Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up

BackgroundAlthough evidence is sufficient to confirm that hybrid coronary revascularization (HCR) is safe and effective in the short term, its value in the long run is debatable.ObjectivesThis study sought to compare the long-term outcomes of HCR with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease.MethodsThree groups of patients, 540 each, receiving HCR, CABG, or PCI between June 2007 to September 2018, were matched using propensity score matching. Patients were stratified by EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (low ≤0.9; 0.9 < medium <1.5; high ≥1.5) and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (low ≤22; 22 < medium <33; high ≥33). Major adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores were compared among the 3 groups.ResultsIn terms of MACCE and SAQ, HCR performed similarly to off-pump CABG but significantly outperformed PCI (P < 0.001). In the low-to-medium EuroSCORE II and medium-to-high SYNTAX score tertiles, MACCE rates in the HCR group were significantly lower than those in the PCI (EuroSCORE II: low, 30.7% vs 41.2%; P = 0.006; medium, 31.3% vs 41.7%; P = 0.013; SYNTAX score: medium, 27.6% vs 41.2%; P = 0.018; high, 32.4% vs 52.7%; P = 0.011) but were similar to those in the CABG group. In the high EuroSCORE II stratum, HCR had a lower MACCE rate than CABG (31.9% vs 47.0%; P = 0.041) and PCI (31.9% vs 53.7%; P = 0.015).ConclusionsCompared with conventional strategies, HCR provided satisfactory long-term outcomes in MACCE and functional status for multivessel disease.     

Hybrid Revascularization for Multivessel Coronary Artery Disease

ObjectivesThe aim of this study was to assess the feasibility of hybrid coronary revascularization (HCR) in patients with multivessel coronary artery disease (MVCAD) referred for standard coronary artery bypass grafting (CABG).BackgroundConventional CABG is still the treatment of choice in patients with MVCAD. However, the limitations of standard CABG and the unsatisfactory long-term patency of saphenous grafts are commonly known.MethodsA total of 200 patients with MVCAD involving the left anterior descending artery (LAD) and a critical (>70%) lesion in at least 1 major epicardial vessel (except the LAD) amenable to both PCI and CABG and referred for conventional surgical revascularization were randomly assigned to undergo HCR or CABG (in a 1:1 ratio). The primary endpoint was the evaluation of the safety of HCR. The feasibility was defined by the percent of patients with a complete HCR procedure and the percent of patients with conversions to standard CABG. The occurrence of major adverse cardiac events such as death, myocardial infarction, stroke, repeated revascularization, and major bleeding within the 12-month period after randomization was also assessed.ResultsMost of the pre-procedural characteristics were similar in the 2 groups. Of the patients in the hybrid group, 93.9% had complete HCR and 6.1% patients were converted to standard CABG. At 12 months, the rates of death (2.0% vs. 2.9 %, p = NS), myocardial infarction (6.1% vs. 3.9%, p = NS), major bleeding (2% vs. 2%, p = NS), and repeat revascularization (2% vs. 0%, p = NS) were similar in the 2 groups. In both groups, no cerebrovascular incidents were observed.ConclusionsHCR is feasible in select patients with MVCAD referred for conventional CABG. (Safety and Efficacy Study of Hybrid Revascularization in Multivessel Coronary Artery Disease [POL-MIDES]; NCT01035567).     

Multivessel coronary stenting versus bypass surgery in patients with multivessel coronary artery disease and normal left ventricular function: immediate and 2-year long-term follow-up

BACKGROUND: Compared with coronary artery bypass surgery (CABG), the clinical benefits of intracoronary stenting have not been established in patients with multivessel coronary lesions. METHODS AND RESULTS: To compare the clinical outcomes of intracoronary stenting with that of CABG, we reviewed the outcomes of patients with multivessel coronary artery disease from an observational database. Two hundred consecutive patients with multivessel coronary artery disease and normal left ventricular function were evaluated. In 200 patients, multivessel stenting was performed in 100 and CABG was performed in 100. Complete revascularization was achieved in 95% in the CABG group and in 69% in the stent group (P <.05). The duration of total hospital stay and coronary care unit admission was significantly shorter in the stent group (P <.05). The long-term survival was similar between the 2 groups. There were no significant differences of cardiac events between the 2 groups except for the recurrence of angina (19% in stenting vs 8% in CABG, P =.03) and target lesion revascularization (19% vs 2%, P <.01) in the patients with stents. CONCLUSIONS: In selected patients with multivessel coronary artery disease and normal left ventricular function, intracoronary stenting may offer an effective alternative to coronary bypass surgery.     

