 11 had moderate IMR preoperatively. At the 1-month and 12-month postoperative follow-ups, the MR severity had improved, compared with the preoperative state, signifying that MR improved in these patients at 1 month and was able to be maintained, as shown in Table 6, which depicts the details of MR grade for each patient and at each time point of the study. Simultaneously, abnormal wall motion showed improvement at the 1-month postoperative assessment, with only 1 patient showing residual low magnitude of LV anterior wall motion, which had returned to a normal state during reevaluation at 12 months.

POSTOPERATIVE PATIENT SURVIVAL:

Over the 12-month period following PCI surgery, none of the 15 patients experienced mortality or required re-revascularization. Only 2 patients encountered acute left heart failure subsequent to the initial PCI procedure, and their heart failure was ameliorated through symptomatic treatment by the Cardiology Department, including the administration of morphine, furosemide, nitroglycerin, and noninvasive ventilation.

AN EXEMPLARY PATIENT CASE:

An 88-year-old man with unstable angina (UA) was selected as an exemplary case. The patient presented with symptoms of chest tightness and shortness of breath following physical activity, leading to hospital admission on May 25, 2021. He exhibited a markedly emaciated physique, with no history of smoking and the absence of predisposing cardiovascular risk factors, such as type 2 diabetes and hypertension. Upon admission, the patient’s blood pressure was recorded as 122/81 mmHg, with a heart rate of 62 beats per min, and a grade IV/VI systolic murmur was audible at the cardiac apex. The ECG results were essentially normal on admission and during the episodes of chest tightness and dyspnea (Figure 2). Moreover, the coronary angiography conducted on May 31, 2021, indicated that the patient had severe 3-vessel CAD (Figures 3, 4), initially almost misdiagnosed as valvular heart disease. The results predicting the mortality risk of the treatment plan for the patient revealed a Global Registry of Acute Coronary Events (GRACE) score [20] of 164, a Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) score [21] of 31. The ACEF score of 1.29 and EuroSCORE of 15.7% indicated a high prediction of mortality risk for CABG. Meanwhile, the NCDR-CathPCI risk evaluation yielded a score of 20, with a mere 0.3% probability of mortality. Consequently, the treatment plan for this patient was ultimately confirmed as PCI surgery. On June 1, 2021, the initial PCI operation successfully opened the chronic total occlusion of the right coronary artery (RCA) and 2 Resolute Onyx zotarolimus-eluting stents (2.75/18 mm and 3.0/25 mm) were implanted. One month later, a Tivoli drug stent (3.0/15mm) was implanted in the left circumflex (LCX) artery, while 2 EXCROSSAL drug stents (2.75/24 mm and 3.0/14 mm) were implanted in the left anterior descending (LAD) artery (Figure 4). In this exemplary case, additional intravascular ultrasound examination was conducted (Figure 5). The results showed a well-apposed LAD stent, with a minimum lumen area of 5.31 mm2 in the distal segment of the stent and 34% plaque load. The minimum lumen area of the proximal segment of the stent was 6.58 mm2, and 120°C calcification was seen with a plaque load of 56%. In addition, the RCA stent was well apposed, with a minimum lumen area of 8.66 mm2 in the distal segment of the stent, visible calcification at 180°C, and a plaque load of 51%. The proximal segment of the stent had a minimum lumen area of 8.51 mm2 and a plaque load of 55%. Preoperatively, echocardiography indicated normal measurements for the left atrium and left ventricle, with normal wall motion and a LVEF of 68%. However, a significant regurgitation was observed in the MV, measuring 8.22 cm2 (Figure 6A). Upon reexamination 1 month after PCI, the echocardiogram indicated a slightly large left atrium, with no abnormalities observed in the left ventricle and normal ventricular wall motion, and there was a mild MR with a regurgitant area of 2.96 cm2 and a LVEF of 67% (Figure 6B). At the 12-month follow-up, the echocardiogram demonstrated that the MR area had reduced to a mere 1.08 cm2, and the IMR had improved (Figure 6C).

