Higher Revascularization Rate Research Articles

Long-Term Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for Multivessel Coronary Revascularization: 5-Year Outcomes From the Asan Medical Center-Multivessel Revascularization Registry

We performed the long-term (5-year) follow-up of a large cohort of patients who underwent drug-eluting stent (DES) or coronary artery bypass graft (CABG) surgery for multivessel revascularization. Limited information is available on very long-term outcomes after multivessel DES treatment relative to CABG. We evaluated 3,042 patients with multivessel disease who received DES (n = 1,547) or underwent CABG (n = 1,495) between January 2003 and December 2005, and for whom complete follow-up data were available for a median 5.6 years (interquartile range: 4.6 to 6.3 years). We compared adverse outcomes (death; a composite outcome of death, myocardial infarction, or stroke; and repeat revascularization). After adjustment for differences in baseline risk factors, 5-year risk of death (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.76 to 1.32, p = 0.99) and the combined risk of death, myocardial infarction, or stroke (HR: 0.97; 95% CI: 0.76 to 1.24, p = 0.81) were similar between the DES group and the CABG group. However, the rates of revascularization were significantly higher in the DES group (HR: 2.93; 95% CI: 2.20 to 3.90, p < 0.001). Similar results were obtained in comparisons of DES with CABG for high-risk clinical and anatomic subgroups with diabetes mellitus, abnormal ventricular function, age 65 years or more, and 3-vessel and left main disease. However, mortality benefit with DES implantation relative to CABG was noted in patients with 2-vessel disease (HR: 0.57; 95% CI: 0.36 to 0.92, p = 0.02). For patients with multivessel disease, DES treatment, compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Endovascular Thrombectomy for Acute Ischemic Stroke in Failed Intravenous Tissue Plasminogen Activator Versus Non–Intravenous Tissue Plasminogen Activator Patients

Intracranial mechanical thrombectomy is a therapeutic option for acute ischemic stroke patients failing intravenous tissue plasminogen activator (IV tPA). We compared patients treated by mechanical embolus removal in cerebral ischemia (MERCI) thrombectomy after failed IV tPA with those treated with thrombectomy alone. We pooled MERCI and Multi MERCI study patients, grouped them either as failed IV tPA or non-IV tPA, and assessed revascularization rates, procedural complications, symptomatic hemorrhage rates, clinical outcomes, and mortality. We also evaluated outcomes stratified by the occlusion site and final revascularization. Among 305 patients, 48 failed, and 257 were ineligible for IV tPA. Nonresponders to IV tPA trended toward a higher revascularization rate (73% versus 63%) and less mortality (27.7% versus 40.1%) and had similar rates of symptomatic hemorrhage and procedural complications. Favorable 90-day outcomes were similar in failed and non-IV tPA patients (38% versus 31%), with no difference according to occlusion site. Among patients failing IV tPA, good outcomes tended to occur more frequently in revascularized patients (47.1% versus 15.4%), although this relationship was attributable solely to middle cerebral artery and not internal carotid artery occlusions, with no difference in mortality. Among IV tPA-ineligible patients, revascularization correlated with good outcome (47.4% versus 4.4%) and less mortality (28.5% versus 59.6%). The risks of hemorrhage and procedure-related complications after mechanical thrombectomy do not differ with respect to previous IV tPA administration. Thrombectomy after IV tPA achieves similar rates of good outcomes, a tendency toward lower mortality, and similar revascularization rates when stratified by clot location. Good outcomes correlate with successful revascularization except with internal carotid artery occlusions in tPA-nonresponders.

