Causes and correlates of death after unsupported coronary angioplasty: implications for use of angioplasty and advanced support techniques in high-risk settings

Is being an elderly woman a risk factor for worse outcomes after percutaneous coronary intervention? A large cohort study from one center

It has remained undefined whether the combination of being elderly (ie, >75 years old) and female is a risk factor for worse outcomes after percutaneous coronary intervention (PCI). A total of 29 211 consecutive patients who underwent PCI were analyzed. Kaplan-Meier estimated 3-year rate of cardiac death was significantly higher in elderly females in comparison with all other groups (P < .05). Using Cox proportional hazard models, being an elderly female was a significant risk factor for cardiac death and cardiac death/MI in comparison with being a young female, OR (95% CI): 2.53 (1.15-5.59), 2.26 (1.27-4.03), or young male, OR (95% CI): 2.22 (1.26-3.91), 2.25 (1.44-3.51); however, it was not a significant risk factor in comparison with being elderly male, OR (95% CI): 1.30 (0.97-1.71), 1.21(0.94-1.55). Elderly females had worse outcomes after PCI therapy than other gender and age groups, but being an elderly female was not an independent risk factor for worse PCI outcomes.

Mode of death after contemporary percutaneous coronary intervention: a report from the Evaluation of Drug Eluting Stents and Ischemic Events registry

BACKGROUND

When selecting clinical trial end points, some investigators prefer cardiovascular death (CVD) while others believe that all-cause mortality is more relevant. However, the relative contribution of CVD to 1-year mortality after contemporary percutaneous coronary intervention (PCI) is not known.

METHODS

We evaluated the mode of death (MOD) in EVENT, a prospective PCI registry at 55 US hospitals. Vital status was assessed at 6 and 12 months as part of the study protocol, and MOD was independently reviewed in blinded fashion.

RESULTS

Between 2004 and 2007, EVENT enrolled 10,144 patients of whom 295 (2.9%) died within the first year: 51 (17%) ≤30 days; and 244 (83%) between 31 and 365 days after index PCI. Overall, CVD accounted for 42% of deaths, and no clear cause could be identified in a substantial subgroup (25% of deaths). Among patients who died ≤30 days, the MOD was more likely to be CVD (odds ratio 3.96, 95% CI 2.08-7.55), whereas the incidence of CVD and non-CVD was similar after 30 days. Findings were similar after a series of sensitivity analyses including reassignment of unknown MOD to the CVD category, using multiple imputation modeling, or when evaluating MOD in prespecified subgroups of patients with diabetes, acute coronary syndromes, or left ventricular dysfunction.

CONCLUSIONS

Among unselected PCI patients, 1-year mortality is approximately 3%, and CVD is confirmed in <50% of all deaths. Regardless of analytic approach, CVD is the primary contributor to overall mortality during the first 30 days after PCI, whereas rates of CVD and non-CVD are remarkably similar after the first month after PCI.

Impact of gender on clinical outcomes after mTOR-inhibitor drug-eluting stent implantation in patients with first manifestation of ischaemic heart disease

BACKGROUND

Women have a worse outcome than men after percutaneous coronary intervention (PCI). However, in the drug-eluting stent (DES) era, limited data are available about the impact of gender-related differences on clinical outcome. Furthermore, many series have also included patients previously treated by coronary-artery bypass grafts or PCI, which may bias the evaluation of DES-related clinical events at follow up. We aimed to assess the impact of gender on clinical outcomes in a consecutive series of patients at first manifestation of coronary artery disease (CAD) undergoing PCI with mTOR-inhibitor DES.

METHODS AND RESULTS

A total of 138 consecutive patients (age 64 ± 13 years, female gender 29%) undergoing successful mTOR-inhibitor DES implantation [sirolimus-eluting stent (SES); zotarolimus-eluting stent (ZES); and everolimus-eluting stent (EES)] for the treatment of stable chronic angina or an acute coronary syndrome, as their first clinical manifestation of CAD, were prospectively enrolled between February 2008 and May 2009. Major adverse cardiac events (MACE), defined as a combination of cardiac death, myocardial infarction (MI), and clinically driven target lesion revascularization (TVR) at 12-month follow up, constituted the endpoint of the study. Fifty-one (37%) patients received SES; 46 (33%) patients received ZES; and 41 (30%) patients received EES. At follow up, 21 (15%) patients experienced a MACE. Three (2%) patients had cardiac death, five (4%) had MI, while 13 (9%) patients underwent clinically driven TVR. MACE occurred more frequently in females than males [10 (25%) vs. 11 (11%), p = 0.05]. At Cox regression analysis, the only independent predictors of MACE were female gender and implantation of more than one stent [hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.46-9.36, p = 0.006; HR 1.26, 95% CI 0.99-2.74, p = 0.01, respectively].

CONCLUSIONS

In conclusion, our finding suggests that women may have a worse outcome as compared with men after mTOR-inhibitor DES implantation.

Assessing the appropriateness of coronary revascularization: the University of Maryland Revascularization Appropriateness Score (RAS) and its comparison to RAND expert panel ratings and American College of Cardiology/American Heart Association guidelines with regard to assigned appropriateness rating and ability to predict outcome

BACKGROUND

Significant regional variation in procedural frequencies has led to the development of the RAND and American College of Cardiology/American Heart Association (ACC/AHA) guidelines; however, they may be difficult to apply in clinical practice. The University of Maryland Revascularization Appropriateness Score (RAS) was created to address the need for a simplified point scoring system.

