Cardiac interventions in Switzerland in 1994

As in the previous seven years, a survey of cardiac invasive, interventional and surgical procedures among the 25 Swiss centers was carried out in 1994 by a detailed questionnaire. The resulting data are presented per individual center and per university, private or public sector. The outstanding findings of the 1994 survey are: There is an ongoing increase in the use of coronary angioplasty. The rapid evolution of coronary angioplasty is predominantly due to an extension of indications towards simple cases since the percentage of multivessel angioplasties has remained low. More than half of all angioplasties have been performed immediately after the respective coronary angiography (ad hoc angioplasty). The use of coronary stents has increased steeply over the past three years. Other new devices like directional coronary atherectomy, rotablation and transluminal extraction have lost further ground. PTCA for ongoing infarction has remained exceptional, probably due to logistical problems. Among the diagnostic tools, only coronary ultrasound has been used regularly. Coronary as well as non-coronary surgery seem to plateau. Percutaneous balloon valvuloplasties remained rather rare interventions. Catheter closure of congenital shunt defects has joined the routine interventional procedures. The majority of interventional catheter procedures have been performed at the five university centers whereas the majority of coronary artery bypass graft interventions have been carried out at private institutions.     

Interventions for coronary stenosis--a Canadian experience of 30 revolutionary years

OBJECTIVE: To report 2324 coronary stenosis interventions (Vineberg procedures [VbP], coronary artery bypass graft operations [CABG] and percutaneous transluminal coronary angioplasties [PTCA]), in 1711 patients of a Canadian military hospital between 1965 and 1995 and to report their evolution and interaction in a historical context. DESIGN: Retrospective examination of clinical and angiographic findings in hard records, collected from the beginning for long term follow-up and later embedded in a custom-designed computer database. PATIENTS: Most were male, mean ages 43.2 and 43.3 years for first and second VbPs; 48.9 and 58.2 years for first and repeat CABGs; and 53.4 and 59.9 years for first and repeat PTCAs, respectively; 12% of all patients were 39 years old or younger at the first intervention. INTERVENTIONS: There were 160 VbPs, 1637 CABGs and 527 PTCAs. Of 1711 subjects, 74% had only one procedure, 15% had more than one of the same kind, and 11% had more than one of different kinds. MAIN RESULTS: Perioperative mortality for VbPs was 4.4%; for 'isolated' first CABGs it was 1.4% and 6.6% for reoperations, when other concurrent major cardiac procedures, excepting ventricular aneurysm repair, were excluded. It was 0.4% for PTCAs. Perioperative mortality for all 1761 'isolated' coronary interventions necessitating thoracotomy, during 30 years, was 2.4%. Angiographic follow-up rates were high and some findings are reported, including early postoperative patency rates for 5065 coronary bypass grafts, and long term follow-up data on graft patency and disease. CONCLUSIONS: Each intervention was used to circumvent or relieve coronary stenosis, in the early years when it became available and, later, as was most appropriate for dealing with specific clinical problems. The impact of advances in the evolution of these interventions on therapeutic decision-making is discussed. Finally, tributes are paid to those responsible for making these procedures possible, including a Canadian surgeon whose role was pivotal.     

Quality assurance in invasive and interventional cardiology in Austria in 1994. Commissioned by the Interventional Cardiology Working Group of the Austrian Cardiology Society

