Multivessel Coronary Intervention Research Articles

Quantitative flow ratio of the donor coronary artery supplying a chronic total occlusion territory.

Coronary physiology to guide multi-vessel coronary intervention is associated with better outcome. In the presence of a coronary chronic total occlusion (CTO), hemodynamic evaluation of intermediate lesions in the donor coronary artery supplying a CTO territory still has limitations. We aim to evaluate implementing quantitative flow ratio (QFR) in assessing angiographically intermediate lesions of the main donor coronary artery supplying a CTO territory. We recruited 219 patients with a single main donor vessel to a CTO territory from a single-center CTO registry between 2017 and 2020. Angiographically intermediate coronary lesions of the donor vessels were evaluated using offline QFR before and at a median of 6 months after successful percutaneous coronary intervention (PCI) of CTO. The mean age of the study population was 66.9 ± 11.3 years, and 77.6% were males. Three-vessel disease was documented in 49.8%. The mean QFR value increased significantly in the donor vessels after successful CTO revascularization (0.93 ± 0.062 vs. 0.95 ± 0.046, p < 0.001) and was more prominent in donor vessels with angiographically intermediate stenosis (0.88 ± 0.063 vs. 0.92 ± 0.053, p < 0.001). While the change in QFR was not significant in angiographically normal donor vessel (0.97 ± 0.025 vs. 0.97 ± 0.026, p = 0.814). Fifteen patients had hemodynamically significant stenosis in the donor coronary artery (QFR ≤ 0.80) before CTO-PCI. Among those patients, 40% (n = 6) were turned to be non-significant with QFR > 0.80 after CTO recanalization, and 30% (n = 5) patients remained significant and were treated with PCI. QFR overestimates the severity of intermediate coronary lesions of a donor vessel supplying a CTO territory like other invasive modalities for physiology assessment.

Emergency coronary angiography in a 90-plus population: outcomes at 5-year follow-up.

Elderly people represent a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Our goal was to evaluate a group of very old patients who underwent emergency coronary angiography (CA). We retrospectively analyzed a group of very old patients (≥90 years old) who underwent emergency CA from 2008 to 2020. Survival and major adverse cardiovascular events (MACE) (a composite of all-cause death, ischemic stroke, ACS, or hospitalization for acute heart failure) were compared with an aged-matched control population with ACS not submitted to emergency CA. A total of 34 patients were enrolled, 56% of whom were female, with a median age of 92 years old. Almost all patients had ST elevation-ACS. In CA, 65% had multivessel disease, and coronary intervention was performed in 71%. More than one-third evolved in Killip class III/IV, and 70% had left ventricular dysfunction. Regarding mortality, 38% of patients died in the index event versus 25% in the aged-matched control group (p=0.319). During 5 years of follow-up, there was no significant difference in mortality between the 2 groups (Log-rank=0.403) and more than 50% of patients died in 2 years. Comparing MACE occurrence, both groups were similar (Log-rank=0.662), with more than 80% having at least one event in 5 years. Very old patients submitted to emergency CA had a high rate of multivessel disease and left ventricular dysfunction, in-hospital and follow-up mortality, and MACE. Compared to an aged-matched control group not submitted to emergency CA, they showed no survival or MACE benefit during a 5-year follow-up.

Correlation of Seattle Angina Questionnaire score and post-procedural outcomes in patients undergoing multi-vessel coronary intervention