HYPOTHESIS

The study was undertaken to compare revascularization appropriateness ratings yielded by the RAND Expert Panel Ratings, ACC/AHA guidelines, and the University of Maryland RAS.

METHODS

We applied these three revascularization appropriateness scoring systems to 153 catheterization laboratory patients with a variety of cardiac diagnoses and treatments. For each patient, appropriateness scores assigned by each of the three systems were compared with each other and with the actual treatment delivered. Concordance of care with appropriateness score was then correlated with outcome.

RESULTS

There were significant differences among all three scoring systems in their ratings and in the concordance of treatment with appropriateness rating. When treatment provided was concordant with RAND ratings, there was a lower occurrence of subsequent coronary artery bypass grafting (CABG), the composite end point of either CABG or percutaneous transluminal coronary angioplasty (PTCA), and the composite end point of death, myocardial infarction (MI), or revascularization. When treatment was concordant with the ACC/AHA guidelines, there was lower occurrence of all-cause mortality, PTCA, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. When treatment provided was concordant with the RAS, there was lower occurrence of cardiac death, all-cause death, CABG, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization.

CONCLUSIONS

The RAS is a simple scoring system to assess revascularization appropriateness. When the RAND, ACC/AHA, and RAS systems are compared in a catheterization laboratory population, they rate the same patient differently and vary in their correlation of appropriateness rating with outcome.

A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions

Gender differences exist in outcomes, particularly early mortality, for percutaneous interventions (PCI) and coronary artery bypass graft surgery (CABG). Better understanding of this issue may target areas for improvement for all patients undergoing revascularization. Therefore, we summarized the evidence on gender differences in PCI and CABG outcomes, particularly early mortality, and mediators of this difference. Using the key terms "women" or "gender," "revascularization," "coronary artery bypass," "angioplasty," "stent," and "coronary intervention," we searched MEDLINE from 1985 to 2005 for all randomized controlled trials (RCTs) and registries reporting outcomes by gender. Bibliographies and the Web sites of cardiology conferences were also reviewed. The literature was examined to identify gender differences in outcomes and mediators of these differences. We identified 23 studies reporting outcomes by gender for CABG and 48 studies reporting outcomes by gender for PCI. The majority of studies noted greater in-hospital mortality in women than in men, with mortality differences resolving with longer follow-up. Early mortality differences were reduced but not consistently eliminated after adjustment for comorbidities, procedural characteristics, and body habitus. Power to detect gender differences after multivariate adjustment was limited by declining mortality rates and small sample size. Gender was an independent risk factor for complications after both CABG and PCI. Women experience greater complications and early mortality after revascularization. Future exploration is needed of gender differences in quality of care and benefit from combinations of stenting and antiplatelet, and anticoagulant medications in order to optimize treatment.

Revascularization in Heart Failure: The Role of Percutaneous Coronary Intervention

Despite being technically challenging and carrying a higher periprocedural risk, the performance of revascularization in patients who have heart failure of ischemic origin can provide substantial clinical benefits. Although several studies have demonstrated a benefit of the performance of coronary artery bypass grafting over percutaneous coronary intervention (PCI) among patients who have depressed ejection fraction undergoing revascularization, most of these studies were conducted during the balloon angioplasty era and before the widespread use of drug-eluting stents that have dramatically reduced the need for repeat revascularization among patients undergoing PCI. The use of lower profile intra-aortic balloon catheters and other novel cardiac support devices may extend the use of PCI and lower rates of periprocedural complications among this high-risk population.

Influence of sex on in-hospital outcomes and long-term survival after contemporary percutaneous coronary intervention

BACKGROUND

Early studies suggested that morbidity and mortality after percutaneous coronary intervention (PCI) were greater for women than men. However, in recent reports, sex-related differences in short-term outcome have decreased as outcomes among women have improved.

OBJECTIVE

The aim of the study was to evaluate the effect of sex on long-term mortality among a large cohort of patients undergoing PCI in the contemporary era.

METHODS

Three hospitals in New York City contributed prospectively defined data elements on 4284 consecutive patients undergoing PCI in 1998 to 1999. All-cause mortality at a mean follow-up of 3 years was the primary end point.

RESULTS

Of the 4284 patients, 1331 (31%) were women. Women were significantly older than men (mean age 67 vs 62 years, P < .001) and less often white (72% vs 80%, P < .001). Hypertension (78% vs 66%, P < .001) and diabetes (36% vs 22%, P < .001) were more prevalent in women. Prior cardiac surgery (14% vs 19%, P = .001) and previous myocardial infarction (MI) (33% vs 36%, P = .08) were less common among women. Presentation with unstable angina was more frequent in women (45% vs 41%, P = .034), whereas presentation with acute MI did not differ by sex. Congestive heart failure developed more commonly among women (7.1% vs 4.1%, P < .001). The extent of coronary disease (1-, 2-, or 3-vessel disease) did not differ between women and men. Mean ejection fraction was 52% in women and 50% in men (P < .001). Stents were placed in 77% of both groups. Procedural success was 97% for both women and men. Inhospital adverse outcomes including death, post-PCI MI, emergency bypass surgery, abrupt closure, and stent thrombosis were uncommon and not different between groups. Mortality at 3 years was 10% for women and 8.9% for men (P = .197). However, using Cox proportional hazards analysis to adjust for comorbidities and possible confounders, female sex was associated with a significant independent reduction in the hazard of long-term mortality (hazard ratio 0.78, 95% CI 0.620-0.969, P = .02).