A complete National Database is the prerequisite for quality control, quality management and improvement. In Austria, we have been reaching for this goal since more than three years. 21 094 diagnostic coronary angiographies (CA) and 4934 PTCAs were performed in all 27 centers (out of which 17 perform PTCA) in Austria during the year 1994. This is a reduction of 3.2% concerning CA and an 8.6% increase in PTCA compared to 1993. 48% of all PTCAs were done during the diagnostic study (CA), multivessel PTCA in 11%, direct PTCA for ongoing infarction in 2.3%. Concerning "new devices", 437 stents (182 during the year 1993) were implanted in 1994; also all 73 cases with rotablator, 105 with intracoronary ultrasound, and 26 directional coronary atherectomies (DCA) are documented. Hospital mortality after PTCA was 0.5% (unchanged from the years 1992 and 1993), emergency bypass surgery rate after PTCA was 1.2% (0.7% during the year 1993), and 1.4% of the patients suffered a myocardial infarction in the cathlab (1.2% during 1993). International comparison shows Austria among the top nations with 2637 CA and 617 PTCA per million inhabitants, corresponding to a ratio of 23% PTCA per 100 CA. Risk adjustment (exercise stress test pre PTCA documented in six cath-labs in 1993, compared to 11 in 1994. Type of stenosis (A, B, C) in five labs in 1993 and in 12 labs in 1994) and outcome control (exercise stress test 3 months after PTCA documented in five cath-labs in 1993, compared to 10 in 1994) are subject to constant improvement of our yearly monitor visits and feedback reaction. Austria is the only nation worldwide to support a complete national database with controlled numbers and parameters since more than 3 years, including yearly monitor visits (Internet address for the 1995 data: http@info.uibk.ac.at/gin/org/i_iik.stu/i_iik+ ++.htm) and feedback reports. We experienced no single negative reaction to our activities, but find them necessary for further quality management targets.     

Late results of percutaneous transluminal coronary angioplasty of two or more major native coronary arteries

Of 613 consecutive patients with multivessel coronary artery disease (CAD) undergoing revascularization, 521 patients (85%) underwent primary management with percutaneous transluminal coronary angioplasty (PTCA). To examine long-term outcome in a series of patients often referred for coronary artery bypass graft (CABG) surgery, all patients undergoing multivessel dilations were identified for late follow-up analysis (n = 161). Mean age was 65 years; 54 patients (34%) were women. Four hundred fifty-five of 502 lesions (90.6%) were successfully dilated. Major in-hospital procedural complications occurred in 6 patients (3.7%), including death in 3 (1.9%), nonfatal Q-wave myocardial infarction in 2 (1.2%), and CABG in 1 (0.6%). Final follow-up data were available in 159 patients (99%) at a mean of 39 +/- 18 months. Including in-hospital events, actuarial 3-year survival was 93%, and 3-year infarct-free survival was 90%. At final follow-up, 143 of 146 patients alive (98%) were angina free. Crossover to CABG was required in 25 patients (16%). Repeat PTCA was performed in 67 patients (42%) (mean 1.7 PTCAs/patient, range 1 to 7). PTCA is an effective therapeutic alternative in the management of most patients with multivessel CAD requiring revascularization. A strategy using multiple repeated PTCA procedures when necessary results in prolonged infarct-free survival, with long-term freedom from angina and limited crossover to CABG.     

Evaluation of successful PTCA by transstenotic flow velocity ratios

Doppler probes mounted on the tip of a guidewire allow the measurement of coronary blood flow velocities, not only proximal but also distal to stenoses eligible for percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to determine the improvement of transstenotic Doppler flow velocity ratios following PTCA and to investigate the possible impact on restenosis during follow-up control angiography three months later. Doppler flow velocity measurements were performed in 29 patients with 29 stenoses eligible for PTCA. Results of PTCA were morphologically evaluated by computer-assisted quantitative coronary angiography (QCA) and measured hemodynamically by determining transstenotic Doppler flow velocity ratios. Successful PTCA according to QCA was present in all cases with a reduction of mean diameter stenosis from 66 +/- 8% to 35 +/- 7%. Resting spectral peak velocities and velocity integrals were markedly reduced distal to lesions (all P < 0.001), resulting in mean transstenotic flow velocity and velocity integral ratios of less than 0.60 prior to PTCA. Owing to endoluminal enlargement, significant improvement of transstenotic Doppler ratios was observed in mean ratios greater than 0.90 (all P < 0.0001). In patients with restenosis, transstenotic ratios following PTCA demonstrated a tendency to be smaller than in patients without restenosis. Transstenotic Doppler flow velocity ratios are diminished in severe coronary stenoses. Improvement of these ratios provides information on hemodynamic success of interventional procedures. Thus, the determination of intracoronary Doppler flow velocity ratios contributes, in addition to angiographic estimation, to the evaluation of stenoses severity and success of interventional procedures.     