Abstract Introduction The Seattle Angina Questionnaire (SAQ) score has been used to assess angina severity in patients undergoing coronary intervention. However, assessment of clinical outcomes using the SAQ score in those with multi-vessel disease (MVD) requiring multiple interventions has not been determined. Purpose To analyse patient-reported outcomes over time among individuals undergoing multiple staged interventions using serial SAQ scores. Methods We performed a retrospective analysis of 531 consecutive elective patients who underwent multi-vessel coronary intervention from January 1, 2015, to December 31, 2018, at a single academic centre. We used a short-form version of the SAQ score calculator that is built into our hospital electronic medical record. Trained clinical staff administered the SAQ at the point of care before each procedure. We divided the baseline SAQ scores into three groups [Group 1: &amp;lt;50, Group 2: 50–66, Group 3: ≥67] and analysed the correlation between the scores and patient-reported angina symptoms before the final staged intervention. Post index procedural outcomes, including myocardial infarction, congestive heart failure, post-procedural bleeding, and blood transfusion were reported. Results In all, 531 patients met inclusion and exclusion criteria. Patients' mean age was 65.66±10.30 years, and 78.3% of patients were males. Group 1 had an increased prevalence of diabetes (59.3% vs. 49.4% and 44%), prior coronary artery bypass surgery (CABG) (24.7% vs. 17.2% and 11.4%), a lower haemoglobin value (12.88±1.56 vs. 13.06±1.7 and 13.33±1.56) compared with group 2 and group 3. The rate of in-stent restenosis (ISR) was 18.7%, 11.5% and 8.6% in group 1, 2, and 3, respectively. Summary SAQ-7 values between interventions had improved significantly in group 1 (22.30±21.35) and group 2 (10.45±17.77), while group 3 failed to show any meaningful change (−1.09±14.79) (P&amp;lt;0.0001). [Table 1] The post-index-procedural outcomes were not statistically different among the three groups. In group 1, women (adjusted odds ratio [aOR]: 3.96; 95% confidence interval [CI]: 2.44 to 6.45; p&amp;lt;0.0001) and prior CABG patients (aOR: 2.03; 95% CI: 1.27 to 3.24; p=0.0031) had higher odds of SAQ-7 improvement between index and staged intervention. Conclusion The lowest baseline SAQ group had a significant improvement of SAQ score between the index and a staged intervention. The study demonstrated that serial SAQ scores could be used as a surrogate to measure patient-reported outcomes in those with MVD undergoing multiple interventions. Funding Acknowledgement Type of funding sources: None.

Successful Multivessel Coronary Interventions in a Patient With Single Coronary Artery.

Successful Multivessel Coronary Interventions in a Patient With Single Coronary Artery.

Hybrid minimally invasive multivessel coronary artery bypass grafting to achieve complete myocardial revascularisation: the first clinical case

Aim. To report the first clinical case of the hybrid procedure combining off-pump minimally invasive multivessel coronary artery bypass grafting (MICS-CABG) and percutaneous coronary intervention (PCI) of the obtuse marginal (OM) artery to achieve complete myocardial revascularisation.Clinical case. Bilateral in situ skeletonised left internal mammary artery (IMA) grafting to the left anterior descending artery was performed, and a Y-shape anastomosis was created from the left IMA-right IMA to the circumflex branch. At 2 hours postoperatively, graft failure caused by subtotal stenosis at the graft was diagnosed. Reconstruction of the anastomosis improved the transit time flow measurement by 3.5 hours postoperatively. Acute myocardial infarction did not develop. On postoperative day 1, graft patency was assessed, and then the OM stent was placed. On postoperative day 8, the patient was discharged and referred to the outpatient centre for further treatment and rehabilitation. Hybrid revascularisation offers the advantages of both CABG and PCI; however, the technical complexity is a major limitation for its widespread use. This case reports the development of adverse events during the surgeon's training to perform this nonstandard technology. Timely diagnosis of the initial graft failure and surgical revision led to a successful and complication-free outcome and avoided prolonged patient rehabilitation.Conclusion. Hybrid revascularisation combining MICS-CABG and PCI with new-generation drug-eluting stents can be a worthwhile alternative to conventional multivessel CABG with minimal invasiveness and complete revascularisation. Received 5 June 2020. Revised 10 September 2020. Accepted 15 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock

Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes. To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock. Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017. Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group. End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year. The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02). In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding. ClinicalTrials.gov Identifier: NCT01927549.

Is multivessel intervention in ST-elevation myocardial infarction associated with early harm? Insights from observational data.

Appraisal of evidence for recommendations for multivessel coronary intervention in ST-elevation myocardial infarction (STEMI). Multi-vessel disease (MVD) is common in patients with ST-segment elevation myocardial infarction (STEMI). Published observational data has suggested that multi-vessel percutaneous coronary intervention (MVPCI) at the time of initial hospitalization for STEMI may be harmful in contrast to evidence from recent randomized trials. We queried the nationwide inpatient sample (NIS) to identify characteristics of hemodynamically stable STEMI patients undergoing MVPCI on index admission and subsequent mortality in raw and adjusted models. To compare our results with published observational data, we searched multiple databases from inception through July 15, 2015. From 2009-2012, excluding cardiac arrest or cardiogenic shock, there were 11,454 MVPCI and 157,011 single-vessel PCI (SVPCI) for STEMI patients in the NIS. Compared to SVPCI, MVPCI on index admission was not associated with higher in-hospital mortality in unadjusted or propensity-adjusted models (MVPCI 1.91% vs. SVPCI 5.32%, P < 0.001). Our analysis of index hospitalization MVPCI versus infarct-related artery (IRA)-only PCI in the meta-analysis of observational studies (19 studies, N = 76,399) demonstrated no difference in in-hospital mortality with MVPCI compared with IRA-only PCI (OR 0.87, 95% CI 0.65-1.17; P = 0.37), with confirmation in study sequential analysis. MVPCI is uncommonly performed during index hospitalization in hemodynamically stable STEMI patients, likely reflecting widespread adherence to prior guidelines. Based on observational data, there does not appear to be early harm associated with MVPCI on the index admission in hemodynamically stable STEMI patients. © 2016 Wiley Periodicals, Inc.