Clinical Outcomes in Middle Cerebral Artery Trunk Occlusions Versus Secondary Division Occlusions After Mechanical Thrombectomy

The benefit of endovascular revascularization of patients with acute ischemic stroke with middle cerebral artery (MCA) secondary division (M2) occlusions as compared with MCA trunk (M1) occlusions is not known. In this analysis, we compared revascularization status and clinical outcomes in patients with angiographically confirmed MCA M1 versus isolated M2 occlusions treated with mechanical thrombectomy using the Merci Retriever devices. We retrospectively analyzed the pooled data of patients with MCA strokes from the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI trials. Patient data were dichotomized into 2 groups: MCA M1 occlusions and isolated M2 occlusions. Baseline characteristics, revascularization rates, hemorrhage rates, complications, outcomes, and mortality were evaluated for both groups. Of 178 patients with MCA occlusion treated in the MERCI and Multi MERCI trials, 84.3% had M1 lesions and 15.7% had isolated M2 lesions. Patients with isolated M2 occlusions were revascularized at a higher rate, required a lower mean number of passes, and were associated with a trend toward shorter mean procedure time than patients with M1 occlusions. No statistically significant differences were found between M2 and M1 groups for symptomatic hemorrhage, clinically significant procedural adverse events, favorable 90-day outcome, or 90-day mortality, although in all instances, the M2 outcomes were numerically better than those in M1 subjects. In multivariate analysis, final revascularization was the strongest independent predictor of good outcome at 90 days. Patients with both MCA M1 occlusions and isolated M2 occlusions can achieve a relatively high rate of revascularization and favorable clinical outcomes after mechanical thrombectomy. In fact, patients with isolated M2 occlusions had a higher rate of revascularization, required fewer passes, and had no increased complications compared with patients with M1 occlusions.

Clinical outcomes using aggressive approach to anatomic screening and endovascular revascularization in a veterans affairs population with critical limb ischemia

This study sought to examine the impact of an aggressive approach to anatomic screening and endovascular revascularization in a veterans administration population with critical limb ischemia (CLI) on the primary treatments received and overall clinical outcomes. The baseline clinical and angiographic characteristics and clinical outcomes of the first consecutive fifty veterans who were referred for the evaluation and treatment of CLI using the strategy outlined were assessed by retrospective review of the computerized medical record and angiographic data. Among the entire cohort, the primary treatments received were as follows--revascularization n = 44 (88%), primary amputation n = 1 (2%), medical treatment n = 3 (6%), and primary minor amputation n = 2 (4%). Endovascular revascularization was the dominant mode of revascularization (94%), with a procedural success rate of 91%. Repeat revascularization was required in 19% of patients who had an initially successful endovascular procedure. A total of eight deaths and four major amputations occurred in the entire cohort over a mean follow-up of 397 +/- 190 days. The 1-year Kaplan-Meier estimates for survival and amputation-free survival for the entire cohort were 90 and 81%, respectively. Resolution of rest pain or complete wound healing was achieved in 85% of patients at a mean of 157 +/-126 days. An aggressive approach to anatomic screening and contemporary endovascular treatment of CLI resulted in a higher rate of revascularization as the primary treatment for CLI than previously reported, and was associated with high rates of overall and amputation-free survival.

Twelve Months Clinical Outcome of Drug‐Eluting Stents Implantation or Coronary Artery Bypass Surgery for the Treatment of Diabetic Patients with Multivessel Disease

Studies comparing coronary artery bypass grafting (CABG) with drug-eluting stent (DES) for the treatment of diabetic patients with multivessel disease are relatively scarce although controversies exist concerning the relative efficacy of CABG versus DES. The aim of this study was to evaluate the effect of drug-eluting stent (DES) implantation in diabetic patients with multivessel disease compared with CABG. We included 645 consecutive diabetic patients who underwent either CABG (n = 282) or DES implantation (n = 363) in our institution from July 2003 to December 2005. At 12 mo after index revascularization procedure, the total mortality rate was similar in the CABG and DES group (3.2% versus 3.0%, hazard ratio [HR] of CABG versus percutaneous coronary intervention [PCI] 0.58, 95% confidence interval [CI]: 0.14 to 2.45, p = 0.460), but the rate of major adverse cardiac cerebrovascular events was lower in the CABG group (7.8% versus 17.9%, HR: 0.15, 95% CI: 0.06 to 0.37, p < 0.001) mainly due to less repeat revascularization with CABG (1.4% versus 11.6%, HR: 0.02, 95% CI: 0.01 to 0.13, p < 0.001). Age, 3-vessel disease, and serum creatinine > or =1.5 mg/dl were positive independent predictors of 12 mo death. At 12 mo, CABG was associated with less adverse events primarily due to less repeat revascularization compared with DES although there was no significant difference in mortality and myocardial infarction (MI) rates between the 2 groups; high repeat revascularization rate related to DES resulted from high restenosis rate in diabetic patients and lower rate of complete revascularization offered by PCI.