CONCLUSIONS

Despite more high-risk characteristics, female sex conferred a long-term survival advantage after PCI.

Simplified scoring system for predicting mortality after percutaneous coronary intervention

OBJECTIVES

We sought to develop a simplified scoring system based on pre-intervention clinical characteristics to predict in-hospital mortality after percutaneous coronary intervention (PCI).

BACKGROUND

Percutaneous coronary intervention is associated with variety of complications, including the risk of death. Factors leading to poor outcomes need to be identified. Currently available indexes are cumbersome and therefore seldom used.

METHODS

Crude mortality and univariate odds ratios (ORs) for mortality associated with multiple clinical characteristics were calculated for 9,954 patients undergoing PCI at the William Beaumont Hospital during 1996 to 1998. Based on the OR, each factor was assigned a weighted score. Using these scores, a classification was constructed to determine the probability of death after PCI, with classes I through IV representing an increasing probability of procedural mortality. This classification was validated in a separate group of patients.

RESULTS

The factors with the highest univariate odds of dying and their scores were: myocardial infarction <14 days = 7; elevated creatinine = 4; multivessel disease = 4; and age >65 years = 3. Classes were created based on the presence of these factors in a given patient. The odds of dying and mortality increased significantly with each class. These results were reproduced in the validation subset.

CONCLUSIONS

Preprocedural clinical risk factors have a differential influence on the probability of death after PCI. Risk classification based on these factors can be used to accurately predict the procedural outcome. This simple classification can be used by interventionalists to assist in management decisions, to provide an estimate of procedural risk to the patients and relatives, and for quality assurance.

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999

OBJECTIVES

We sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men.

BACKGROUND

Previous work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). From 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates.

RESULTS

From 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (p(trend) < or = 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, p(trend) = 0.378) and men (by 37.6%, p(trend) = 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096).

CONCLUSIONS

Concurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

Effect of gender on the outcomes of contemporary percutaneous coronary intervention

Limited information exists regarding the outcomes of newer percutaneous coronary intervention (PCI) technologies in women. This study sought to determine whether female gender is an independent risk factor for PCI mortality and/or complications in contemporary practice. Using information from the National Cardiovascular Network (NCN) Database on 109,708 (33% women) PCI cases from 22 hospitals between January 1994 and January 1998, we examined the association of gender with unadjusted and risk-adjusted procedural outcomes. Women undergoing PCI were older, smaller, and had more comorbid illness than men, but less extensive coronary disease. Temporal trends in PCI device selection were similar in men and women. Compared with men, women had higher unadjusted procedural mortality rates (1.8% vs 1.0%, p <0.001), more strokes (0.4% vs 0.2%, p <0.001), and higher vascular complication rates (5.4% vs 2.7%, p <0.001). However, after adjusting for baseline clinical risk factors, and importantly, body surface area, women and men had similar PCI mortality risks (adjusted odds ratio 1.07, 95% confidence interval 0.92 to 1.24). Gender was not an independent risk factor for mortality among subgroups receiving coronary stent or atherectomy devices after risk adjustment. However, women undergoing PCI remained at higher risk for stroke, vascular complications, and repeat in-hospital revascularization than men, even after risk adjustment. We conclude that in contemporary practice, a patient's body size rather than gender, conveys independent risk for mortality after PCI.

Long-term outcome of coronary balloon angioplasty in diabetic patients

Diabetes is recognised to increase morbidity and mortality after coronary revascularization. We compared clinical outcomes in mean 5-year-long follow-up of coronary balloon angioplasty in diabetic and non-diabetic patients. We studied 621 patients undergoing elective angioplasty from 1987 to 1996. There were 60 (9.7%) patients with diabetes who were compared with 561 non-diabetic patients. Diabetics were older, more often obese, less frequently were current smokers, and less frequently had hypercholesterolaemia. Diabetic patients in comparison with non-diabetics had lower ejection fraction and more frequently had angioplasty of complex (B2 or C) lesions, but there were no differences between both groups in the other clinical and angiographic risk factors. Clinical success of angioplasty, as well as complications rate were similar in both groups. In follow-up restenosis occurred more frequently in diabetics (46.3 vs. 32.2%, P=0.03), resulting in significantly higher re-intervention rate (50.0 vs. 35.4%, P=0.03). Especially diabetic patients were more frequently referred to CABG (20.4 vs. 9. 9%, P=0.02). There were no significant differences in deaths (1.9 vs. 2.8%) and myocardial infarction (3.7 vs. 4.4%). Diabetics presented worse CCS status at the end of observation (Class 0 and I - 61.1 vs. 74.4%, P=0.037). Angioplasty proved to be a safe procedure in diabetic patients. Despite higher restenosis and re-intervention rate in diabetics, mortality as well as myocardial infarction rate was the same in both groups during mean 5-year follow-up.

Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease

The field of interventional cardiology began in the late 1970s and consisted primarily of balloon catheter angio plasty until the early 1990s. Although understanding of the process of coronary angioplasty has evolved signifi cantly, restenosis still remains the Achilles' heel of the interventional cardiologist. This article reviews the cur rent issues involved in interventional cardiology for coronary disease from patient selection, anticoagulant therapy, restenosis, current interventional devices (stent mania), and future devices (intracoronary radiation). Noncoronary interventional procedures, vaivuloplasty, and atrial septal defect closure are also reviewed to provide an overview of cardiac interventional proce dures for the anesthesiologist.

Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Unprotected Left Main Trunk Intervention Multi-center Assessment

The ULTIMA registry was a prospective, multicenter, international registry of 277 patients who underwent percutaneous coronary interventions of unprotected left main trunk stenosis. The 40 patients who underwent an emergency percutaneous left main intervention for acute myocardial infarction are the focus of this study. We compared the results of primary angioplasty with primary stenting, characterizing both the short-term (in-hospital) and long-term (12-month) outcomes. Of the 40 patients, 23 underwent primary angioplasty, whereas 17 underwent primary stenting. The angiographic success rate was an 88% for the cohort. The in-hospital death or coronary artery bypass grafting rate was 65% for the entire group, 74% for the percutaneous transluminal coronary angioplasty group (PTCA), and 53% for the stent group (p = 0.2). The in-hospital death rate was 55% for the entire cohort, 70% for the PTCA group, and 35% for the stent group (p = 0.1). The 12-month rate of death or bypass surgery was 83% and 58% for the PTCA and stent groups, respectively (p = 0.047). The 12-month survival rate was 35% and 53% for the PTCA and stent groups, respectively (p = 0.18). Bypass surgery was required in 6 patients in the PTCA group and 2 patients in the stent group (p = 0.07). Patients undergoing percutaneous interventions for unprotected left main myocardial stenosis during an acute myocardial infarction are critically ill; an initial percutaneous revascularization approach appears feasible and may be the preferred revascularization strategy. Primary stenting was associated with improved clinical outcomes.

Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. The Northern New England Cardiovascular Disease Study Group

BACKGROUND

Some deaths after percutaneous coronary angioplasty (PTCA) occur in high-risk situations (eg, shock), whereas others are unexpected and related to procedural complications. To better describe the epidemiologic causes of death after PTCA, we undertook a systematic review of all in-hospital PTCA deaths in Northern New England from 1990 to 1993.

METHODS

The medical records of 121 patients who died during their acute hospitalization for PTCA were reviewed with a standardized data extraction tool to determine a mode of death (eg, low output failure, arrhythmia, respiratory failure) and a circumstance of death (eg, death attributable to a procedural complication, preexisting acute cardiac disease). Any death not classified as a procedural complication was reviewed by a committee and the circumstance of death assigned by a majority rule.

RESULTS

Low-output failure was the most common mode of death occurring in 80 (66.1%) of 121 patients. Other modes of death included ventricular arrhythmias (10.7%), stroke (4.1%), preexisting renal failure (4.1%), bleeding (2.5%), ventricular rupture (2.5%), respiratory failure (2.5%), pulmonary embolism (1.7%), and infection (1.7%). The circumstance of death was a procedural complication in 65 patients (53.7%) and a preexisting acute cardiac condition in 41 patients (33.9%). Women were more likely to die of a procedural complication than were men.

CONCLUSION

Procedural complications account for half of all post-PTCA deaths and are a particular problem for women. Other deaths are more directly related to patient acuity or noncardiac, comorbid conditions. Understanding why women face an increased risk of procedural complications may lead to improved outcomes for all patients.

Cost of cardiac care in the three years after coronary catheterization in a contained care system: critical determinants and implications

OBJECTIVES

We sought to determine the clinical, angiographic, treatment and outcome correlates of the intermediate-term cost of caring for patients with suspected coronary artery disease (CAD).

BACKGROUND

To adequately predict medical costs and to compare different treatment and cost reduction strategies, the determinants of cost must be understood. However, little is known about the correlates of costs of treatment of CAD in heterogeneous patient populations that typify clinical practice.

METHODS

From a consecutive series of 781 patients undergoing cardiac catheterization in 1992 to 1994, we analyzed 44 variables as potential correlates of total (direct and indirect) in-hospital, 12- and 36-month cardiac costs.

RESULTS

Mean (+/-SD) patient age was 65+/-10 years; 71% were men, and 45% had multiple vessel disease. The initial treatment strategy was medical therapy alone in 47% of patients, percutaneous intervention (PI) in 30% and coronary artery bypass graft surgery (CABG) in 24%. The 36-month survival and event-free (death, infarction, CABG, PI) survival rates were 89.6+/-0.2% and 68.4+/-0.4%, respectively. Median hospital and 36-month costs were $8,301 and $28,054, respectively, but the interquartile ranges for both were wide and skewed. Models for log(e) costs were superior to those for actual costs. The variances accounted for by the all-inclusive models of in-hospital, 12- and 36-month costs were 57%, 60% and 71%, respectively. Baseline cardiac variables accounted for 38% of the explained in-hospital costs, whereas in-hospital treatment and complication variables accounted for 53% of the actual costs. Noncardiac variables accounted for only 9% of the explained costs. Over time, complications (e.g., late hospital admission, PI, CABG) and drug use to prevent complications of heart transplantation became more important, but many baseline cardiac variables retained their importance.

CONCLUSIONS

1) Variables readily available from a comprehensive cardiovascular database explained 57% to 71% of cardiac costs from a hospital perspective over 3 years of care; 2) the initial revascularization strategy was a key determinant of in-hospital costs, but over 3 years, the initial treatment become somewhat less important, and late complications became more important determinants of costs.

Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996

BACKGROUND

Coronary artery bypass surgery (CABG) has been considered the therapy of choice for patients with unprotected left main (ULMT) coronary stenoses. Selected single-center reports suggest that the results of percutaneous intervention may now approach those of CABG.

METHODS AND RESULTS

To assess the results of percutaneous ULMT treatment from a wide variety of experienced interventional centers, we requested data on consecutive patients treated after January 1, 1994, from 25 centers. One hundred seven patients were identified who were treated either electively (n=91) or for acute myocardial infarction (n=16). Of patients treated electively, 25% were considered inoperable, and 27% were considered high risk for bypass surgery. Primary treatment included stents (50%), directional atherectomy (24%), and balloon angioplasty (20%). Follow-up was 98.8% complete at 15+/-8 months. Results varied considerably, depending on presentation and treatment. For patients with acute myocardial infarction, technical success was achieved in 75%, and survival to hospital discharge was 31%. For elective patients, technical success was achieved in 98.9%, and in-hospital survival was strongly correlated with left ventricular ejection fraction (P=.003). Longer-term event (death, infarction, or bypass surgery) -free survival was correlated with ejection fraction (P<.001) and was inversely related to presentation with progressive or rest angina (P<.001). Surgical candidates with ejection fractions > or = 40% had an in-hospital survival of 98% and a 9-month event-free survival of 86+/-5%, whereas patients with ejection fractions < 40% had 67% and 22+/-12% in-hospital and 9-month event-free survivals, respectively. Nine hospital survivors (10.6%) experienced cardiac death within 6 months of hospital discharge.

CONCLUSIONS

While results for selected patients appear promising, until early post-hospital discharge cardiac death can be better understood and minimized, percutaneous revascularization of ULMT stenosis should not be considered an alternative to bypass surgery for most patients. When percutaneous revascularization of ULMT is required, directional atherectomy and stenting appear to be the preferred techniques, and follow-up angiography 6 to 8 weeks after treatment is probably advisable.

Evaluation of an active coronary perfusion balloon device using Doppler flow wire during PTCA

The aim of this study was to assess whether active coronary perfusion catheters (APC) can provide a sufficient coronary flow in large caliber vessels during balloon inflation. To prevent myocardial ischemia during PTCA, these APC may be employed. However, it is as yet unknown whether the active flow rate of these devices approaches the flow rate prior to PTCA during balloon inflation. Therefore, we measured the efficacy of the APC during balloon inflation in vessels supplying a large amount of myocardium. In 12 patients (1 female, 11 males, 53 +/- 12.6 yr) with stenosed vessels (average diameter 3.4 +/- 0.26 mm), the coronary flow velocity was measured using a 0.014" Doppler guidewire, which was placed distally bypassing the balloon of the APC. The active perfusion balloon catheter was advanced through a 7F guiding catheter along a 0.014" guidewire. After removal of the guidewire, arterial blood being withdrawn from the side port of the femoral angioplasty sheath was pumped through the catheter to the distal coronary vessel. The perfusion volumes of the pump were set to different levels between 30 to 60 ml/min. Intracoronary flow rate was calculated by the angiographically assessed vessel luminal area [symbol: see text] average peak velocity [symbol: see text] 0.5. The mean coronary flow rate prior to PTCA was 43 +/- 17.7 ml/min. Maximum flow during PTCA was 55 +/- 19.6 ml/min. We found a good correlation between the preset external pump rate and the coronary flow in situ (r = 0.92). Pre-PTCA flow rates were achieved in 11 of 12 patients (92%) during balloon inflation. No relevant decrease in the arterial pressure occurred during dilation times of 4.6 +/- 1.63 min. Only two patients showed significant ECG changes during these balloon inflations. After an average follow-up period of 13 +/- 6.3 mo, only one patient (8%) had a significant re-stenosis requiring the implantation of a stent. The combination of intravascular Doppler velocity measurements with quantitative coronary angiography offers the opportunity of exact online flow registration during angioplasty. Using APC, It is possible to maintain a sufficient coronary flow in the distal vessel during balloon inflation even in large vessels. Therefore, as compared with mechanical circulatory assist devices, coronary assist by APC is a little invasive, but according to our measurements it might be a sufficient tool for performing PTCA also in high-risk patients.

Low-normal or excessive body mass index: newly identified and powerful risk factors for death and other complications with percutaneous coronary intervention

Recognized risk factors account for only a small portion of the variance in the 4% to 10% incidence of major ischemic events associated with percutaneous coronary intervention. Body mass index (BMI) (body weight in kg/[height in m]2) is a clinically useful estimate of body fat and has been shown to correlate with mortality from several causes. We sought to evaluate the effect of BMI as a potential risk factor for the complications of percutaneous coronary intervention in 3,571 consecutive percutaneous coronary intervention patients treated at a single referral center. Patients were prospectively divided into the nonobese (BMI < or = 25), mildly obese (BMI 26-35), and very obese (BMI > 35), based on accepted definitions. Multiple logistic regression analyses were used to determine the correlates of major complications from 25 candidate variables, including BMI < or = 25 (n = 614 patients) and BMI > 35 (n = 275 patients), recorded prospectively in a relational database. Death occurred in 2.8% of the BMI < or = 25 group, in 3.7% of the BMI > 35 group, and in 0.9% of the BMI 26-34 group (p < 0.001), but there was no difference in the incidence of other ischemic events. Blood product transfusion was required in 12% of the BMI < or = 25 group, in 7% of the BMI 25-34 group, and in 8% of the BMI > 35% group (p = 0.003). Multivariate analysis, after adjustment for other significant correlates, demonstrated that both BMI < or = 25 (odds ratio [OR] = 2.7, p = 0.005) and BMI > 35 (OR = 7.4, p < 0.001) were independent correlates of death. Low-normal or high BMI is a newly described and powerful risk factor for in-hospital death after percutaneous coronary intervention.