One‐Year Follow‐Up of Nonrandomized Comparison between Coronary Artery Bypass Grafting Surgery and Drug‐Eluting Stent for the Treatment of Unprotected Left Main Coronary Artery Disease in Elderly Patients (Aged ≥75 Years)

Purpose: The present observational study compares in‐hospital and 12‐month clinical outcomes in elderly patients with unprotected left main coronary artery disease treated either with coronary artery bypass grafting or drug‐eluting stent. Methods: From January 2004 to December 2007, 211 patients (pts) with unprotected left main coronary artery (ULMCA) stenosis, aged 75 or older, underwent coronary revascularization either with coronary artery bypass graft (CABG) (106 pts) or drug‐eluting stent (DES) (105 pts). The decision to treat with CABG or percutaneous coronary intervention (PCI) was dependent on the patient's and the physician's choice. The occurrence of major adverse cardiac or cerebrovascular events (MACCE: death, nonfatal myocardial infarction, or stroke) and revascularizations was recorded after 1 year of follow‐up. A multivariate logistic regression analysis was performed using a propensity score method to take potential baseline differences between groups into account. Results: In‐hospital MACCE rates were 5.7% and 3.8% in the CABG and PCI groups, respectively (P = 0.748). After 1 year of follow‐up, these rates were, respectively, 13.9% and 14.9% (P = 0.841), and rates for target vessel revascularization at 12 months were 1.0% and 13.9% (P < 0.001). The PCI group was significantly associated with older age, dyslipidemia, history of cancer, high Euroscore, elevated creatininemia, single‐vessel disease, fewer chronic occlusions of the left anterior descending artery, and more LMCA stenosis ≥70%. The multivariate logistic regression analysis was adjusted for age, diabetes, left ventricular ejection fraction, Euroscore, and plasma creatininemia and stratified on the score of propensity to be treated with PCI. In the subgroup below median propensity score, the adjusted odds ratio for 1‐year MACCE was OR = 0.91 (95% confidence interval: 0.14 to 5.98; P = 0.924) whereas OR was 0.16 (0.04–0.69; P = 0.013) in the subgroup above median propensity score. Conclusions: In patients with a high probability of being treated with PCI (older age, high Euroscore, high creatininemia, single‐vessel disease, …), the 1‐year risk of MACCE was significantly lower in PCI‐ than in CABG‐treated subjects. No significant difference was found in other cases.     

A Comparison Between Coronary Artery Bypass Grafting Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease

Background:

Unprotected left main coronary artery (ULMCA) disease occurs in 3% to 5% of patients with coronary artery disease and is mainly treated by coronary artery bypass grafting (CABG) surgery. Drug‐eluting stents (DESs) have renewed interest for the percutaneous coronary intervention (PCI) treatment of ULMCA stenosis. This study compared the long‐term clinical outcome of PCI with DESs or CABG in real world patients with ULMCA disease.

Hypothesis:

PCI with DESs may be a better treatment for ULMCA disease compared with CABG.

Methods:

Consecutive patients who had coronary revascularization because of ULMCA disease in Zhongshan Hospital, from May 2003 to November 2009, were retrospectively enrolled. They were classified in the PCI or the CABG group according to treatments that were given initially. Of 515 patients having follow‐up data, 233 were treated by PCI, whereas 282 were treated by CABG. The patients in the CABG group were of older age, had higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Synergy Between PCI With Taxus Drug‐Eluting Stent and Cardiac Surgery (SYNTAX) scores, and had longer hospitalization stays than the PCI group.

Results:

At the end of follow‐up, there was no difference in major adverse cardiac and cerebrovascular events between the 2 groups. However, the incidence of cardiac death (0.4% vs 4.6%) in the PCI group was less than that in the CABG group, whereas target vessel revascularization (7.3% vs 3.2%) was higher in the PCI group.

Conclusions:

In ULMCA disease, CABG tends to be chosen in patients with higher risk according to the EuroSCORE and SYNTAX scores. PCI with DESs seemed to have favorable early and long‐term clinical outcomes compared with CABG in our center. Clin. Cardiol. 2012 DOI: 10.1002/clc.22070 Qing Qin, MD, and Juying Qian, MD, contributed equally to this work. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

In‐hospital outcomes in invasively managed acute myocardial infarction patients who receive morphine

Objective

We aimed to analyze the association between morphine and in‐hospital outcomes in invasively managed ST elevation myocardial infarction (STEMI) and non‐ST elevation acute coronary syndrome (NSTE‐ACS) patients.