Methods and Limitations of Assessing New Noninvasive Tests

Outcomes-based approaches are the preferred methodology for technology validation. As discussed in part I of this review, the difficulties of performing an unbiased diagnostic evaluation are increasingly appreciated.1 An outcomes-based approach is advantageous in that it mimics the clinical application of testing. By risk stratifying patients, the results of this approach can be applied directly to clinical practice.2 Nonetheless, outcomes-based technology validation is not without challenges and limitations. These issues include the need for multivariable modeling for observational data, end point selection, and limitations of estimating posttest risk. Finally, it is increasingly appreciated that the future “gold standard” for outcomes-based assessments will be demonstrating whether imaging can identify which therapeutic approach optimizes patient benefit rather than merely identifying risk. ### Study Design Requirements of imaging studies include a relevant study population, comparison with an appropriate control group, and follow-up for outcomes. Designing randomized controlled trials (RCTs) that address imaging questions is challenging. The RCT may utilize imaging results as inclusion criteria or the basis for therapeutic assignment. Randomization to strategies with versus without imaging is problematic. The use of imaging per se affects outcomes only if a therapy is triggered; hence, in these studies, therapy and imaging results must be linked.3,4 Comparisons of imaging methods/modalities must mandate that test results are acted on rather than “available to the physician” (thus, an emphasis on efficacy rather than effectiveness). Because observational studies are far more common, they will be our focus. Although limited by inherent design flaws (eg, selection biases, potentially spurious observations, missing covariates), patients in observational studies better represent those seen in practice. #### Patient Selection Unlike diagnostic-based validation in which only patients referred to a gold standard after testing are included, in prognostic-based approaches all eligible patients are followed up at a preselected time point after testing to determine their status relative …

Interventional catheter treatment of bypass graft stenosis: comparison of intracoronary stent implantation and balloon angioplasty

Balloon angioplasty of a stenosed bypass graft has a much higher risk of recurrent stenosis than dilatation of a stenosed native coronary artery. Intracoronary stent implantation has established itself as the better treatment of native coronary artery stenosis than conventional balloon angioplasty. However, there is still uncertainty whether intracoronary stent implantation in stenosed bypass vessels gives better long-term results than conventional balloon angioplasty. Results were retrospectively analyzed of unrandomized 224 primarily successful interventions--122 balloon dilatations and 102 stent implantations--performed between January 1996 and June 1998 on stenosed coronary bypass grafts, re-examined by coronary angiography an average of 6 months later. All but 11 patients were on combined aspirin and ticlopidine antiplatelet aggregation treatment. There was a significantly lower 6-month restenosis rate (30.4%) after stent implantation than after balloon dilatation (51.6%). The re-intervention rate was also significantly lower after stent implantation. These data suggest that stent implantation of stenosed coronary bypass grafts under cover of platelet-aggregation inhibition with aspirin and ticlopidine provides a lower restenosis and thus higher revascularization rate than conventional balloon dilatation.

Implantation of sirolimus-eluting stents in saphenous vein grafts is associated with high clinical follow-up event rates compared with treatment of native vessels

