Revascularization Percutaneous Coronary Intervention Research Articles

Retrograde Recanalization of Chronic Total Occlusions in Europe: Procedural, In-Hospital, and Long-Term Outcomes From the Multicenter ERCTO Registry

BackgroundA retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). ObjectivesThe authors describe the European experience with and outcomes of retrograde PCI revascularization for coronary CTOs. MethodsFollow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization. ResultsThe mean patient age was 62.0 ± 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 ± 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score ≥3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up. ConclusionsThe number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes.

Long-term mortality in patients with coronary heart disease after surgical revascularization and percutaneous coronary intervention

Introduction. Numerous randomized trials have compared success of surgical myocardial revascularization (CABG) and percutaneous coronary intervention (PCI) in the treatment of coronary artery disease. Large clinical registries published that compared to percutaneous intervention, coronary surgery is still associated with better long-term survival. Objective. The aim was to examine the overall and cardiac mortality after coronary artery bypass graft and percutaneous coronary intervention and examine the validity of non-randomized studies in the evaluation of their successes. Method. The study included 186 patients with coronary artery disease (57.2 ± 7.5 years), 93 (50%) with CABG (57.9 ± 9.0 years) and 93 (50%) with PCI (56.3 ± 5.0) (p>0.05). From the total number of patients was isolated a subgroup of 109 patients who had intervention more than five years ago, 62 (56.9%) of them with CABG and 47 (43.1%) with PCI. We assessed the overall and cardiac mortality in patients with CABG and PCI. Start of the follow-up was the date of myocardial revascularization. Patients with CABG were followed 84.4 ± 64.4 months, and those with PCI 65.7 ± 49.4 months (p<0.01). Results In the group of patients treated with CABG, followed for 7 years in average, died 28 (30.1%), with an average annual mortality of 4.2%. Cardiac death was diagnosed in 26 (27.9%) patients, and annual mortality was 3.9%. In the group of patients treated with PCI, followed in average of 5.5 years, died 7 (7.5%), with an average annual mortality rate of 1.3%. Cardiac death was diagnosed in 6 (6.4%) patients with an annual mortality rate 1.2%. At the end of the first year, the mortality rate of patients treated with CABG and PCI was 5.3% and 1.0%, in the third year 9.6% and 4.3% and in the fifth year 13.9% and 4.3% respectively. In the subgroup of patients who have survived at least five years from date of the intervention, in next five years, died 11.3% of patients with CABG and 2.1% with PCI (p <0.01). Mortality of patients with three vessel disease treated with CABG, was 32.8%, during 5.7 years of follow-up and the mortality of the patients with PCI was 11.7% during 6.7 years of follow-up (p <0.05). The mortality of patients with multivessel disease, treated with CABG and PCI was 27.9% and 12.9% respectively (p <0.05). Conclusion. Patients treated by PCI compared to patients treated by CABG exhibited lower average annual cardiac mortality, lower mortality in first five years from the time of revascularization, and significantly lower mortality in three vessel and multivessel disease. The low mortality rate of patients treated by percutaneous coronary intervention with stent implantation indicates favorable impact of PCI treatment on long term survival of patients with coronary artery disease. A small number of patients and significant differences in clinical, angiographic and echocardiography characteristics of patients are limiting factor valid and relevant comparison of success between CABG and PCI revascularization therapy.

Complete percutaneous coronary intervention revascularization after unsuccessful surgical revascularization with allergy to aspirin

A 72-year-old diabetic (type II) patient with multivessel coronary artery disease (distal LMCA, critical LAD/D2 bifurcation stenosis, proximal OM1 stenosis and ostial PD of RCA) and normal systolic left ventricular function underwent surgical revascularization (9/2012). Since a long segment of LAD was intramural, LIMA was found to be too short so patient obtained two venous grafts — on LAD and diagonal branch. Marginal branches as well as PD were found not suitable for grafting. 48 hours later ST elevation in inferior leads was observed and urgent angiography was carried out. Grafts to LAD and D2 had a TIMI III flow, showing LAD antero- and retrogradely but with a stenosis of LAD at the point of junction. Venous graft to D2 fills retrogradely the artery as well as the median part of the LAD. In addition native D2 is shown to be significantly narrowed distally to the point of graft junction. Probable cause of the ECG changes were due do ostial PD stenosis and being a smaller caliber vessel and patient haemodinamically stable, patient was treated conservatively, than later discharged. But at outdoor control silent ischaemia was documented and new angiography performed showing disfunction of the graft to distal LAD and still normally functioning graft to D2 but with stenosis as previous. We considered complete secondary revascularization but had to face a known allergy to aspirin and the need of effective dual antiplatelet therapy in a diabetic. Our strategy was to divide interventions in two steps — firstly we did PCI on LAD with 2 DES in proximal and median segment (Xience 2,5x28 + 3,0x18) and OM with 1 BMS (Yukon 3,0x16) under the protection of enoxaparine which was changed to varfarine and 140mg of clopidogrel which was substituted by ticagrelor. The primary result was excellent. In the second act intervention on LMCA and D2 via venous graft (DES) is considered after possible desensibilization treatment for aspirin allergy that poses us now the greatest problem.