Discussion

In the past, the treatment program for patients with CAD with moderate to severe IMR was predominantly explored within the domain of cardiac surgery, and the cardiac surgeons needed to deliberate on whether to undertake surgical intervention on the MV while the patient was undergoing revascularization procedures. If there were no apparent structural abnormalities or organic lesions in the valve leaflets, chordae tendineae, or papillary muscles in the condition of IMR, some patients experienced an improvement or even disappearance of MR after the complete rectification of the ischemic factors [22]. Our research provides compelling corroboration of this phenomenon. In our study, 15 cases of MVD with concomitant moderate to severe IMR were included. Following a meticulous preoperative risk assessment, all patients received PCI as their preferred treatment modality, and the postoperative echocardiographic results indicated an improvement in the condition of MR.

Currently, it is widely believed that the primary mechanism underlying IMR is ischemic LV remodeling, which can lead to papillary muscle displacement, resulting in traction on the MV and poor leaflet coaptation, and possibly be accompanied by reduced cardiac function, thereby giving rise to IMR [23]. It has been reported that papillary muscle infarction is a predictive factor for the occurrence of moderate to severe IMR in patients with CAD [24]. Moreover, in comparison to anterior myocardial infarction, inferior myocardial infarction is more prone to induce IMR, as asymmetrical papillary muscle motion is more commonly observed in patients with inferior wall myocardial infarction [25]. Consistent with the aforementioned literature, most of the 15 patients we included in our study exhibited lesions in the inferior wall blood supply vessels. Upon observing and analyzing the coronary angiography results of the patients, it was revealed that 13 of these patients presented with severe 3-vessel CAD. Before severe stenotic lesions or acute occlusion occurred in the vessels, there was often good collateral circulation present. These collateral vessels mutually supported each other, maintaining a relatively stable coronary blood flow. Nevertheless, the occurrence of acute ischemia will disrupt this original equilibrium, leading to changes in the functionality of the MV apparatus; simultaneously, ischemia of the ventricular wall results in ventricular remodeling, ultimately culminating in the occurrence of IMR. In our study, all 15 patients exhibited segmental abnormalities in ventricular wall motion and moderate to severe IMR. It is precisely due to the presence of these collateral circulations that a portion of the blood supply to the ventricular myocardial tissue and papillary muscles was relatively preserved, and echocardiography also indicated that these patients did not manifest valve prolapse, chordae tendineae rupture, or organic lesions of the papillary muscles. Furthermore, based on the angiographic findings, only 2 cases presented with 2-vessel CAD, wherein the vessels without stenotic lesions contributed less to the overall myocardial blood supply, due to their limited supply blood.

Complete coronary revascularization is an effective method for improving IMR, and previous research has demonstrated that PCI and CABG can reduce the incidence of IMR following AMI and improve prognosis [26]. However, whether or not to perform concurrent MV intervention when correcting the etiology of IMR requires a comprehensive evaluation of various factors [27]. In a study involving 2757 patients with moderate to severe IMR, a comparison of the mortality risk among patients treated with different approaches revealed a 30%, 42%, and 42% reduction in mortality risk for the groups treated with PCI, CABG, and CABG combined with MVS, respectively, in contrast to the medical therapy group. Notably, the combination of CABG+MVS did not demonstrate a reduced risk of mortality, compared with only CABG [28]. For patients with severe IMR, guidelines recommend concurrent surgical intervention on the MV during CABG due to the risk of exacerbating heart failure and deterioration [29]. One study, involving 137 patients with severe IMR who underwent PCI without any other invasive intervention beyond PCI, indicated that LV size decreased and EF increased significantly after PCI in the patients with improvement in IMR, compared with patients without improvement. Importantly, patients with improvement in IMR had numerically better survival, and the improvement in IMR was associated with LV reverse remodeling [5]. In addition, another study showed that patients with greater severity of MR were more likely to be of an older age and more often presented with large myocardial infarction [30]. Nevertheless, regarding patients with moderate MR, there remains ongoing debate over treatment strategies, particularly for special populations such as the elderly, those with low body weight, and those with potential renal insufficiency, with limited relevant literature available. Among the 15 patients included in our study, the ACEF scores were generally on the high side, ranging from 1.03 to 1.67, with an average of 1.28±0.20 points. Even for isolated CABG surgery, the surgical mortality rate was notably high, ranging from 1.72% to 16.04%. The NCDR CathPCI risk scores ranged from 14 to 44 points, with an average of 25.80±9.13 points. The surgical mortality risk for PCI was lower than that for CABG, thus making it the chosen treatment approach for all enrolled patients. Furthermore, all 15 patients successfully underwent PCI surgery.