The clinical effectiveness of sirolimus-eluting stents (SES) for treatment of patients with saphenous vein graft disease is not well defined. This analysis sought to evaluate the clinical follow-up after treatment of stenotic saphenous vein grafts using SES in a large patient registry. Patients treated with SES for saphenous vein graft disease were compared with patients receiving SES in native vessel disease. This is a subanalysis from the prospective multicenter German Cypher Stent Registry. Only patients with completed 6 months clinical follow-up were included. The analysis comprises 344 patients with 353 lesions in saphenous vein grafts treated with 400 SES (Cypher, Cordis Inc., Cordis Corp., Warren, New Jersey, USA) and 6411 patients with 7607 native coronary artery lesions treated with 8725 SES. Mean SES length per lesion was 22.6+/-11.7 mm and mean stent diameter 3.0+/-0.3 mm in saphenous vein graft lesions. Target vessel revascularization rate was 18.1% and major adverse cardiovascular events (MACE) rate was 23.8% at 6-month follow-up after SES implantation for saphenous vein graft lesions. Even after adjustment for different baseline characteristics, target vessel failure and MACE rate were significantly higher after SES implantation for saphenous vein graft lesions than for native coronary vessel stenosis [odds ratio: 2.10 (95% confidence interval: 1.40-3.13), P<0.001] and [odds ratio: 2.15 (95% confidence interval: 1.49-3.09), P<0.001], respectively. Treatment of saphenous vein graft disease is associated with high target vessel revascularization and MACE rates also with the use of SES if applied to unselected patients. Target vessel revascularization and MACE rates remain significantly higher after SES for saphenous vein graft lesions than after SES in native vessel disease.

Provisional T‐stenting and kissing balloon in the treatment of coronary bifurcation lesions: Results of the French multicenter “TULIPE” study

In previous prospective studies, a strategy of (a) stenting of the main branch, (b) provisional T-stenting of the side branch, and (c) final kissing balloon inflation, was associated with high success and low target lesion revascularization (TLR) rates on the long-term. To examine the performance of this strategy in a multicenter study. Consecutive patients were treated at 14 French medical centers for de novo coronary bifurcation lesions with the same technique used. Immediate results and clinically-driven TLR at 7 months were examined. The mean reference diameters of the main and side branches were 3.2 +/- 0.6 mm and 2.4 +/- 0.5 mm, respectively. The side branch was stented in 34% of patients. A <30% residual stenosis in the main branch was achieved in 99%, <50% in the side branch in 90%, and both in 89% of procedures. The in-hospital major adverse cardiovascular event were a Q-wave and 5 non-Qwaves MI (0.54% and 2.7%). At 7 months of follow-up, 3 patients (1.76%) had died, 1 suffered a non-Q-wave MI (0.59%), and 28 (15.88%) underwent TLR. By multivariate analysis, a lower left ventricular ejection fraction (OR: 0.934), moderate calcifications (OR: 7.86), and non-use of the "jailed" wire technique (OR: 4.26) were associated with reinterventions during follow-up. A strategy of provisional T-stenting with a tubular stent and final kissing balloon angioplasty for the treatment of coronary bifurcation lesions was safe and associated with a low TLR rate at 7 months. This strategy should be applicable to the new era of drug eluting stents.

Emergent Stenting of Extra-Cranial Internal Carotid Artery Occlusion in Acute Stroke has a High Revascularization Rate