TCTAP A-071 Clinical Outcomes of Multivessel Coronary Intervention in Octogenarians Hospitalized for Acute Coronary Syndrome: Comparisons with Younger Counterparts

TCTAP A-071 Clinical Outcomes of Multivessel Coronary Intervention in Octogenarians Hospitalized for Acute Coronary Syndrome: Comparisons with Younger Counterparts

The Role of Multivessel Coronary Intervention in ST-Segment Elevation Myocardial Infarction Complicated by Cardiogenic Shock

192 www.ccmjournal.org Cardiogenic shock (CS) complicates 7–10% of ST-segment elevation myocardial infarctions (STEMI). In the last decade, increased availability of percutaneous coronary intervention (PCI) has decreased the prevalence of CS in STEMI; despite this, mortality in these patients remains above 50%. It has been demonstrated that prompt PCI can improve outcomes among patients with STEMI complicated by CS (1, 2). A majority of these patients have associated multivessel disease (MVD) (3, 4) that is an independent predictor of mortality (5, 6). Optimal revascularization strategies in these patients remain controversial (7–13). Guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology state that only the infarctrelated artery (IRA) should be treated during the initial intervention for patients not in CS (14, 15). There are exceptions, although present guidelines do not explicitly recommend it. The Role of Multivessel Coronary Intervention in ST-Segment Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Have We Reached a Verdict?*

Abstract 18607: High-Risk, Multi-Vessel Coronary Intervention Guided by Viability-Imaging and Supported by Awake-ECMO in Patients With Severe Ischemic Cardiomyopathy is Feasible, Safe, and Efficacious

Background: The burden of end-stage coronary artery disease is rising and its care is complicated by cardiac failure and hospitalization. Recruitment of ischemic but viable myocardium is warranted to balance risk and benefit. Mechanical support enables high-risk coronary interventions despite severe LV-dysfunction. We aimed to develop a therapeutic algorithm of viability guided, awake-ECMO supported revascularization to stabilize therapy-refractory patients. Methods/Results: In this single-center study, consecutive patients (n=5, 61±9 yrs, all male) were prospectively enrolled (baseline: EF/echo study 15±4%; EF/SPECT-CT 17±5%). Myocardial perfusion SPECT-CT and viability 18-fluordesoxy-glucose (FDG)-PET imaging was performed. Veno-arterial ECMO (rate 3050±495 rpm, flow 2.8±1.0 l/min) was inserted in awake patients. Targeted by viability pattern, complex interventional revascularization was performed (2.8±1.1 vessels/patient, 3.0±1.5 stents/patient) without complications. Because no procedure/ECMO-related complications occurred, patients were discharged 5-7 days after PCI. During follow-up cardiac function improved significantly (ΔBNP: -42±15 %, p=ns; EF/echo: follow-up 26±7 %, ΔEF +11±7% vs. baseline, p&lt;0.05; EF/SPECT-CT 29±7%, ΔEF +11±6% vs. baseline, p&lt;0.05). This observation was associated with a clinical improvement (NYHA: 2.2±0.8; 6-minute walk: 242±76m; workload: max. 69±24W, VO 2 max. 9±2 ml/(min*kg), O 2 -pulse 8±2 ml/beat). Reflecting the recruitment of hibernating myocardium, perfusion defect score (SRS) was 27±15, LV-perfusion/metabolism mismatch 37±15%, and extent of scar 20±25%. Following revascularization, the perfusion defect score decreased (SRS: follow-up 21±14, p&lt;0.05); 50 of 85 myocardial segments showed significant improvement. All patient reported freedom from acute events for 172±61 days. Conclusion: We developed a novel algorithm of high-risk, multi-vessel coronary intervention guided by perfusion/viability-imaging and supported by transient awake-ECMO in fragile patients. This interdisciplinary strategy was safe, feasible, and efficacious in recruiting hibernating myocardium, and improving formerly unstable patients.