42 Retrospective calculation of syntax score in 200 patients undergoing elective coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI); are we following best practice?

<h3>Introduction</h3> Cardiologists are generally the gatekeepers of coronary artery disease and have been much criticised for not discussing all patients being considered for revascularisation therapy at an MDT (multi-disciplinary team) meeting or not referring patients with traditional “surgical disease” for CABG. At the Freeman Hospital (FRH), a large cardiothoracic unit in the North of England, patients are typically referred for PCI or CABG by cardiologists working within the Newcastle upon Tyne Trust or from district general hospitals within the network. Patients are not routinely discussed at MDT but can be brought to the weekly meeting at the discretion of the referrer. The recently reported SYNTAX study allows objective quantification of the degree of coronary disease and facilitates an evidence based decision between CABG and PCI. This gives us the opportunity to examine whether elective revascularisation is being performed appropriately at our institution. <h3>Methods</h3> We performed a retrospective analysis at the Freeman Hospital. 200 patients who had elective revascularisation between April 2009 and April 2010 were selected. This included 100 cases of CABG and 100 of PCI. Half of each were referrals from other hospitals. Patients9 SYNTAX scores were calculated using pre-procedure angiograms. MDT meeting records and patients9 notes were reviewed. <h3>Results</h3> The average SYNTAX score for patients undergoing elective PCI was 15, compared to 29 for those undergoing CABG. 84% of patients undergoing elective PCI had SYNTAX scores less than 22. 35% of all patients referred for elective CABG had scores greater than 33. The average SYNTAX score for CABG referrals from outside the trust was lower (25) than from within the trust (31). <h3>Discussion</h3> The majority of patients undergoing PCI at the FRH have SYNTAX scores in the lowest tertile. There is no difference in the SYNTAX scores in patients having PCI from referral bases within the centre or from outside. In total almost one quarter of all patients undergoing CABG have a SYNTAX score in the lowest tertile. And this rises to almost one third in those patients referred from district general hospitals. Only a small number of these patients have an additional clear indication for CABG over PCI. Furthermore we found that a significant proportion of these do not go through MDT planning. These results may indicate that cardiologists are more likely to bring patients to MDT meetings than surgeons and, according to SYNTAX scoring, more patients are inappropriately having CABG than are inappropriately having PCI. Based on this data in our institution discussing all patients at an MDT and the use of SYNTAX scoring at point of referral would be more likely to increase PCI revascularisation rates.

Young patients with chest pain: 1-year outcomes

Objective Prior studies found that young adult chest pain patients without known cardiac disease with either no cardiac risk factors or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day cardiovascular events. Longer-term event rates in this subset of patients are unknown. We hypothesized that patients younger than 40 years without past cardiac history and a normal ECG are at less than 1% risk for 1-year adverse cardiovascular events. Methods We conducted a prospective cohort study in an urban university emergency department evaluating patients younger than 40 years who received an ECG for evaluation of potential ACS. Cocaine users, cancer patients, and patients with a history of myocardial infarction or revascularization were excluded. Structured data collection at presentation included demographics, chest pain description, history, laboratory results, and ECG data. Hospital course was followed. Follow-up was obtained by telephone, record review, and social security death index search. Our main outcome was 1-year adverse cardiovascular events (death; acute myocardial infarction [AMI]; or revascularization—percutaneous coronary intervention [PCI] or coronary artery bypass graft). Descriptive statistics and 95% confidence intervals were used. Results Of 3846 chest pain patients, 609 met criteria. Of those, 35.5% were admitted. Patients had a mean age of 34.8 years (SD, 3.8 years). They were most often female (57.6%) and black (69.5%). There were 7 patients (1.1%; 95% CI, 0.5%-2.4%) with adverse cardiovascular events over the year. Of the subset of 560 patients with a normal/nonspecific ECG, there were 2 deaths (0.4%), 3 AMI (0.5%), and 2 PCIs (0.4%) by 1 year for a composite adverse cardiovascular event rate of 6 (1.1%; 95% CI, 0.4%-2.3%). Of the subset of 269 patients with no cardiac risk factors and a normal/nonspecific ECG, there were no deaths, 1 AMI, and 1 PCI for a composite adverse cardiovascular event rate at 1 year of 0.3% (0.01%-2.1%). The addition of an initial cardiac marker to this group resulted in a cohort that was event-free at 1 year (95% CI, 0%-1.4%). Conclusions Patients younger than 40 years without a cardiac history who present to the ED with symptoms consistent with ACS but have either no risk factors or a normal or nonspecific ECG have a very low rate of adverse events during the subsequent year.