As treatment options for both cerebral and extracranial aneurysms evolve, the search for an understanding of the molecular pathogenic events which underlie their formation continues in earnest. A recent article by Yoshimura, et al. in Nature Medicine offers provocative evidence that an improved understanding of the molecular events underlying abdominal aortic aneurysm (AAA) formation may be used for therapeutic gain (2). The AAAs develop as a result of chronic inflammation of the aortic wall, a decrease in medial smooth muscle cells and destruction of structural connective tissue proteins. Central aspects of this process include atherosclerosis, oxidative and mechanical stress, increased local production of proinflammatory cytokines and increased expression of matrix metalloproteinases (MMPs) that degrade structural proteins. And while inhibiting MMPs in animal models of aneurysms can prevent aneurysm expansion, aneurysm regression by drug therapy had not been reported previously. Yoshimura and colleagues now implicated a coordinating role for c-Jun N-terminal kinase (JNK) in the development of these aneurysms in mice, and demonstrated AAA regression after administration of a selective JNK inhibitor (2). JNK-working through the transcription factor c-Jun-is a known participant in inflammatory pathways, prompting the authors to investigate its role in AAA development. The authors first showed in microarray analysis of vascular smooth muscle cells that JNK activation was associated with a coordinated set of gene upregulation including MMP-9 and other proinflammatory proteins. They then showed co-localization of MMP-9 and activated JNK in AAA vascular smooth muscle cells. Interestingly, they also showed that activated JNK led to downregulation of genes such as lysyl oxidase and prolyl 4-hydoxylase involved in matrix deposition. In their mouse model of AAA-induced by periaortic 0.5M CaCl2-the authors convincingly demonstrated the regression of AAA as measured by reduced aortic diameter after subcutaneous administration of SP600125, a selective JNK inhibitor.Figure: Potential therapeutic targeting for aneurysm wall.In collaboration with Nobuo Hashimoto's neurosurgical group, the same investigators had reported activated JNK by immunohistochemistry in cerebral aneurysms a number of years ago (1), but these observations have not been extensively pursued. While AAA and cerebral aneurysms are disparate entities, they nevertheless may have overlapping pathogenic features; as such, we may do well to extend Yoshimura's observations to cranial disease. Moreover, this work is an elegant demonstration of the paradigm of molecular medicine-namely, that an enhanced understanding of molecular pathogenesis may guide therapeutic targeting. IAN F. DUNN, M.D. ROBERT M. FRIEDLANDER, M.D., M.A. BASIC SCIENCES

Emergent Stenting of Extra-Cranial Internal Carotid Artery Occlusion in Acute Stroke has a High Revascularization Rate

Emergent Stenting of Extra-Cranial Internal Carotid Artery Occlusion in Acute Stroke has a High Revascularization Rate

Comparison of clinical and angiographic features and longterm follow-up events between patients with variant angina and patients with ST elevation myocardial infarction

We investigated to what extent patients with variant angina and significant coronary stenosis (≥ 70%) present a clinical and angiographic profile similar to patients with ST elevation myocardial infarction. Thus, the clinical and angiographic features as well as follow-up events of 200 patients were prospectively analyzed and were compared with those of 422 patients with a first ST elevation myocardial infarction survivors of the early phase (3 days) and those of 70 patients with variant angina and non significant stenosis. Age and incidence of smoking, systemic hypertension, diabetes and maximum ST elevation were similar in the 2 groups. Furthermore, among patients with significant coronary stenosis, stenosis severity and the proportion of eccentric lesions were also comparable. Incidence of recent–within 30 days prior to admission–angina at rest was higher in variant angina patients with significant stenosis (67% vs. 27%, p < 0.001) than in those with myocardial infarction but long standing angina at rest (> 30 days) was low and comparable in these 2 groups (15% vs. 11%, ns). Also, in a 5-year follow-up most patients from these 2 groups were free from angina at rest (86% vs. 84%) which in variant angina patients was largely attributable to a high revascularization rate (72%). Moreover, the rate of myocardial infarction/cardiac death (20% vs. 19%) was also similar. Patients with variant angina and non-significant stenosis, however, had longer antecedent angina, more frequent follow-up angina and a lower incidence of cardiac events than the other 2 groups. Thus, these findings suggest that patients with variant angina and significant coronary stenosis generally behave as an acute coronary syndrome–likely associated with an acutely complicated plaque–rather than as recurrent vasospastic angina, and should be managed accordingly.

Emergent Stenting of Extracranial Internal Carotid Artery Occlusion in Acute Stroke Has a High Revascularization Rate