Initial experience with the use of abciximab in the salvage treatment of acute coronary thrombosis in the Hemodynamics Laboratory

The optimal treatment of acute thrombotic complications in the Catheterization Laboratory has not been defined yet, due to the limited efficacy shown by various pharmacological regimens, even when associated to coronary angioplasty (PTCA). The aim of our study was therefore to evaluate the effects of abciximab (ReoPro), a new potent inhibitor of the platelet glycoprotein IIb/IIIa, when administered as a "rescue" treatment for acute thrombotic coronary occlusion during diagnostic or interventional procedures. Sixteen patients (12 males, 4 females, mean age 59.3 +/- 9.2 years, range 43-77 years), with unstable angina and consecutively treated with abciximab due to clinical instability attributable to coronary thrombosis angiographically proven during PTCA (9 cases) or diagnostic angiography (7 cases), were identified. The individual angiographic films and medical records were then reviewed in order to evaluate the effects of treatment on coronary flow, thrombus size and occurrence of in-hospital adverse events: death, non-fatal acute myocardial infarction (AMI), need for urgent myocardial revascularization and hemorrhage. The administration of abciximab, in association with PTCA (associated in turn with stent implantation in 8 cases), induced a significant increase of coronary TIMI flow grade (0.3 +/- 0.6 vs 2.4 +/- 0.9; p < 0.05) and a significant decrease of thrombus "score" (size) 2.4 +/- 0.9 vs 1.3 +/- 0.6; p < 0.01). No deaths nor need for urgent myocardial revascularization were observed; in 31% of cases (5 patients) evolution towards AMI occurred, while however 94% of cases (15 patients) had a coronary occlusion before treatment. No major hemorrhagic complications were observed, while in 12% of cases (2 patients) a groin hematoma associated with moderate hemoglobin drop, developed. In conclusion, the administration of abciximab, associated with the common "rescue" interventional procedures, in patients with acute thrombotic coronary occlusion in the Catheterization Laboratory, appears to be effective in restoring adequate coronary flow and reducing the thrombus size (limiting therefore the evolution towards AMI), and safe, not having been associated with significant hemorrhagic complications.     

Sexual orientation and family development: introduction

A new guiding catheter for PTCA is described. In our department, 302 patients (405 lesions) underwent transradial coronary angioplasty using the 6 Fr Kimny guiding catheter since January 1996. The total engagement rate using the Kimny guiding catheter was 91.3% (370/405). The engagement rate after the modified Kimny guiding catheter was introduced in May 1996 increased to 96.0% (243/253). The stent delivery success rate was 98.4%. We had two dislodged stents. PTCA for both left and right coronary arteries in a single procedure with the Kimny guiding catheter was performed via the radial artery in 27 patients. In 24 of these patients (89%) we engaged both coronaries successfully. In the remaining 3 patients we switched to another catheter. Except for 4 patients with non-Q-wave myocardial infarction, no major cardiac complications were encountered. No major entry site-related complications were seen, and no patient required vascular surgery or blood transfusions. In one patient the Kimny guiding catheter tip caused a minor dissection of the LMT, but no ischemic event occurred as a result. In conclusion, the Kimny device is a useful PTCA guiding catheter for routine angioplasty and stenting.     