Background

Morphine is commonly used for analgesia in the setting of acute coronary syndromes (ACS); however, recently its utility in ACS has come under closer scrutiny.

Methods

We identified all STEMI and NSTE‐ACS patients undergoing coronary angiogram +/? percutaneous intervention between January 2009 and July 2016 in our center and recorded patient characteristics and inpatient outcomes.

Results

Overall, 3027 patients were examined. Overall, STEMI patients who received morphine had no difference in in‐hospital mortality [4.18% vs. 7.54%, odds ratio (OR): 0.36, P = 0.19], infarct size (mean troponin level 0.75 ng/mL vs. 1.29 ng/mL, P = 0.32) or length of hospital stay (P = 0.61). The NSTE‐ACS patients who received morphine had a longer hospital stay (mean 6.58 days vs. 4.78 days, P < 0.0001) and larger infarct size (mean troponin 1.16 ng/mL vs. 0.90 ng/mL, P = 0.02). Comparing matched patients, the use of morphine was associated with larger infarct size (mean troponin 1.14 ± 1.92 ng/mL vs. 0.83 ± 1.49 ng/mL, P = 0.01), longer hospital stay (6.5 ± 6.82 days vs. 4.89 ± 5.36 days, P = 0.004) and a trend towards increased mortality (5% vs. 2%, OR: 2.55, P = 0.06) in NSTE‐ACS patients but morphine did not affect outcomes in the propensity matched STEMI patients.

Conclusion

In a large retrospective study, morphine was associated with larger infarct size, a longer hospital stay and a trend towards increased mortality in invasively managed NSTE‐ACS patients even after adjustment for clinical characteristics.

     

Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVEHybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.METHODSThis cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.RESULTSThere was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67−1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34−0.77)). CONCLUSIONSFor patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.

For most patients with multivessel disease coronary artery disease, either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is the recommended option. The advantage of CABG surgery is generally the durability of the bypass grafts, and CABG surgery is recommended especially among the highest risk patients (e.g., three vessel disease, left main (LM) disease, multivessel disease with proximal left anterior descending artery (LAD) disease).^[1-4] Nevertheless, an advantage of CABG surgery is the superior outcomes achieved with left internal mammary artery (LIMA) grafts to the LAD for patients with LAD disease.^[5-7]Hybrid coronary revascularization (HCR) is an approach that has been developed to combine the main advantages of both CABG surgery and PCI. It consists of using a LIMA anastomosis to the LAD via a minimally invasive CABG surgery approach (no sternotomy) in addition to PCI for other diseased coronary arteries. The rationale for using this approach in lieu of using PCI for all diseased coronary arteries is the potential for more durability of the LAD revascularization as a result of the LIMA to LAD anastomosis. Several studies have compared HCR to CABG surgery, but they are limited with respect to sample size, number of institutions represented, duration, and inability to capture population-based practice.^[8-24] Multi-center studies comparing HCR with PCI, which are arguably more relevant since these two alternatives are the least invasive ones, are extremely limited.^[25,26]The purposes of this study are to: (1) describe the use of HCR and the characteristics of patients undergoing HCR vs. PCI in a population-based setting, and (2) compare short- and medium-term outcomes for HCR and PCI for patients with multi-vessel coronary artery disease accompanied by LAD disease using New York’s clinical cardiac registries.     

Determining the In‐Hospital Cost of Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Background: The economic impact of bleeding in the setting of nonemergent percutaneous coronary intervention (PCI) is poorly understood and complicated by the variety of bleeding definitions currently employed. This retrospective analysis examines and contrasts the in‐hospital cost of bleeding associated with this procedure using six bleeding definitions employed in recent clinical trials. Methods: All nonemergent PCI cases at Christiana Care Health System not requiring a subsequent coronary artery bypass were identified between January 2003 and March 2006. Bleeding events were identified by chart review, registry, laboratory, and administrative data. A microcosting strategy was applied utilizing hospital charges converted to costs using departmental level direct cost‐to‐charge ratios. The independent contributions of bleeding, both major and minor, to cost were determined by multiple regression. Bootstrap methods were employed to obtain estimates of regression parameters and their standard errors. Results: A total of 6,008 cases were evaluated. By GUSTO definitions there were 65 (1.1%) severe, 52 (0.9%) moderate, and 321 (5.3%) mild bleeding episodes with estimated bleeding costs of $14,006; $6,980; and $4,037, respectively. When applying TIMI definitions there were 91 (1.5%) major and 178 (3.0%) minor bleeding episodes with estimated costs of $8,794 and $4,310, respectively. In general, the four additional trial‐specific definitions identified more bleeding events, provided lower estimates of major bleeding cost, and similar estimates of minor bleeding costs. Conclusions: Bleeding is associated with considerable cost over and above interventional procedures; however, the choice of bleeding definition impacts significantly on both the incidence and economic consequences of these events.     