Acute ischemic stroke attributable to extracranial internal carotid artery (ICA) occlusion is frequently associated with severe disability or death. In selected cases, revascularization with carotid artery stenting has been reported, but the safety, recanalization rate, and clinical outcomes in consecutive case series are not known. We retrospectively reviewed all of the cases of ICA occlusions that underwent cerebral angiography with the intent to revascularize over a 38-month period. Two groups were identified: (1) patients who presented with an acute clinical presentation within 6 hours of symptom onset (n=15); and (2) patients who presented subacutely with neurologic fluctuations because of the ICA occlusion (n=10). Twenty-five patients with a mean age of 62+/-11 years and median National Institutes of Health Stroke Scale (NIHSS) of 14 were identified. Twenty-three of the 25 patients (92%) were successfully revascularized with carotid artery stenting. Patients in group 1 were younger and more likely to have a tandem occlusion and higher baseline NIHSS when compared with group 2. Patients in group 2 were more likely to show early clinical improvement defined as a reduction of their NIHSS by > or =4 points and a modified Rankin Score of < or =2 at 30-day follow-up. Two clinically insignificant adverse events were noted: 1 asymptomatic hemorrhage and 1 nonflow-limiting dissection. Endovascular treatment of acute ICA occlusion appears to have a high-recanalization rate and be relatively safe in our cohort of patients with acute ICA occlusion. Future prospective studies are necessary to determine which patients are most likely to benefit from this form of therapy.

Diabetes and Coronary Revascularization

ContextPatients with diabetes mellitus account for approximately 25% of the nearly 1.5 million coronary revascularization procedures performed each year in the United States and experience worse outcomes compared with nondiabetic patients.ObjectivesTo summarize the current state of evidence comparing the effectiveness and safety of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) in diabetic patients and to examine developments that may affect future outcomes in this high-risk group.Evidence AcquisitionUsing the key terms diabetes mellitus, revascularization, coronary artery bypass, angioplasty, and coronary intervention, we searched MEDLINE from 1985 to 2004 for all randomized controlled trials (RCTs) comparing CABG surgery and PCI that reported outcomes in diabetic patients. Bibliographies and the Web sites of cardiology conferences were also reviewed. Studies comparing drug-eluting stents and bare-metal stents were identified in a similar fashion. The literature was reviewed to identify clinical measures that may impact revascularization outcomes in diabetic patients.Evidence SynthesisWe identified 6 RCTs comparing CABG surgery and PCI in a total of 950 diabetic patients. A mortality benefit for CABG over balloon-only PCI has been demonstrated in diabetic patients with multivessel coronary artery disease but has not been clearly established against stent-assisted PCI or in high-risk CABG patients. Use of glycoprotein IIb/IIIa receptor inhibitors has improved survival in diabetic patients undergoing PCI. Restenosis after PCI in diabetic patients has led to substantially higher repeat revascularization rates than after CABG. The use of drug-eluting stents has led to dramatic reductions in restenosis in diabetic patients. Ongoing RCTs comparing CABG and PCI using drug-eluting stents in diabetic patients will clarify the impact of these advances on outcomes.ConclusionsThere is a relative lack of data from RCTs specifically comparing CABG surgery and PCI as currently practiced in diabetic patients. The mortality advantage and decreased rates of revascularization seen with CABG in subgroups from early trials may not be applicable in the era of drug-eluting stents, glycoprotein IIb/IIIa inhibitors, and the latest medical therapies.

Sirolimus-eluting stent treatment for isolated proximal left anterior descending artery stenoses

Stenting of isolated proximal LAD stenoses is still a controversial issue since it is associated with higher target vessel revascularization (TVR) rate than both bypass surgery using the internal mammary artery, and stenting of other coronary artery territories. The sirolimus- eluting stent (SES) has been reported to significantly reduce restenosis rates in de novo coronary lesions. Therefore, we compared patients from the German Cypher Registry treated with SES for isolated proximal LAD lesions with those stented for isolated lesions in the proximal LCX or RCA. A total of 349 patients treated with SES were analyzed. 249 patients were treated for proximal LAD stenosis, and 100 for proximal LCX/RCA stenoses. The combined clinical endpoint was MACCE (death of any cause, non-fatal MI and non-fatal stroke) and TVR at 6 months. In-hospital events (death, MI and TVR) did not differ significantly between both groups (3.2% for the LAD group vs 2.0% for the LCX/RCA-group, p=0.73). The combined end point of death of any cause, non-fatal MI and non-fatal stroke at six months was 2.6% in the LAD group, and 2.2% in the LCX/RCA group (p=1.0). TVR occurred in 4.8% of the LAD group and in 6.5% of the LCX/RCA group at six months (p=0.58). The percentage of patients free from angina at daily activities was 80.6% in the LAD group, and 77.4% in the LCX/ RCA group (p=0.52). SES once implanted into isolated proximal LAD stenoses appears as effective as reported in other vessel territories. Accordingly, stenting of the proximal LAD using SES might prove a suitable alternative to surgery.