Acute angiographic and clinical results of long balloon percutaneous transluminal coronary angioplasty and adjuvant stenting for long narrowings

Historically, long coronary artery stenoses undergoing percutaneous transluminal coronary angioplasty (PTCA) are reported to have reduced procedural and clinical success in comparison with shorter lesions. The efficacy of long balloons (30 or 40 mm) in long lesions was evaluated. Eighty-two patients had 84 PTCA procedures with a primary long balloon. In all, 86 lesions were available for analysis. Data were collected prospectively on standard PTCA procedure forms. Coronary angiograms were reviewed and measured with digital calipers. Hospital charts were examined for complications. PTCA was performed in the left anterior descending artery in 44 cases (51%), the right coronary artery in 29 (34%) and the circumflex artery in 13 (15%). With the use of a modified classification system, 47 lesions (55%) were class C, 24 (28%) were class B2 and 15 (17%) were class B1. Mean lesion length was 22 +/- 11 mm (range 10 to 72), and 38 lesions (44%) were > or = 20 mm. Twelve patients received an intracoronary stent. The long balloon alone produced angiographic success (< 50% residual stenosis) in 77 lesions (90%). Angiographic success was achieved ultimately in all stenoses, using a stent in 7 patients and a short balloon in 2. There were 2 deaths (2%) and 1 Q-wave myocardial infarction (1%). One patient needed coronary artery bypass surgery. Clinical success without death, Q-wave infarction or bypass surgery was achieved in 83 of 86 procedures (97%). In conclusion, the use of long PTCA balloons with adjuvant stenting produced excellent results in these long stenoses. Lesion length was not a precursor of poor angiographic or clinical outcome.     

Intravascular ultrasound assessment of direct percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction

BACKGROUND: Acute myocardial infarction is caused by sudden thrombotic occlusion of the coronary artery due to a previous rupture of atherosclerotic plaque. OBJECTIVE: To use intracoronary ultrasound measurements to evaluate lumen and plaque changes in patients with acute myocardial infarction. METHODS: Patients (n = 103) with acute myocardial infarction who had been scheduled to undergo primary percutaneous transluminal coronary angioplasty (PTCA) were selected. Both before and after successful coronary angioplasty, intracoronary 30 MHz ultrasound studies were performed using a 3.5F monorail catheter. The ultrasound catheter was successfully advanced into the occluded vessel segment without major complications prior to PTCA in 79 of 103 (76.7%) patients and after PTCA in 88 of 103 (85.3%) patients. RESULTS: The plaques were eccentric in 66 patients (83.5%). The plaque morphology was purely low echogenic in 14 (17.7%), highly echogenic in six (7.6%) and mixed in 59 (74.7%) patients. Partial (59 of 79, 74.7%) or ring-like calcification (3 of 79, 3.8%) was observed in 62 patients (78.5%). Plaque fissuring or dissection was detected prior to PTCA in 25 patients (31.7%). Coronary angioplasty successfully enlarged the inner luminal area from 2.1 +/- 0.7 to 7.4 +/- 1.9 mm2 (P < 0.01), whereas the plaque-thrombus area decreased significantly (13.8 +/- 1.7 mm2 before and 9.0 +/- 1.9 mm2 after PTCA; P < 0.01). The total vessel area remained virtually constant (15.9 +/- 1.9 mm2 before and 16.4 +/- 2.5 mm2 after PTCA, NS). PTCA-induced plaque rupture or dissection was observed in only 13 (16.5%) patients. CONCLUSION: Intracoronary ultrasound imaging can be performed safely and successfully prior and subsequent to PTCA in selected patients with acute myocardial infarction. Early reperfusion via PTCA seems to be attributable to a significant reduction in the amount of low-echogenic plaque and thrombus material, whereas factors like balloon-induced dissection and stretching of vessels play only a minor role.     