Multivessel Coronary Intervention During Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction. A Review of Consecutive Cases

Background: A 30-year-old female with severe oedema and effort intolerance had undergone tricuspid valve replacement (27mm bioprosthesis) 9 years previously for endocarditis complicating intravenous drug use. Echocardiography showed severe tricuspid valve stenosis with calcified leaflets. The desire for children and cervical neoplasia meant a second surgical bioprosthesis would require later re-replacement via a 3rd sternotomy when she may have young children; a mechanical valve with warfarinisation also had significant fetal and maternal pregnancy risks. Methods and procedure:No published literature on the use of percutaneous valves in the tricuspid position was identified. Personal communication identified 2 previous cases of percutaneous Melody valve use in the tricuspid position. Ethics approval for off-label use and informed consentwere obtained. The internal diameter of the previous bioprosthesis was known to be 20mm. Under general percutaneous coronary intervention (PCI) for acuteSTelevation myocardial infarction (STEMI) (Level of evidence C). There is some divergence of opinion about appropriate management of multivessel coronary disease (MVCD) foundduringSTEMI, appropriatenessofmultivessel coronary intervention (MVCI), and the clinical evidence. Methods: Retrospective review of consecutive primary and rescue STEMI PCI cases for a single operator between July 2006 and November 2009. Results: 102 cases were identified, mean follow-up 21.8 months. Mean age 62.7 years ±sd 11.9, 69/102 (68%) male, 17/102 (17%) rescue PCIs. 56/102 patients had single vessel disease; 14/56 (25%) transfers, 6/56 (10.7%) shock. Of 56 cases with single vessel disease, 2/56 (3.6%) died (1 shock, 1 hypoxic brain injury), 6/56 (10.7%) suffered target vessel revascularisation (TVR) (5 bare stent restenosis, 1 stent thrombosis). Of 46 patients with MVCD disease, 28/46 (60.9%) underwent culprit only PCI. 18/46 underwent MVCI (39.1%); 3/18 transfers (16.7%), 5/18 (27.8%) shock. 6/18 patients had 2 vessel PCI for triple vessel disease, 12/18 patients had complete revascularisation for 2 vessel disease. 2/18 (11.1%) patients with MVCI had TVR from ISR, 1/18 (5.6%) died (from shock). Conclusion: Contrary to guidelines, a sizeable proportion of cases with MVCD underwent MVCI during index STEMIPCI.Observedoutcomeswere similar to other subgroups,particularlypatientswith singlevesseldisease.We conclude that selected cases of MVCD can probably be safely treated withMVCI with potential advantages to the patient and institution logistics.

Multivessel Coronary Intervention During Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction. A Review of Consecutive Cases

Multivessel Coronary Intervention During Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction. A Review of Consecutive Cases

Multiple Coronary Lesion Instability in Patients With Acute Myocardial Infarction as Determined by Optical Coherence Tomography

Autopsy studies have suggested that acute myocardial infarction (AMI) represents a pan-coronary process of vulnerable plaque development. We performed multifocal optical coherence tomographic (OCT) examination to compare coronary lesion instability between AMI and stable angina pectoris (SAP). A total of 42 patients with AMI (n = 26) or SAP (n = 16) who had multivessel disease and underwent multivessel coronary intervention were enrolled in the present study. The OCT examination was performed not only in the infarct-related/target lesions, but also in the noninfarct-related/nontarget lesions. OCT-derived thin-cap fibroatheroma (TCFA) was defined as a lesion with a fibrous cap thickness of <65 microm. In the infarct-related/target lesions, plaque rupture (77% vs 7%, p <0.001) and intracoronary thrombus (100% vs 0%, p <0.001) were observed more frequently in AMI than in SAP. The fibrous cap thickness (57 + or - 12 vs 180 + or - 65 microm, p <0.001) was significantly thinner in AMI and the frequency of OCT-derived TCFA (85% vs 13%, p <0.001) was significantly greater in AMI than in SAP. In the noninfarct-related/nontarget lesions, the frequency of plaque rupture was not different between the 2 groups. Intracoronary thrombus was observed in 8% of AMI, but it was not found in SAP. The fibrous cap thickness (111 + or - 65 vs 181 + or - 70 microm, p = 0.002) was significantly thinner in AMI and the frequency of OCT-derived TCFA (38% vs 6%, p = 0.030) was significantly greater in AMI than in SAP. Multiple OCT-derived TCFAs in both the infarct-related/target and the noninfarct-related/nontarget lesions were observed in 38% of patients with AMI but not in patients with SAP (p = 0.007). In conclusion, the present OCT examination demonstrated multiple lesion instability in the presence of AMI.