Clinical and economic outcomes of multivessel coronary stenting compared with bypass surgery: a single-center US experience

Background Randomized trials comparing multivessel stenting with coronary artery bypass surgery (CABG) have demonstrated similar rates of death and myocardial infarction but higher rates of repeat revascularization after stenting. The impact of these alternative strategies on overall medical care costs is uncertain, particularly within the US health care system. Methods We performed a retrospective, matched cohort study to compare the clinical and economic outcomes of multivessel stenting and bypass surgery. The stent group consisted of 100 consecutive patients who underwent stenting of ≥2 major native coronary arteries at our institution. The CABG group consisted of 200 patients who underwent nonemergent isolated bypass surgery during the same time frame, matched (2:1) for age, sex, ejection fraction, diabetes mellitus, and extent of coronary disease. Detailed clinical follow-up and resource utilization data were collected for a minimum of 2 years. Total costs were calculated by use of year 2000 unit prices. Results Over a median follow up period of 2.8 years, there were no significant differences in all-cause mortality rates (3.0% vs 3.0%), Q-wave myocardial infarction (5.1% vs 4.0%), or the composite of death or myocardial infarction (7.1% vs 7.0%) between the stent and CABG groups (P = not significant for all comparisons). However, at 2-year follow up, patients with stents were more likely to require ≥1 repeat revascularization procedure (32.0% vs 4.5%, P < .001). The initial cost of multivessel stenting was 43% less than the cost of CABG ($11,810 vs $20,574, P < .001) and remained 27% less ($17,634 vs $24,288, P = .005) at 2 years. Conclusions Multivessel stenting and CABG result in comparable risks of death and myocardial infarction. Despite a higher rate of repeat revascularization, multivessel stenting was significantly less costly than CABG through the first 2 years of follow-up. (Am Heart J 2003;145:334-42.)     

Elderly Patients with Late Onset of Coronary Artery Disease: Clinical and Angiographic Findings

A group of elderly patients who did not clinically manifest coronary artery disease until after the age of 65 years were studied. Clinical and angiographic findings of these older patients were compared to findings of patients who had clinical manifestation of coronary artery disease before age 65. In both groups the most common initial manifestation was acute ischemic chest pain (62% vs 75%, NS). However, only 14 (34%) of the 41 elderly patients with chest pain sustained an acute myocardial infarction, compared to 62 (60%) of the 103 younger patients (P is less than 0.05). In 8% of the elderly patients the initial manifestation was acute heart failure not associated with an acute myocardial infarction; none of the younger patients had heart failure without an associated acute infarction (P is less than 0.002). Two percent of the patients over 65 years of age and 4% of the patients under 65 years sustained out-of-hospital cardiac arrest as the initial manifestation of coronary artery disease (NS). Risk factors were more common in the younger patients, with elevated cholesterol levels noted in 24% of the younger patients as compared to only 12% of the elderly patients (P is less than 0.05). Angiographically, elderly patients more commonly demonstrated multivessel coronary artery disease (68% vs 57%, P is less than 0.02) and left main vessel disease (11% vs 2%, P is less than 0.01). Even though multivessel coronary artery disease was common, the majority of elderly patients had normal left ventricular function, as did the younger patients; only 9% of patients in each age group had left ventricular ejection fractions of less than 35%. Treatment varied between the age groups, with coronary artery bypass surgery performed in 38% of the elderly patients as compared to 25% of the younger patients (P is less than 0.05). Only 3% of the patients in each group died during the acute hospitalization, and approximately 95% of the discharged patients in each group were still alive at 24 months mean follow up. We conclude that even though multivessel disease is usually present, coronary artery disease may be clinically silent until the patient is quite old. Left ventricular function is usually well preserved in these elderly patients, and with therapy their prognosis is excellent.     