Registry of activities of the Section of Hemodynamics and Interventional Cardiology in 1997

The results of the Spanish Registry of Hemodynamic and Interventional Cardiology in 1997 are presented. The Registry collects the activity of 83 centers which constitute all the cardiac catheterization laboratories in Spain. The main activity was adult cardiac catheterization in 75 centers and exclusively pediatric cardiac catheterization in 8. A total of 72,370 diagnostic catheterization procedures, 80% coronary angiographies (57,960; 1,462 per million inhabitants), were performed which represents a 13% total increase compared to 1996. Coronary intervention increased by 23% compared to 1996, for a total number of 18,545 procedures. The ratio of coronary interventions per million inhabitants was 468. Success rates of coronary interventions (91.3%) and complications (3.7%) were similar to those registered in previous years. In the specific field of revascularization devices, there has been a dramatic increase in the use of stents. In 1997, coronary stents were employed in 11,417 cases (a 61% increase compared to 1996) which represents 61.5% of all coronary revascularizations procedures. A total of 14,170 prosthesis were implanted, 72% in a elective way, with a low rate of complications (0.95% subacute closure; 1.45% myocardial infarction and 0.75% mortality). Compared to 1996, directional coronary atherectomy (92 procedures) showed a slight decrease, whereas rotational atherectomy (554 procedures) increased by 49% with double the number of centers performing this technique. As in previous years, a slight decrease (7% compared to 1996) in adult valvuloplasties (559 vs 599) was noted. Pediatric interventional procedures decreased by 17% (465 vs 558 procedures) compared to the 1996 Registry.     

Left main coronary artery stenosis following aortic valve replacement using a solid coronary perfusion catheter: report of two cases

We experienced two cases of iatrogenic left main coronary artery stenosis (IOCS) following double (aortic and mitral) valve replacement (DVR). The solid coronary perfusion catheter may attribute IOCS, with grave consequence. There have been no IOCS since the time we exchanged a solid catheter for a soft one. One case, she was successfully treated percutaneous transluminal coronary angioplasty (PTCA), because she developed angina pectoris about 5 years after PTCA. But she developed angina pectoris again and angiographically left main coronary was severe stenotic. So she was undergone aorto coronary bypass grafting (CABG) to the left anterior descending. The other case, he developed angina pectoris about 3 months after DVR. He was treated with PTCA. Angiographically left mine coronary artery stenosis reduced 50% from 90%. Generally the treatment of IOCS is CABG, but we performed PTCA for 2 patients. Because we thought it was very hazardous for us to perform them open heart surgery. When it is very hazardous to perform patients open heart surgery, they need to be performed PTCA.     

Direct percutaneous transluminal coronary angioplasty in acute myocardial infarction. Predictors of short-term outcome and the impact of coronary stenting. Study Group of The Arbeitsgemeinschaft Leitender Kardiologischer Krankenhaus?rzte (ALKK)

BACKGROUND: Direct percutaneous transluminal coronary angioplasty (PTCA) is widely accepted in the treatment of acute myocardial infarction since excellent results had been reported from several small randomized trials. Less favourable results were observed in large-scale registries. In particular, the use of stents in acute myocardial infarction has become common practice without documented evidence of clinical efficacy. METHODS: Data were analysed from a registry of all consecutive percutaneous transluminal coronary angioplasty procedures from 62 centres in Germany, including 2331 direct percutaneous transluminal coronary angioplasty in acute myocardial infarction from July 1994 to April 1997. RESULTS: The overall angiographic success rate of percutaneous transluminal coronary angioplasty, defined as complete antegrade perfusion of the infarct vessel, was 87%. In-hospital mortality was 11.2%. The most important predictor of death was the presence of cardiogenic shock in 15% of patients, of whom 52% died. Mortality in patients without shock was 3.9%. Failed percutaneous transluminal coronary angioplasty was associated with a mortality of 36%. Further independent predictors of death were older age, multivessel disease, and anterior myocardial infarction. Stents were used in 4.1% of the procedures in 1994, increasing to 53% in 1997. However, this was not accompanied by improved clinical outcome. Mortality with coronary stenting was 9.9% vs 11.6% without stents (ns). CONCLUSIONS: Direct percutaneous transluminal coronary angioplasty is a valuable treatment strategy in acute myocardial infarction, although the results are less exceptional than reported from some highly specialized centres. Failed percutaneous transluminal coronary angioplasty seems to be harmful, thus outweighing much of the benefit from successful procedures. Stents did not improve the clinical outcome significantly, despite technically successful placement in 98%. Mortality from cardiogenic shock continues to be excessively high despite direct PTCA.     