Can We Override Clopidogrel Resistance?

Clopidogrel, a thienopyridine antiplatelet agent, has been used alone or in association with aspirin to prevent vascular complications in atherothrombotic patients. It is also, in combination with aspirin, the key treatment to prevent stent thrombosis in patients who have undergone percutaneous coronary intervention. It is estimated that >40 million patients worldwide receive clopidogrel. Recent investigations into genetic mechanisms that influence clopidogrel efficacy suggest that a common variant present in ≈30% of whites has the potential to identify patients with a deficient clopidogrel metabolic activation who are consequently at risk of recurrent cardiovascular events, including stent thrombosis.1–3 Stent thrombosis is the most serious complication of coronary stent implantation, often leading to empiric modifications of antiplatelet treatments, although stent thrombosis pathogenesis is complex and the weight of the various factors involved is not known.4 We report 7 recent cases of stent thrombosis with demonstrated platelet resistance to clopidogrel, and we describe a novel clinical approach using pharmacodynamic and genetic information to override clopidogrel resistance. ### Patient Selection and Characteristics The clinical characteristics of 7 patients who presented with stent thrombosis on clopidogrel treatment (75 mg maintenance dose [MD]) are presented in the Table. Stent thrombosis was angiographically proven in all patients and occurred on days 1, 3, 5, 6 (2 patients), 11, and 70, with a median time from stent implantation to stent occlusion of 6 days (interquartile range, 4 to 8.5 days). Clinical presentation was ST-elevation myocardial infarction in all cases, and 4 of 7 patients had a history of myocardial infarction. Stent thrombosis occurred in 6 patients with a bare metal stent and 1 patient with a drug-eluting stent. Primary percutaneous coronary intervention revascularization of stent thrombosis was performed with a new bare metal stent in 6 patients; in the remaining patient, a drug-eluting stent was implanted. View this table: Table. Baseline Characteristics of the …

Surgical revascularization for cardiac allograft vasculopathy: Is it still an option?

Cardiac allograft vasculopathy remains a major cause of mortality after cardiac transplantation. Percutaneous revascularization has become the mainstay of therapy given the poor historical outcomes with surgery. Outcomes following surgical revascularization are evaluated to determine whether surgery remains a viable therapeutic option. A retrospective analysis was performed of 13 heart transplant recipients who had cardiac allograft vasculopathy requiring coronary artery bypass grafting with or without adjunctive percutaneous coronary intervention for revascularization from 1999 to 2008. Thirteen patients had 14 coronary artery bypass grafting procedures at 141 +/- 66 months after transplantation. The average number of grafts was 2.3. Eight were performed without cardiopulmonary bypass, of which 5 were approached via left thoracotomy and the remainder via repeat sternotomy. One patient had renal failure and a cerebrovascular accident. Percutaneous coronary intervention before or after coronary artery bypass grafting was required in 3 patients. There were no perioperative mortalities. At mean follow-up of 39 +/- 36 months, 3 patients have died, 2 from progressive cardiac allograft vasculopathy and 1 from lung cancer. Kaplan-Meier survival for this group of patients was 92%, 83%, and 83% at 1, 5, and 7 years, respectively. Surgical revascularization for cardiac allograft vasculopathy remains a viable treatment option for appropriate patients and may be performed safely with good medium-term outcomes. However, patients remain at risk for disease progression and may require percutaneous or surgical reintervention.