Development and construct validation of performance metrics for multivessel coronary interventions on the VIST virtual reality simulator at PCR2005.

The first aim of this study was the development of performance metrics in a virtual reality simulation for interventional procedure in a real case of multivessel coronary disease. A second aim was to assess the construct validity of these metrics by comparing the performance of interventional cardiologists with different levels of experience. Ninety-four practicing interventional cardiologists attending the EuroPCR 2005 in Paris, France participated in this study. Complete data was available on eighty-nine participants (95%). Participants were divided into three categories depending on experience. Group 1 (novices): N = 33, < 1 years experience; Group 2 (intermediate experience): N = 14, >50 cases per year for the last two years and Group 3 (master physicians): N = 42 participants completed > 100 cases per year during the last five years. Over a period of months during 2004-2005 we identified potential performance metrics for cases of coronary artery disease which were then applied to a case of a patient admitted because of stable angina (class 1) with multivessel coronary disease. Patient's coronary anatomy and lesions were then reconstructed and implemented for the VIST virtual reality simulator. All participants were required to perform this case. Overall, experienced interventional cardiologists performed significantly better than the novices for traditional metrics such as time (p = 0.03), contrast fluid (p = 0.0008) and Fluroscopy time (p = 0.005). Master physicians performed significantly better than the other two groups on metrics which assessed technical performance e.g., time to ascend the aorta (p = 0.0004) and stent placement accuracy (p = 0.02). Furthermore, master physicians made fewer handling errors than the intermediated group who in turn made fewer than the novice group (p = 0.0003). Performance consistency was also a linear function of experience. Novel performance metrics developed for the assessment of technical skills for a simulated intervention for multi-vessel coronary disease showed that more experienced interventional cardiologists performed the procedure better than less experienced interventionalists thus demonstrating construct validity of the metrics.

Outcome of Multivessel Coronary Intervention in the Contemporary Percutaneous Revascularization Era

Clinical outcomes after multivessel versus single-vessel percutaneous coronary intervention (PCI) in the era of stents, glycoprotein IIb/IIIa inhibitors, and clopidogrel pretreatment have not been well studied. Thus, we compared outcomes from the Do Tirofiban and ReoPro Give Similar Efficacy Outcome Trial (TARGET) for patients who underwent multivessel versus single-vessel PCI and separately considered the effect of acute coronary syndromes on the results. Composite clinical outcomes (death, myocardial infarction, and target vessel revascularization) were evaluated at 30 days and 6 months and mortality at 1 year. Safety analysis included in-patient major and minor bleeding. Despite similar baseline characteristics, patients who underwent multivessel PCI (n = 775) had significantly higher 30-day and 6-month composite event rates than did those who were treated in a single coronary artery territory (n = 3,969). This association remained significant at 30 days (hazard ratio 1.57, 95% confidence interval 1.06 to 2.33, p = 0.025) after using propensity matching to minimize confounding factors. The higher event rate was primarily due to an increase in periprocedural myocardial infarction. However, there were no significant differences in propensity-matched ischemic outcomes at 6 months and 1 year or in bleeding. In addition, in a propensity-matched analysis that included 810 patients with acute coronary syndrome, multivessel stenting resulted in numerically more ischemic events than did single-vessel stenting, although this did not reach statistical significance (hazard ratio 1.32, 95% confidence interval 0.85 to 2.05, p = 0.221). In conclusion, multivessel PCI was more often associated with periprocedural myocardial infarction than single-vessel intervention, although this did not translate into higher 1-year mortality. A randomized trial comparing multivessel PCI with staged or surgical revascularization is warranted.

Selective Renal Arterial Infusion of Fenoldopam for the Prevention of Contrast‐Induced Nephropathy

Contrast-induced nephropathy (CIN) remains an important complication of angiographic procedures, particularly among patients with significant renal impairment. To date, vasodilator therapies such as fenoldopam have failed to prevent CIN, possibly because significant hypotension as a result of systemic infusion has limited the ability to deliver adequate drug levels to the renal vasculature. We present a case of averted CIN after multivessel coronary intervention in a diabetic patient with severe renal insufficiency, potentially due to bilateral renal arterial infusion of fenoldopam. Our subsequent experience with intrarenal fenoldopam in nine additional procedures in eight other high risk patients resulted in one case of asymptomatic transient CIN. Further studies are warranted to evaluate the efficacy of intrarenal administration of vasodilator therapies such as fenoldopam for the prevention of CIN.