Final height and craniofacial development after surgical resection of craniopharyngioma

There is a subgroup of patients with coronary artery disease who are refractory to the therapeutical methods so far applied. We report on 128 patients who fulfill this definition and have therefore undergone pure transmyocardial laser revascularisation (TMLR) or transmyocardial laser revascularisation in combination with coronary bypass surgery at our institution. The patients can be characterized by a long history of coronary artery disease with multiple revascularizing procedures, e.g. bypass surgery or percutaneous transluminal coronary angioplasty (PTCA), pronounced symptoms of coronary artery disease and chronic heart failure in the presence of markedly reduced left ventricular ejection fractions and intense antiischemic medical therapy. The patients were 62.2 +/- 9.8 (SD) years of age, in 89.9% of them at least one bypass operation and in 44.5% up to more than three percutaneous transluminal coronary angioplasties (PTCAs) had been performed prior to TMLR. There was a history of myocardial infarction in 90.7% of patients and 89.8% were in the Canadian Cardiovascular Society (CCS) classes III or IV and 94.5% of them were in the NYHA classes III or IV. The left ventricular ejection fraction was 49.5 +/- 16.4% and all of the patients were under intense antiischemic medical treatment which included nitrates or molsidomine in 96.9%, beta blockers in 53.1%, angiotensin converting enzyme inhibitors (ACE inhibitors) in 44.5%, digitalis in 22.7% and diuretics in 52.3% of patients. The preoperative data on myocardial viability, inducible ischemia and coronary morphology provided important clinical information for the decision, which revascularizing method would be the most appropriate for each vessel or myocardial region. This had to be weighed against the patient's operative risk, which is predominantly determined by the left ventricular ejection fraction, the arteriosclerotic involvement of the remaining vascular system and concomitant diseases, particularly of pulmonary origin.     

Laser angioplasty and recanalization

Percutaneous transluminal coronary balloon angioplasty (PTCA) still is the most frequently applied interventional technique for treatment of coronary artery disease. Plastic deformation of the obstructive plaque with creation of splits, intimal tears and dissections is the main mechanism of PTCA for lumen widening. As a result, acute complications due to flow limiting dissections and acute vessel closure can unpredictably occur resulting in myocardial infarction, urgent bypass surgery and death. Furthermore, long-term success of PTCA is limited by restenosis. In order to overcome these limitations of PTCA, alternative interventional techniques were developed, which instead of deforming the obstructive plaque ablate this tissue. These techniques include high and low speed rotational angioplasty, directional atherectomy, the transluminal extraction catheter, ultrasound angioplasty and laser (Light Amplification by Stimulated Emission of Radiation) angioplasty. 308 nm XeCl excimer laser angioplasty today is the laser technique of choice for clinical application. This pulsed laser requires direct contact to the obstructive plaque. It creates fast (< 200 microseconds) expanding gas bubbles which induce plaque ablation. Main indications for 308 nm XeCl excimer laser angioplasty are diffuse and long coronary lesions and total coronary occlusions. Despite promising initial results this technique showed no better acute and long-term results in comparison to PTCA for the treatment of these types of lesions ("Amsterdam-Rotterdam" Study, "Excimer Rotational Balloon Angioplasty Comparison" Study). As a result, this interventional technique was rarely applied for patient treatment. More recently, the concept of plaque ablation by 308 nm XeCl excimer laser angioplasty was renewed for the treatment of in-stent restenosis. This indication is being investigated in the "Laser Angioplasty of Restenosed Stents" trial. First results document the practicability and safety of this approach. Long-term results are awaited. With ongoing miniaturization, laser guidewires were developed for the recanalization of chronic total occlusions. The randomized multicenter "Total Occlusion Trial with Angioplasty assisted by Laser guidewire "Study documented a success rate of laser wire recanalization in up to 66% in contrast to 47.5% for mechanical wires only. Long-term results are still awaited. Technical and procedural progress including saline flush during laser application, homogeneous light distribution and the concept of smooth laser ablation is pushed foreward to make excimer laser angioplasty safer, more predictable and more effective.     