单支血管和多支血管支架术治疗女性冠心病患者临床疗效比较研究

目的:研究单支血管和多支血管支架术治疗女性冠心病患者的近期和远期临床疗效.方法:研究对象为我院2004-04至2005-04所有接受冠状动脉狭窄支架置入治疗486例女性患者,分为置入单支血管组(n=344)和多支血管组(n=142).所有患者完成1年临床随访,其中103例(21%)患者在支架术后6～9个月接受冠状动脉造影随访.结果:多支血管组较单支血管组支架置入成功率(99.1%比99.2%)、操作并发症(2.8%比0.6%)差异无统计学意义.1年随访显示多支血管组较单支血管组发生主要不良心脏事件(8.4%比3.8%,P=0.01)和靶病变血运重建(4.2%比1.7%,P＜0.01)明显升高,差异有统计学意义;而心脏性死亡、急性心肌梗死两组比较差异无统计学意义.冠状动脉造影随访分析显示再狭窄多支血管组(19.6%)较单支血管组(15.1%)差异无统计学意义.结论:1年随访表明,女性冠心病患者单支血管支架术较多支血管支架术临床预后更佳.     

Staged versus index procedure complete revascularization in ST‐elevation myocardial infarction: A meta‐analysis

Background

Complete revascularization of patients with ST‐elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct‐related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial.

Method

We performed a meta‐analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST‐elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel‐Haenszel risk ratios were calculated using random effect model.

Results

Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow‐up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09‐2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42‐4.58, P < 0.01), cardiovascular mortality (RR: 2.8, 95%CI: 1.33‐5.86, P = 0.01), and short‐term (<30 days) mortality (RR: 3.54, 95%CI: 1.51‐8.29, P < 0.01) occurred less often in staged versus index procedure multivessel revascularization. There was no difference in major adverse cardiac events (RR: 1.14, 95%CI: 0.88‐1.49, P = 0.33), repeat myocardial infarction (RR: 1.14, 95%CI: 0.68‐1.92, P = 0.61), and repeat revascularization (RR: 0.92, 95%CI: 0.66‐1.28, P = 0.62).

Conclusion

In patients with ST‐elevation myocardial infarction and multivessel coronary artery disease, a strategy of complete revascularization as a staged procedure compared to index procedure revascularization results in reduced mortality without an increase in repeat myocardial infarction or need for repeat revascularization.

     

Economic outcomes of percutaneous coronary intervention with drug‐eluting stents versus bypass surgery for patients with left main or three‐vessel coronary artery disease: One‐year results from the SYNTAX trial

Objectives: To evaluate the cost‐effectiveness of alternative approaches to revascularization for patients with three‐vessel or left main coronary artery disease (CAD). Background: Previous studies have demonstrated that, despite higher initial costs, long‐term costs with bypass surgery (CABG) in multivessel CAD are similar to those for percutaneous coronary intervention (PCI). The impact of drug‐eluting stents (DES) on these results is unknown. Methods: The SYNTAX trial randomized 1,800 patients with left main or three‐vessel CAD to either CABG (n = 897) or PCI using paclitaxel‐eluting stents (n = 903). Resource utilization data were collected prospectively for all patients, and cumulative 1‐year costs were assessed from the perspective of the U.S. healthcare system. Results: Total costs for the initial hospitalization were $5,693/patient higher with CABG, whereas follow‐up costs were $2,282/patient higher with PCI due mainly to more frequent revascularization procedures and higher outpatient medication costs. Total 1‐year costs were thus $3,590/patient higher with CABG, while quality‐adjusted life expectancy was slightly higher with PCI. Although PCI was an economically dominant strategy for the overall population, cost‐effectiveness varied considerably according to angiographic complexity. For patients with high angiographic complexity (SYNTAX score > 32), total 1‐year costs were similar for CABG and PCI, and the incremental cost‐effectiveness ratio for CABG was $43,486 per quality‐adjusted life‐year gained. Conclusions: Among patients with three‐vessel or left main CAD, PCI is an economically attractive strategy over the first year for patients with low and moderate angiographic complexity, while CABG is favored among patients with high angiographic complexity. © 2011 Wiley Periodicals, Inc.     