Drug-Eluting Stents in the Management of Coronary Artery Disease

Of the >1 million patients who undergo coronary intervention in the US annually, 10–45% develop stent restenosis. Designed to inhibit tissue growth following coronary intervention, the drug-eluting stent (DES) is a breakthrough technology that has been shown to reduce restenosis by 80%, dramatically lowering the percentage of patients requiring repeat intervention. The health-economic implications of DES are complex and depend on the perspective from which they are viewed (i.e. hospital, payor, or physician). For hospitals, DES are a truly disruptive technology. Hospitals are caught between substantially higher costs (DES cost 3-fold more than bare-metal stents), inadequate reimbursement for those higher costs, and potentially declining revenue (fewer bypasses and repeat interventions for restenosis). In contrast, DES appear to be very cost effective for payors. Randomized studies have suggested that the higher initial costs of DES are nearly offset by reduced follow-up costs related to fewer repeat angioplasties and bypass surgeries. Furthermore, overall cost reductions to payors will occur as patients are converted from bypass surgery to multi-vessel coronary intervention with DES. Their high price continues to be a barrier to the use of DES, while the concerns about safety and stent thrombosis have substantially diminished. With greater competition, declining DES prices, and further studies demonstrating safety and efficacy in a wider range of real-world patients, DES will become the default platform for transcatheter coronary intervention in the near future.

Angiographic Outcome in Multivessel Disease (GABI II Study) Using New Coronary Device Interventions and Comparison with GABI I Trial Results

Percutaneous coronary interventions using stents were investigated in patients with multivessel disease. Acute and long-term results were compared with those of the German Angioplasty Bypass Surgery Investigation trial in a prospective multicenter study. The study included 134 patients in whom 277 lesions were treated. Angiographic success and procedural success were achieved in 268 of 277 lesions (97%) and 118 of 134 patients (88%), respectively. Control angiography performed in 90 of 118 eligible patients (76%) exhibited restenosis in 43 of 182 lesions (24%). Multivariate regression analysis found that a diffuse lesion, the lesion and stent length, and the final luminal diameter were predictive for restenosis. Thus, immediate and long-term results of multivessel coronary intervention utilizing stents were improved compared to percutaneous transluminal coronary angioplasty of multivessel lesions. However, there is still need for improvement of long-term results, especially in particular lesion subgroups.

Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction

The feasibility and safety of simultaneous multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction was analyzed in a retrospective, case-controlled study. Patients who underwent multivessel coronary intervention had a higher risk of adverse clinical outcomes through 6 months compared with matched controls in whom coronary intervention was limited to the infarct-related artery.

Abciximab: Cost-effective survival advantage in clinical trials and clinical practice

Adjunctive blockade of the platelet glycoprotein (GP) IIb/IIIa receptor during either percutaneous coronary intervention (PCI) or for patients who present with non-ST segment elevation acute coronary syndromes has demonstrated efficacy in reducing platelet-mediated adverse cardiovascular ischemic events. The three currently available agents (abciximab, eptifibatide, tirofiban) differ markedly in pharmacodynamic and pharmacokinetic profiles, receptor affinity, and cost. Although pharmacoeconomic substudies are available from placebo-controlled randomized trials of platelet GPIIb/IIIa blockade during PCI, “real-world” cost-effectiveness data from high-volume practice are lacking. Therefore, in-hospital and late (6-month) clinical outcomes and cumulative cost/charge data were analyzed on 1472 consecutive PCI procedures (70% received abciximab) performed by high-volume operators at a single institution. 1 Data were adjusted for lack of randomized treatment allocation with the use of a propensity scoring technique. Adjunctive abciximab therapy for PCI was associated with a significant (3.4%) reduction in mortality to 6 months. Based on the economic cost-effectiveness concept of cost per life year gained relative to standard therapy, 2 , 3 abciximab provided a cost-effective survival advantage in high-volume interventional practice that compares very favorably with currently accepted standards. Clinical and procedural demographics associated with increased cost-effectiveness include multivessel coronary intervention, stent deployment, recent (<1 week) myocardial infarction (MI), and impaired left-ventricular (LV) function. (Am Heart J 2000;140:S148-53.)