In this study, we focused on an exemplary case of an 88-year-old elderly man for detailed exposition. The patient was admitted with unstable angina and the initial PCI procedure successfully opened the chronic total occlusion lesion in the RCA, leading to a marked improvement in MR at the 1-month follow-up. Owing to the good collateral circulation between the RCA and LAD, the opened RCA provided blood supply to the stenotic LAD, resulting in a significant improvement of blood supply in the papillary muscles and LV wall. This elucidates the underlying reasons for the improvement in MR even before achieving complete coronary revascularization, which was also a common characteristic among these select patients. At 12 months after PCI, echocardiography indicated normal cardiac function, with only minimal MR. Overall, in comparison to the preoperative condition, the MR improved in all 15 patients at the 1-month and 12-month follow-up examinations, and postoperative LV function did not deteriorate further and even showed signs of improvement.

This retrospective analysis demonstrates that isolated PCI procedures can achieve complete coronary revascularization for patients with MVD accompanied by moderate to severe IMR. Particularly for patients with AMI combined with IMR, undertaking PCI at an early stage can markedly reduce the area of myocardial infarction, salvage ischemic myocardial tissue, and improve cardiac function and LV remodeling, thereby ameliorating the functional impairment of the MV apparatus resulting from severe ischemia. The potential factors contributing to the improvement of IMR were analyzed as follows. (1) Based on patient history and PCI timing analysis, patients admitted within 1 to 4 h of the onset of AMI successfully underwent their first PCI within 2 h of hospital admission; the remaining AMI patients with onset and the unstable angina patients with exacerbations sought medical attention within 30 days, and these patients completed their first PCI within 1 week of admission, and all patients achieved complete revascularization at 1 month after their first PCI. (2) Although all enrolled patients had 2- or 3-vessel CAD, nearly all these vessels exhibited good collateral circulation. (3) Preoperative echocardiography revealed no organic changes in the MV leaflets, chordae tendineae, or papillary muscles for all patients, with the LVIDd less than 60 mm and LVEF greater than 45%. Finally, (4) MR is alleviated by improved blood flow to the anterior and/or posterior MV leaflets after the anatomical blood supply is improved. Hence, preoperative assessment to determine whether the MR was functional or organic was crucial, necessitating the expertise of a seasoned echocardiographer to ascertain the absence of chordae tendineae rupture, papillary muscles displacement, or other organic changes in the MV. Meanwhile, if cardiologists can prudently integrate the results of echocardiography for effective discrimination and selection of such patients, and devise a suitable PCI strategy to accomplish complete coronary revascularization, it is possible to avoid concurrent MV intervention, which could also spare certain patients from bearing the high mortality risk associated with undergoing surgical procedures.

Conclusions

In conclusion, if the MR is deemed functional, and LV dilation and compromised cardiac function are not evident for patients with MVD and combined moderate to severe IMR, especially in those with advanced age, low body weight, and potential renal insufficiency, PCI can represent a justifiable therapeutic strategy to avoid open chest surgery, reduce the risk of perioperative mortality associated with larger surgical trauma, and result in quick recovery after the procedure. At the 1-month post-PCI juncture, there was an amelioration in MR area among these patients.

Nonetheless, it is imperative to acknowledge the constraints of this study. Our study was a single-center retrospective study with a small sample size, and the patients included in the analysis consisted exclusively of PCI success cases, potentially leading to a bias in the overall assessment of the disease. Most of these patients were followed up for only 1 year after surgery, which is insufficient for a comprehensive evaluation of the long-term prognosis and outcomes after PCI. Thus, future larger scale studies are warranted to validate these preliminary findings.

Each patient with CAD accompanied by moderate to severe MR possesses unique clinical characteristics, and there is no perfect formula to select the most optimized surgical and treatment strategies. Such patients should be evaluated holistically, taking into account the etiology, magnitude of MR, extent of atrioventricular chamber dilatation, and individual conditions, with treatment plans tailored to their specific needs, requiring the collaborative efforts between cardiology and cardiac surgery teams.