Anesthesia for abdominal surgery after percutaneous transluminal coronary angioplasty (PTCA)

From December 1989 to October 1996, 1,318 PTCAs (percutaneous transluminal coronaly angioplasty) were performed for AMI (acute myocardial infarction) or postinfarction angina in our institute. Within 7 days to 71 days after successful PTCA, five patients who had been diagnosed as cholelithiasis or gastric cancer were operated under general anesthesia. Performed operations were cholecystectomy in the first patient, subtotal gastrectomy in the second, third and fourth patients, and total gastrectomy and cholecystectomy in the fifth patient. There was no serious cardiac complication during the operations and perioperative period. PTCA is considered to have decreased cardiac complications in patients with ischemic heart disease having undergone abdominal surgery.     

Does low individual operator coronary interventional procedural volume correlate with worse institutional procedural outcome?

OBJECTIVES: To assess the relation between individual operator coronary interventional volume and incidence of complications, the in-hospital outcome at a single, moderate volume urban academic center was prospectively collected over a 3-year period. BACKGROUND: A minimum of 75 coronary interventions/operator per year may be required in the future to obtain formal certification. However, few data exist regarding individual operator volumes and procedural outcome. METHODS: Between January 1993 and December 1995, 1,389 consecutive procedures were performed or supervised by nine geographic full-time operators: 171 (12.3%) utilized various devices, and 350 (25.2%) involved multivessel coronary intervention. Left ventricular ejection fraction was 59 +/- 15% (mean +/- SD), and there were 1.7 +/- 0.7 vessels diseased (with > or = 70% stenosis). Clinical indications included stable angina in 22.5% of cases, unstable angina in 31.9%, acute myocardial infarction (MI) in 2.9%, post MI in 20.6%, shock or acute heart failure in 3.0% and restenosis in 19.1%. In the last consecutive 857 lesions in 655 cases, 20.7% type A, 55.5% type B and 23.8% type C lesions were categorized before coronary intervention. RESULTS: Average yearly operator volume ranged from 26 to 83 cases (mean 51 +/- 26). Each operator has performed a total of 590 +/- 268 coronary interventions, with 10.0 +/- 4.3 years of coronary interventional experience. The mean angioplasty volume rating for the nine operators was 180 +/- 37 (> 170 considered adequate). The in-hospital major complication rate was 1.4% (95% confidence interval 0.7% to 1.893%) for all coronary interventions, including death in 3 patients, bypass surgery in 13, arrhythmia in 3 and Q wave MI in 2. To ascertain how these outcomes compared with standard measures of coronary interventional outcome, four previously published registries were reanalyzed in a similar manner. The rate of complications in the present study was found to be significantly lower than that of the 1992-1993 Society for Cardiac Angiography and Intervention registry (1.9%, n = 19,594, p < 0.05 [excludes ventricular arrhythmias]), the 1994 American College of Cardiology database (3.9%, n = 38,963, p = 0.001), the Mid-America Heart Institute outcome in 1988 (2.3%, n = 5,413, p = 0.02) and the 1985-1986 National Heart, Lung, and Blood Institute Registry (7.2%, n = 1,801, p = 0.001). Odds ratios and 95% confidence intervals showed the outcome in the current study to be at least comparable to the standard registries. CONCLUSIONS: Despite individual operator volumes below those currently being considered for credentialing, the overall institutional outcome was excellent in a diverse and complex patient population.     