PTCA with the use of cardiac assist devices: risk stratification, short- and long-term results

Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% +/- 8.9%) in combination with significant coronary artery disease (2.7 +/- 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patient's circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 x sepsis, 1 x early reocclusion, 1 x cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patient's condition is stabilized by means of supported PTCA.

Distal coronary hemoperfusion during percutaneous transluminal coronary angioplasty

Distal coronary hemoperfusion during percutaneous transluminal coronary angioplasty (PTCA)-with an autoperfusion balloon or active system-facilitates prolonged balloon inflation. Prolonged inflations may tack up intimal dissections and improve the primary angioplasty result in complex lesions. Additionally, distal perfusion may reduce the likelihood of cardiogenic shock during high-risk PTCA. Autoperfusion balloons are most frequently used to treat acute or threatened closure. There currently is no prospective clinical study showing that stent implantation for this complication is more successful and more cost-effective. The blood flow rates through autoperfusion balloons may not abolish myocardial ischemia, and higher flow rates can often be achieved with pumps. Therefore, during high-risk PTCA, pumps may be preferred to prevent hemodynamic collapse. Clinical application of perfusion pumps is hampered by the risk for mechanical hemolysis during prolonged perfusion and the high velocity of the bloodstream that exits the PTCA catheter, causing distal vessel wall trauma.

Subacute occlusion, bleeding complications, hospital stay and restenosis after Palmaz-Schatz coronary stenting under a new antithrombotic regimen

OBJECTIVES

This study was designed to evaluate the effect of an antithrombotic regimen without full early anticoagulation on subacute occlusion, bleeding, hospital stay and restenosis after elective coronary stenting.

BACKGROUND

Subacute occlusion is a major limitation of stenting. Aggressive antithrombotic therapy is not fully prophylactic against this complication, carries risk of bleeding, prolongs hospital stay and reduces cost-effectiveness.

METHODS

We studied 110 consecutive patients (121 lesions) who underwent elective Palmaz-Schatz stenting. Intravenous heparin was given only during the procedure. After stenting, patients took aspirin, dipyridamole, dextran, warfarin and low molecular weight heparin (enoxaparin, 40 mg subcutaneously daily, stopped when an international normalized ratio of 2 to 3 was achieved). The first 52 patients (group A) underwent coronary angiography 24 h after stenting, and hospital stay was extended until an international normalized ratio of 2 to 3.5 was achieved. The remaining 58 patients (group B) were discharged 24 h after stenting. Clinical and angiographic follow-up were performed 1 and 6 months after stenting for all patients.

RESULTS

In group A the activated partial thromboplastin time remained normal (30 +/- 6.2 s [mean +/- SD]) during enoxaparin administration, and hospital stay was 9.1 +/- 4.3 days. In group B hospital stay was 27 +/- 8 h. No major cardiac events occurred within the first month in patients from both groups. At 1 and 30 days all stented lesions remained patent. Only two patients (1.8%, 95% confidence interval [CI] 0.32% to 7%) developed bleeding. At 6 months, the restenosis rate was 22% (95% CI 15% to 30%).

CONCLUSIONS

After coronary stenting with optimal angiographic results, this new antithrombotic regimen prevented subacute stent occlusion and bleeding, with a brief hospital stay. No detrimental effect on the previously reported restenosis rate was observed.

Percutaneous transluminal coronary angioplasty failures in patients with multivessel disease. Is there an increased risk?

In recent years, there has been a nationwide trend toward performing percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease. The clinical course of 57 consecutive patients who required emergency first-time coronary artery bypass grafting operations were reviewed to assess for difference in outcome between the 28 patients (49%) with single-vessel disease and the 29 patients (51%) with multivessel disease. The two groups were similar in preoperative characteristics except for a higher proportion of chronic obstructive pulmonary disease in the patients with multivessel disease (p = 0.03). Twice as many patients with multivessel disease were in shock (single-vessel disease = 4 [14%], multivessel disease = 8 [28%], p = not significant) en route to the operating room and significantly more patients with multivessel disease required on-going cardiopulmonary resuscitation (single-vessel disease = 0 [0%], multivessel disease = 5 [17%], p = 0.03). Significantly more coronary artery bypass grafts were placed in the patients with multivessel disease (single-vessel disease = 1.5 +/- 0.6, multivessel disease = 2.9 +/- 0.7, p < 0.01), which required longer aortic clamping time (p = 0.02) and cardiopulmonary bypass time (p < 0.01). There were seven postoperative deaths; all but one occurred in patients with multivessel disease (single-vessel disease = 1 [4%], multivessel disease = 6 [21%], p = 0.05). According to multivariate analysis, incremental risk factors of mortality were preoperative shock (p < 0.01), urgent or emergency percutaneous transluminal coronary angioplasty (p = 0.06), and multivessel disease (p = 0.12). Despite a similar incidence of myocardial infarction (single-vessel disease = 8 [29%], multivessel disease = 12 [41%], p = not significant), patients with multivessel disease had a higher incidence of cardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 11 [38%], p = 0.04) and noncardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 12 [41%], p = 0.02). By multivariate analysis, incremental risk factors of morbidity were preoperative shock (p < 0.01), multivessel disease (p = 0.02), and ejection fraction < 50% (p = 0.07). In the subset of patients with multivessel disease, preoperative shock, ejection fraction < 50, and an age of 60 years or greater were associated with higher morbidity and mortality. In conclusion, the risk of percutaneous transluminal coronary angioplasty failure is considerably higher in patients with multivessel disease. In certain subsets of patients with multivessel disease, coronary artery bypass grafting would be a safer procedure when compared with percutaneous transluminal coronary angioplasty for initial myocardial revascularization.