Higher Revascularization Rates Not Linked with Better Post-MI Survival

Conventional wisdom holds that increased use of revascularization procedures improves post-MI outcomes, but few studies have addressed whether factors

Relevance of Increased Lung Thallium Uptake on Stress Imaging in Patients With Unstable Angina and Non-Q Wave Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI)-IIIB Study

Objectives. This study sought to determine the significance of abnormal thallium-201 (Tl-201) lung uptake on stress imaging in the absence of perfusion abnormalities.Background. Abnormal Tl-201 lung uptake, represented by an increased lung/heart ratio (LHR), on stress imaging is a marker of stress-induced left ventricular dysfunction and poor prognosis in patients with coronary artery disease.Methods. We evaluated 1,271 patients from the Thrombolysis in Myocardial Infarction (TIMI)-IIIB trial (86% of TIMI-IIIB cohort) with unstable angina or non-Q wave myocardial infarction, who underwent predischarge exercise (92%) or dipyridamole stress (8%) Tl-201 imaging. An increased LHR (≥0.50) was related to perfusion abnormalities and adverse cardiac events at 1 year.Results. Of 1,271 patients, there were 762 (60%) with and 509 (40%) without perfusion abnormalities. An increased LHR was seen in 227 patients (18%) (173 [23%] with, 54 [11%] without perfusion abnormalities). Patients with an increased LHR had a lower left ventricular ejection fraction, higher body weight, lower exercise capacity and a higher prevalence of angina on exercise than patients with a normal LHR. In the two groups with increased LHR, there was no difference in age, hypertension, previous myocardial infarction, total exercise time, frequency of angina and ST segment depression on exercise. However, the group with an increased LHR and normal myocardial perfusion had a preponderance of women (65% vs. 30%, p < 0.001). At 1-year follow-up, patients with an increased LHR had a higher cardiac event rate than those with a normal LHR (18% vs. 10%, respectively, p = 0.001) despite a higher revascularization rate (28% vs. 15%, p < 0.001). An increased LHR was associated with increased adverse cardiac events, irrespective of the presence or absence of perfusion abnormalities.Conclusions. An increased LHR continues to be associated with higher adverse cardiac events in the current era of aggressive interventional management of coronary artery disease. An increased LHR in the absence of myocardial perfusion abnormality is seen mostly in women and overweight patients. However, despite the apparent absence of perfusion abnormalities, an increased LHR in this group is also associated with a higher rate of adverse cardiac events.

The Short‐ and Long‐Term Outcome of Left Internal Mammary Artery Angioplasty

Failure of internal mammary artery (IMA) bypass grafts is uncommon. However, as their use continues to increase, this complication will be encountered more frequently by interventional cardiologists. The purpose of this article is to describe the short‐ and long‐term outcome of patients undergoing IMA angioplasty through a retrospective review of patients undergoing internal mammary angioplasty at two centers from January 1988 to June 1995. Percutaneous recanalization was attempted on 82 lesions either within an IMA or in the ongoing native left anterior descending artery during 74 procedures in 67 patients. The mean time from bypass surgery was 23 months. The lesion success rate was 84%. Dissection of the IMA occurred in 18% of procedures and was the most common cause for procedural failure and unfavorable outcome. Long‐term follow‐up was available in 82% of patients at a mean follow‐up of 45 months postprocedure. Clinical events occurred in 23 patients (34%) with 4 deaths (1 of which occurred during the initial hospitalization and after emergency bypass surgery), 2 repeat coronary bypass operations, and 17 patients with repeat coronary angioplasties. Despite the high repeat revascularization rate, 80% of patients were asymptomatic or had only infrequent angina at follow‐up. We conclude that angioplasty of or through an IMA bypass graft can be performed with a satisfactory procedural success rate and long‐term symptomatic benefit.