Mounting Evidence for Safety and Improved Outcomes of Drug-Eluting Stenting

Mounting Evidence for Safety and Improved Outcomes of Drug-Eluting Stenting

Five-Year Follow-Up of the Medicine, Angioplasty, or Surgery Study (MASS-II)

Clinical trials are organized for many different reasons. Most drug and device trials are designed to demonstrate the safety and efficacy of a drug or device, not to prove that they are the optimal treatments for patients. On the other hand, treatment strategy trials are designed to study the value of one therapeutic regimen compared with another when equipoise or confusion exists regarding which course to pursue. Assumptions are based on prior knowledge and opinion; in the case of coronary artery disease, most trials have been divided into those studying patients who “need” revascularization (ie, EAST [Emory Angioplasty versus Surgery Trial], BARI [Bypass Angioplasty Revascularization Investigation], CABRI [Coronary Artery Bypass Revascularization Investigation], RITA [Second Randomized Intervention Treatment of Angina], GABI [German Angioplasty Bypass Intervention], ARTS [Arterial Revascularization Therapies Study], SOS [Stent or Surgery], ERACI II [Estudio Randomizado Argentino de Angioplastia vs Cirugia II], and meta-analyses of these trails1,2⇓) and those in whom medical therapy is judged to be a reasonable choice. The latter list is short—RITA-2 [Second Randomized Intervention Treatment of Angina]3 and the awaited COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation]4 and BARI 2D [Bypass Angioplasty Revascularization Investigation 2 Diabetes]5 trials. Article p 1082 An assumption is made that patient groups can be identified that will be suitable candidates either for equipoise between 2 revascularization choices or for medical therapy versus revascularization. The study by Hueb et al6 in this issue of Circulation enrolled patients, most of whom would have been eligible for percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) trials, to 3 arms including medical therapy only. Eligible patients had multivessel coronary artery disease (3 vessels, 58%; 2 vessels, 42%), and the left anterior descending artery was involved in 92% of the patients. Therefore, these patients seem …

Urgent revascularization with PCI was more cost-effective than CABG in medically refractory, high-risk myocardial ischemia

Source Citation Stroupe KT, Morrison DA, Hlatky MA, et al. Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients....

Impact of Completeness of Percutaneous Coronary Intervention Revascularization on Long-Term Outcomes in the Stent Era

Impact of Completeness of Percutaneous Coronary Intervention Revascularization on Long-Term Outcomes in the Stent Era

Cost-Effectiveness of Coronary Artery Bypass Grafts Versus Percutaneous Coronary Intervention for Revascularization of High-Risk Patients

A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients. Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer's perspective, and effectiveness was measured by survival. After 3 years, average total costs were 63,896 dollars for PCI versus 84,364 dollars for CABG patients, a difference of 20,468 dollars (95% confidence interval [CI] 13,918 dollars to 27,569 dollars). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were 81,790 dollars for PCI versus 100,522 dollars for CABG patients, a difference of 18,732 dollars (95% CI 9873 dollars to 27,831 dollars), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications. PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.

Impact of Completeness of Percutaneous Coronary Intervention Revascularization on Long-Term Outcomes in the Stent Era

The importance of completeness of revascularization by percutaneous coronary intervention in patients with multivessel disease is unclear in that there is little information on the impact of incomplete revascularization outside of randomized trials. The objective of this study is to compare long-term mortality and subsequent revascularization for percutaneous coronary intervention patients receiving stents who were completely revascularized (CR) with those who were incompletely revascularized (IR). Patients from New York State's Percutaneous Coronary Interventions Reporting System were subdivided into patients who were CR and IR. Then subsets of IR patients were contrasted with CR patients. Differences in long-term survival and subsequent revascularization for CR and IR patients were compared after adjustment for differences in preprocedural risk. A total of 68.9% of all stent patients with multivessel disease who were studied were IR, and 30.1% of all patients had total occlusions and/or > or =2 IR vessels. At baseline, the following patients were at higher risk: those who were older and those with more comorbid conditions, worse ejection fraction, and more renal disease and stroke. After adjustment for these baseline differences, IR patients were significantly more likely to die at any time (adjusted hazard ratio=1.15; 95% confidence interval, 1.01 to 1.30) than CR patients. IR patients with total occlusions and a total of > or =2 IR vessels were at the highest risk compared with CR patients (hazard ratio=1.36; 95% confidence interval, 1.12 to 1.66). IR with stenting is associated with an adverse impact on long-term mortality, and consideration should be given to either achieving CR, opting for surgery, or monitoring percutaneous coronary intervention patients with IR more closely after discharge.

Percutaneous coronary intervention for revascularization of the diabetic patient

The field of interventional cardiology has progressed rapidly in recent years with the advent of new technology and expanding role of adjunctive pharmacology. This article provides an overview of both current and historical approaches to treating coronary artery disease in the diabetic patient.

P3340 Impact of intravascular ultrasound on target lesion revascularization in percutaneous coronary intervention

P3340 Impact of intravascular ultrasound on target lesion revascularization in percutaneous coronary intervention