Cardiopulmonary support for complex angioplasty

The role of cardiopulmonary support (CPS) in interventional procedures is currently in evolution. The authors review the clinical applications and technical considerations involved in CPS including discussion of indications, hemodynamic effects, complications, and prophylactic versus stand-by techniques. Use of the technique in high risk percutaneous transluminal coronary angioplasty patients is discussed.

Autoperfusion balloon versus stent for acute or threatened closure during percutaneous transluminal coronary angioplasty

Efficacy and major clinical end points were compared in 61 patients treated with a Stack autoperfusion balloon versus 36 patients who received a Palmaz-Schatz stent for acute or threatened closure during coronary angioplasty. The groups were comparable regarding baseline clinical characteristics. Procedural success was achieved in 43 patients (70%) treated with an autoperfusion balloon versus 34 patients (94%) who received a stent (p < 0.02). Emergency bypass surgery was performed in 13 patients (21%) with the autoperfusion balloon versus none of the patients with a stent (p < 0.001). In the stent group, 3 patients (8%) died (p < 0.05); 2 deaths were caused by thrombotic reclosure, and 1 patient died after unsuccessful stent delivery. Subacute reclosure during hospitalization occurred in none of the patients with autoperfusion versus 8 patients with the stent (22%) (p < 0.0002). Therefore, the number of patients with successful stent implantation at discharge decreased to 26 (72%). At 3-month follow-up in all patients with a successful intervention, reclosure or angiographic restenosis (> 50%) occurred in 13 patients with autoperfusion (30%) versus 3 patients with stents (12%) (p = NS). There was no difference in event-free survival during follow-up. Thus, both interventions were equally successful in the treatment of acute and threatened closure. More emergency surgery was performed in the autoperfusion balloon group, whereas a higher subacute reclosure rate was seen in the stent group. At 3-month follow-up, there were no significant differences regarding reclosure, restenosis, and event-free survival.

Discordance in the predictors of mortality vs. those of ischemic complications following transcatheter coronary intervention

Outcomes of percutaneous transluminal coronary angioplasty (PTCA) depend upon the skill of the angioplasty team and on the characteristics of the patient population. Comparisons of outcomes from different laboratories must take into account the latter. A discordance may exist between the baseline predictors of death in hospital following PTCA and those for periprocedural ischemia. Baseline clinical and procedural characteristics of 3,725 patients who underwent PTCA during 1991 and 1992 were compared with complications by multivariate analysis. The age of the patient and the occurrence of an MI within the previous 30 days were the most powerful independent predictors of death. Ischemic complications were not independently associated with these factors. Emergency CABG was associated independently with target lesion complexity and abrupt reclosure, with unstable angina or attempted saphenous vein graft dilatation. Thus, mortality may more directly reflect baseline clinical characteristics than the skill of operators in avoiding ischemic complications.

Survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction

To assess the effects of coronary angioplasty in patients with severe left ventricular dysfunction, the results of procedures, performed between 1987 and 1991, in 100 patients (90 male) with left ventricular function < or = 0.35 (range, 0.20 to 0.35) and anginal symptoms were analyzed. Mean age was 62 +/- 10 years (range, 38 to 85 years). Ninety-five patients had previous myocardial infarction and 27 patients had previous coronary artery bypass grafting. Unstable angina was present in 81 percent of patients. Single-vessel disease was present in 6 patients, double vessel was present in 31 patients, and triple-vessel disease was present in 63 patients. Percutaneous transluminal coronary angioplasty (PTCA) was attempted on 164 vessels, 27 of these with chronic total occlusion. The overall angiographic success rate was 84 percent. Myocardial infarction occurred in four patients, six patients underwent urgent coronary bypass surgery, and seven patients died of cardiac causes. There was a 9 percent incidence of total in hospital mortality. Major complications were significantly more frequent in patients with triple-vessel disease. Clinical success was achieved in 75 patients, 55 of these with incomplete revascularization. Long-term follow-up (mean, 19 +/- 7 months) was available in all patients with clinical success. Thirteen patients had repeated PTCA, 8 patients had coronary surgery, and 13 patients died. In conclusion, in patients with severe left ventricular dysfunction, acute complications and late mortality rate are high. Patients with triple-vessel disease are a higher risk subset and have no long-term benefits by PTCA.