Assessment of Coronary Flow Parameters by Transesophageal Echocardiography in Patients with Isolated Coronary Artery Ectasia: Effect of Intravenous Nitroglycerin

Background: We sought to assess coronary flow parameters in patients with isolated coronary artery ectasia (CAE) as compared to subjects with normal coronaries. Methods: Consecutively, we enrolled 30 patients with ectasia of the left anterior descending (LAD) coronary artery (study group), and 10 subjects with normal coronaries (control group). All patients underwent transesophageal echocardiography to visualize the LAD. Spectral recordings of proximal LAD flow velocities were made and velocity time integrals were calculated. The diameter of the proximal LAD was measured and LAD blood flow was calculated. Nitroglycerin (0.3 mg) was administered intravenously and measurements were repeated 5 minutes later. Results: The mean age of the whole series was 48.6 ± 8 years, 39 (97.5%) being males. A significantly higher baseline systolic, diastolic, and total coronary blood flow was found in the study group as compared to the control group (46.1 ± 34.3 vs. 23.1 ± 8.2, 123.9 ± 73.3 vs. 68.1 ± 21.6, 170.1 ± 97.9 vs. 91.1 ± 26.8 cm³/min, respectively, P < 0.05 for all). Within the study group, nitroglycerin administration caused a significant decrease in peak diastolic velocity; systolic, diastolic, and total velocity time integrals; and both diastolic and total coronary blood flow (P < 0.05 for all). Meanwhile, within the control group, nitroglycerin administration caused a significant increase in the total coronary blood flow (P < 0.05). Conclusions: Patients with CAE have higher resting coronary blood flow in comparison with subjects with normal coronaries. Intravenous nitroglycerin administration causes significant reduction of coronary blood flow in ectatic coronary arteries. (Echocardiography 2010;27:1004‐1010)     

Two-Year outcomes after utilization of the TAXUS paclitaxel-eluting stent in bifurcations and multivessel stenting in the ARRIVE registries

Aims: Examine the incidence of clinical events after utilization of the TAXUS^® Express^® paclitaxel‐eluting stent (PES) in multivessel and bifurcation coronary stenting in an unselected patient population. Methods and Results: The ARRIVE Program compiled data on 7,492 patients receiving ≥1 TAXUS Express PES, including patients with multivessel stenting (MVS; n = 1,208) and bifurcation stenting (n = 575). Patients were enrolled at procedure start with no mandated inclusion/exclusion criteria; all cardiac events were monitored with independent adjudication of end‐points. Compared to simple use (single vessel/single stent) patients undergoing native intervention (N = 2,698), MVS patients had significantly more baseline comorbidities. Both groups had higher 2‐year rates of mortality (7.3%[MVS] and 7.5%[bifurcation] vs. 4.2%[simple‐use], P < 0.001), myocardial infarction (5.5% and 4.6% vs. 2.2%, P < 0.001 and P = 0.002), target vessel revascularization (15.5% and 14.8% vs. 7.7%, P < 0.001), and Academic Research Consortium definite/probable stent thrombosis (4.3% and 4.4% vs. 1.4%, P < 0.001) than the simple‐use group. Conclusions: ARRIVE multivessel and bifurcation stenting patients have significantly higher clinical risk through 2 years compared to simple‐use patients. In the absence of large randomized controlled trials in these populations, ARRIVE provides important insight into clinical outcomes over an extended period of time. (J Interven Cardiol 2011;24:342–350)     

Provisional stenting for multivessel PCI

Background: Bare stents reduce acute complications and repeat revascularization following percutaneous coronary intervention (PCI), but are costly and may lead to in‐stent restenosis. It remains unclear whether stents should be universally implanted or whether provisional stenting mainly to suboptimal balloon dilatation results is an acceptable approach for multivessel PCI. Objective: To compare the long‐term clinical restenosis and target lesion revascularization (TLR) of stented and non‐stented coronary artery lesions in patients who had multivessel PCI. Methods: We performed retrospective analysis of matched data from 129 consecutive patients who underwent multivessel PCI (at least optimal balloon angioplasty to one coronary artery segment and balloon angioplasty plus stenting to another coronary artery in the same patient, all lesions are de novo native coronary artery lesions with vessel diameter ?2.5?mm). The study endpoint was restenosis and repeat revascularization at one‐year follow‐up. Results: Baseline characteristics were similar in both groups. Low in‐hospital MACE (3.1%). Acute myocardial infarction, emergency revascularization via either PCI or CABG was detected and angiographic success was achieved in 99.3% of lesions in both groups. The rate of clinically driven angiographic restenosis and TLR at one‐year (follow‐up?100%) was similar (17.1% versus 18.6%, P?=?0.871, and 13.9% versus 16.3%, P?=?0.728, for optimal balloon angioplasty versus provisional stenting. Conclusions: The main findings from this study are that long‐term angiographic restenosis and TLR was comparable for optimal balloon angioplasty and provisional stenting, suggesting that provisional stenting is an acceptable approach for multivessel PCI.     