Figures

Flow diagram of patient inclusion in this study.Figure 1. Flow diagram of patient inclusion in this study. Electrocardiogram of the classic case patient. (A) Electrocardiogram on admission; (B) electrocardiogram during symptomatic episodes of chest tightness and shortness of breath.Figure 2. Electrocardiogram of the classic case patient. (A) Electrocardiogram on admission; (B) electrocardiogram during symptomatic episodes of chest tightness and shortness of breath. Coronary angiography reveals severe 3-vessel coronary artery disease of the classic case patient. (A) Proximal 100% occlusion of the right coronary artery (RCA); (B) multiple vessels of the distal anterior descending and septal branches send collateral circulation to the distal RCA, and the RCA is a chronic occlusive lesion; (C, D) After successful opening of the chronic total occlusion of the right coronary artery, implantation of Resolute 2.75/18 mm and Resolute 3.0/25 mm drug-eluting stents.Figure 3. Coronary angiography reveals severe 3-vessel coronary artery disease of the classic case patient. (A) Proximal 100% occlusion of the right coronary artery (RCA); (B) multiple vessels of the distal anterior descending and septal branches send collateral circulation to the distal RCA, and the RCA is a chronic occlusive lesion; (C, D) After successful opening of the chronic total occlusion of the right coronary artery, implantation of Resolute 2.75/18 mm and Resolute 3.0/25 mm drug-eluting stents. Implantation of drug-eluting stents. (A) focal severe stenosis lesion in the mid-segment of the left circumflex (LCX); (B) focal severe stenosis lesion in the mid-segment of the left anterior descending (LAD); (C) implantation of a 3.0/15 mm Tivoli drug stents in the LCX; (D) implantation of 2 EXCROSSAL drug stents (2.75/24 mm and 3.0/14 mm) in the LAD.Figure 4. Implantation of drug-eluting stents. (A) focal severe stenosis lesion in the mid-segment of the left circumflex (LCX); (B) focal severe stenosis lesion in the mid-segment of the left anterior descending (LAD); (C) implantation of a 3.0/15 mm Tivoli drug stents in the LCX; (D) implantation of 2 EXCROSSAL drug stents (2.75/24 mm and 3.0/14 mm) in the LAD. Representative intravascular ultrasound images of left anterior descending and right coronary artery blood vessels in the exemplary case.Figure 5. Representative intravascular ultrasound images of left anterior descending and right coronary artery blood vessels in the exemplary case. Transthoracic echocardiogram in the 4-chamber view of the classic case patient. (A) Significant mitral regurgitation on admission; (B) mild mitral regurgitation 1 month after the initial percutaneous coronary intervention procedure; (C) the further reduction in the degree of mitral regurgitation at 1-year follow-up after surgery.Figure 6. Transthoracic echocardiogram in the 4-chamber view of the classic case patient. (A) Significant mitral regurgitation on admission; (B) mild mitral regurgitation 1 month after the initial percutaneous coronary intervention procedure; (C) the further reduction in the degree of mitral regurgitation at 1-year follow-up after surgery.

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Figures

Figure 1. Flow diagram of patient inclusion in this study.Figure 2. Electrocardiogram of the classic case patient. (A) Electrocardiogram on admission; (B) electrocardiogram during symptomatic episodes of chest tightness and shortness of breath.Figure 3. Coronary angiography reveals severe 3-vessel coronary artery disease of the classic case patient. (A) Proximal 100% occlusion of the right coronary artery (RCA); (B) multiple vessels of the distal anterior descending and septal branches send collateral circulation to the distal RCA, and the RCA is a chronic occlusive lesion; (C, D) After successful opening of the chronic total occlusion of the right coronary artery, implantation of Resolute 2.75/18 mm and Resolute 3.0/25 mm drug-eluting stents.Figure 4. Implantation of drug-eluting stents. (A) focal severe stenosis lesion in the mid-segment of the left circumflex (LCX); (B) focal severe stenosis lesion in the mid-segment of the left anterior descending (LAD); (C) implantation of a 3.0/15 mm Tivoli drug stents in the LCX; (D) implantation of 2 EXCROSSAL drug stents (2.75/24 mm and 3.0/14 mm) in the LAD.Figure 5. Representative intravascular ultrasound images of left anterior descending and right coronary artery blood vessels in the exemplary case.Figure 6. Transthoracic echocardiogram in the 4-chamber view of the classic case patient. (A) Significant mitral regurgitation on admission; (B) mild mitral regurgitation 1 month after the initial percutaneous coronary intervention procedure; (C) the further reduction in the degree of mitral regurgitation at 1-year follow-up after surgery.

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