Optimizing surgical backup for multiple simultaneous percutaneous transluminal coronary angioplasty procedures

At busy interventional centers, it may be difficult to coordinate surgical backup for multiple simultaneous PTCA procedures. We sought to determine the actual risk of two simultaneous cases requiring surgery, and to identify a group in which multiple simultaneous PTCA procedures could be performed at low risk. We prospectively applied the ACC/AHA A/B/C lesion classification system and an empiric low/medium/high risk classification (based on patients' overall clinical picture) to 1,128 PTCA procedures over a 9 month period; 22 of these patients (1.9%) went directly from the catheterization laboratory to emergency CABG. The incidence of emergency CABG by groups was A-low 1/166, A-medium 1/71, A-high 0/22, B-low 1/116, B-medium 10/481, B-high 2/52, C-low 2/47, C-medium 3/88, and C-high 2/85. The patients were divided into two groups: minimal risk (A + B-low: 3/375 or 0.8%) and increased risk (B-med/high + C: 19/753 or 2.5%). The difference between the groups was significant using chi square with an alpha < 0.05. The risk of two cases requiring surgery at the same time was calculated as a function of the number of simultaneous PTCA procedures performed. Six or fewer minimal risk PTCA, one increased risk plus up to three minimal risk, and a maximum of two increased risk cases were found to have a risk of < 0.001. We conclude that it is possible to identify a group of patients with minimal risk, in whom multiple simultaneous procedures can be performed with a negligible probability of two cases requiring surgery at the same time.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of direct angioplasty for treatment of patients with acute myocardial infarction in hospitals with and without on-site cardiac surgery. The Myocardial Infarction, Triage, and Intervention Project Investigators

BACKGROUND

In the Myocardial Infarction, Triage, and Intervention (MITI) registry of acute myocardial infarction, 441 (12%) of 3750 patients had direct angioplasty as initial treatment. Approximately half (233) were performed in hospitals with no on-site surgery.

METHODS AND RESULTS

Procedure success rates, use of emergent surgery, and factors influencing outcome were compared in both angioplasty groups as well as with 653 patients treated with thrombolytic therapy in the same hospitals. There was no difference in baseline characteristics between patient groups treated by angioplasty in the two types of hospitals. Patency was established in 88% of patients. Only 1.4% underwent emergent surgery. Overall, survival was 93% but was significantly worse after a failed procedure in all ECG and hemodynamic subsets as well as in those with prior bypass surgery. In a multivariate analysis, age, initial heart rate, blood pressure, and prior bypass surgery but not type of hospital were predictive of survival. Survival rates were similar, but there tended to be fewer strokes (0.6% versus 2.1%, P = .12), shorter hospital stays (7.0 versus 8.1 days, P < .001), and less recurrent ischemia (20% versus 30%, P = .009) in patients treated by angioplasty compared with thrombolysis. Readmission and reinfarction rates were similar for both treatments.

CONCLUSIONS

Observations from this community registry suggest that mortality after direct angioplasty is low and the use of emergent surgery is infrequent. Outcome in this registry study was dependent on initial hemodynamic findings and infarct location but not on the presence of on-site surgery. Compared with thrombolytic therapy, the incidence of complications was the same or lower, but this needs confirmation in randomized trials.

Intracoronary stenting compared with conventional therapy for abrupt vessel closure complicating coronary angioplasty: a matched case-control study

OBJECTIVES

A case-control analysis was performed to compare clinical outcome after intracoronary stenting with that after conventional therapy for abrupt vessel closure.

BACKGROUND

Previous studies have demonstrated that stenting after abrupt vessel closure results in marked angiographic improvement and preservation of coronary flow, leading to the anticipation of similar improvement in clinical outcome.

METHODS

Sixty-one of 92 consecutive patients treated at two clinical sites by intracoronary stenting for abrupt vessel closure were matched, according to angiographic features of closure and estimated left ventricular mass threatened by ischemia, with patients treated conventionally during the 18 months before stent availability. In 33 pairs of matched patients, vessel closure was established; in 28 pairs, it was threatened (coronary dissection or worsening stenosis with preservation of normal anterograde flow). Baseline clinical and angiographic characteristics were comparable in the two matched groups. Patients with indeterminate mechanisms of total occlusion (31%) or dissections < 15 mm long (43%) predominated; patients with visible thrombus (8%) or dissections > 15 mm long (18%) were infrequently represented. Stents were successfully deployed in 60 of 61 patients at a median of 52 min (range 3 to 269) after the onset of closure.

RESULTS

When compared with conventional treatment, stenting resulted in less residual stenosis (26% vs. 49% diameter stenosis, p < 0.001), a greater likelihood of restoration of Thrombolysis in Myocardial Infarction (TIMI) grade 3 blood flow (97% vs. 72%, p < 0.001) and a reduction in the need for emergency bypass surgery (4.9% vs. 18%, p = 0.02). However, the incidence of Q wave myocardial infarction was nearly the same in the two groups (32% vs. 20%, respectively, p = NS). In the group with stenting, peak creatine kinase level and the frequency of Q wave infarction after established vessel closure increased with the time to stent placement (p = 0.001 and 0.054, respectively); the incidence of procedure-related Q wave infarction in patients who underwent stenting within 45 min of closure was very low (3.9%). In-hospital death occurred in 3.3% of patients in each treatment group. At a mean of 6.3 months of follow-up after hospital discharge, survival free from late cardiac death, myocardial infarction, bypass surgery or coronary angioplasty was 74.9% and 81.3% in the stent and the control treatment group, respectively (p = NS).

CONCLUSIONS

Although early treatment of established vessel closure by intracoronary stenting was associated with a low incidence of both myocardial infarction and emergency bypass surgery, the likelihood or severity of infarction was not reduced among those in whom stents were implanted later. Patients with threatened vessel closure could not be shown to benefit from stent treatment. These data provide preliminary indications for stent placement in the acute period to be validated in larger randomized studies.