冠状动脉瘤样扩张与电子束CT检测的冠状动脉钙化

为探讨冠状动脉瘤样扩张患者电子束CT检测的冠状动脉钙化的特点及其临床和病理意义 ,将 2 7例经选择性冠状动脉造影确诊的冠状动脉瘤样扩张患者行电子束CT检查以计算钙化积分 ,并与 2 7例年龄和性别匹配的冠状动脉造影正常者进行比较。结果发现 ,冠状动脉瘤样扩张组钙化阳性率、钙化积分中位数及钙化积分的自然对数转换值均显著高于正常对照组 (P <0 .0 1或 0 .0 0 1)。冠状动脉瘤样扩张组中 2 1例粥样硬化性瘤样扩张患者钙化阳性率为 81.0 % ;弥漫性扩张动脉的钙化积分对数转换值显著低于局限性扩张动脉 (1.2 2± 1.79比 2 .86± 1.85 ,P <0 .0 5 )。结果提示 ,粥样硬化性冠状动脉瘤样扩张患者多数存在较为广泛的冠状动脉钙化 ,且钙化程度与病变类型有关。     

Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study

Objective : To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background : The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods : Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results : In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions : HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES. © 2011 Wiley Periodicals, Inc.     

Coronary Artery Anomalies in D-Transposition of the Great Artery Following Arterial Switch Operation

Background: The survival rate of patients following arterial switch operation (ASO) exceeds 95%, but coronary artery anomalies (CAA) contribute to a 2% incidence of sudden cardiac arrest later in life. Therefore, we aimed to assess abnormal findings of coronary arteries in post-ASO patients. Methods: Coronary computed tomography angiography (CCTA) is performed on post-ASO patients who meet institutional criteria. Intraoperative findings of coronary artery patterns were retrospectively reviewed and categorized using the Leiden classification system. Coronary artery anomalies were detected by CCTA and associations with coronary artery compromise were explored. Results: Forty-three patients who had CCTA with a median age of 15.6 years (12–21.3 years) were included in the study. Unusual coronary patterns were identified in 20 (46%) patients before ASO. CCTA identified 25 CAA in 22 patients (eleven with prepulmonic course, nine with interarterial course, three with acute take-off angle, and two with significant stenosis). Postoperative CAA was more common in patients with unusual coronary patterns (90% vs. 17.4%; p < 0.001). Nine patients experienced chest pain and two patients required coronary artery bypass graft. A common ostium of RCA and LAD or LMCA were associated with significant chest pain (OR 14.3%, 95% CI 2.5 to 82.3). Conclusions: Coronary artery anomalies in post-ASO are common. All post-ASO patients should have coronary artery imaging before participating in competitive sport and when they reach adolescence. Patients with unusual preoperative coronary artery patterns should undergo coronary artery imaging when feasible. Follow-up imaging studies are indicated in patients with post-operative coronary artery abnormalities.     

胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术

目的介绍并探讨经胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术的外科技术和临床经验.方法经胸骨下段正中较小切口游离左侧乳内动脉,用于冠状动脉前降支旁路移植术.对冠状动脉多支病变患者同时游离大隐静脉,用于冠状动脉其它分支旁路移植术.在非体外循环,心脏跳动下,完成冠状动脉单支或多支病变血管的旁路移植术.观察术后恢复情况.结果全组22例患者采用该手术方法,其中5例为前降支单支病变,17例为多支病变.22例患者前降支旁路移植术均采用左乳内动脉.平均冠状动脉旁路移植支数2.40±1.04(1～4)支/人.冠状动脉旁路移植的靶血管包括前降支、对角支、右冠状动脉或后降支和高位边缘支.全组患者术后恢复顺利,无严重术后并发症和死亡.患者术后平均8.1±1.6天痊愈出院.结论该手术方法创伤较小,安全易行,对有手术适应证的多支病变患者是一种较好的微创冠状动脉旁路移植手术方法.