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.     

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)     

Health service costs of coronary angioplasty and coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial

For some patients with coronary artery disease, percutaneous transluminal coronary angioplasty (PTCA) is an alternative to coronary artery bypass grafting (CABG). We report comparative health service costs of these interventions within the Randomised Intervention Treatment of Angina (RITA) trial. Medications were costed at published UK prices; other resource use was costed with a set of unit costs estimated at two recruiting centres to the RITA trial, one in London and one outside. Over 2-year follow-up of 1011 patients, the estimated mean additional cost for those randomised to CABG compared with PTCA was 1050 pounds (95% CI 621 pounds-1479 pounds), with unit costs from the non-London centre, and 1823 pounds (1202 pounds-2444 pounds), with unit costs from the London centre. The initial average cost of treating a patient randomised to PTCA is about 52% of that of CABG, but after 2 years this increased to about 80% because of the greater need for subsequent interventions. The balance of advantage between PTCA and CABG may change after several years: funding has been obtained to continue RITA follow-up for 10 years. However, on the basis of patients' status at 2 years, the cost advantages of PTCA cannot be ignored. Further research is necessary to assess whether the advantage of PTCA in terms of cost is translated into one of cost-effectiveness.     

Reduction of in-hospital complications after elective percutaneous transluminal coronary angioplasty using a combined pretreatment with ticlopidine and aspirin

OBJECTIVES: In a retrospective study the effect of a combined pretreatment using ticlopidine and aspirin (ASA) in patients undergoing elective PTCA procedures was investigated with respect to in-hospital complications of PTCA and with respect to the efficacy in avoiding a subacute stent thrombosis in case of stent implantation. The systematically performed pretreatment with ticlopidine and ASA takes the delayed begin of full antiplatelet effect of ticlopidine into account. METHODS: 1108 consecutive patients (group 1) underwent elective PTCA without pretreatment with ticlopidine. In case of stent implantation oral anticoagulation was initiated in this group. In 758 consecutive patients (group 2) with elective PTCA, a combined regimen with ticlopidine and ASA was initiated at least 24 h prior to PTCA and was continued in case of stent implantation. The rate of procedural success, necessary reinterventions, cardiac events (myocardial infarction, death) and complications as well as the rate of subacute stent thrombosis in the subgroups with stent implantation were evaluated. RESULTS: The number of patients without in-hospital cardiac complications (myocardial infarction, coronary artery bypass surgery, death) and without re-PTCA interventions was 92.8% in group 1 and 96.3% in group 2 (p < 0.005). Especially the rate of necessary reinterventions was significantly reduced in group 2 compared with group 1 (5.3% vs. 2.4%, p < 0.001). Cardiac events were reduced in group 2 (myocardial infarction: 2.0% vs. 1.1%, coronary artery bypass graft: 0.8% vs. 0.5%, exitus: 0.5% vs. 0%), the incidence of bleeding complications was similar in both groups (2.5% vs. 2.4%). The combined pretreatment with ticlopidine and ASA with a stent implantation rate of 16.4% in group 2 was effective to avoid a subacute stent thrombosis (1.6%, independent of the indication to stent implantation). One patient of 758 in group 2 had allergic reactions to ticlopidine. CONCLUSIONS: The "prophylactic" pretreatment with ticlopidine and ASA in combination with a higher rate of stent implantation reduces necessary reinterventions and cardiac events after PTCA and is effective to avoid subacute stent thrombosis without increase of complications, especially bleeding complications. Thus, this pretreatment can be proposed even in patients scheduled for elective PTCA without planned stent implantation to reduce the interval between a necessary unforeseen stent implantation and the full treatment effects of ticlopidine.