Ten-year follow-up of percutaneous transluminal coronary angioplasty for proximal left anterior descending coronary artery stenosis in 351 patients

Objectives. We sought to evaluate the short- and long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery.Background. Both the supposedly high rate of acute complications and relatively poor long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery have led to a search for alternative interventional techniques.Methods. We analyzed the success rates and long-term follow-up results in 351 consecutive patients who underwent balloon angioplasty for stenosis of the left anterior descending coronary artery proximal to its first side branch. The power of the study was >80% in detecting a difference of 9% in the proportion of patients who survived at 10 years, assuming an 80% survival rate in the control group.Results. There were 60 ostial and 291 nonostial stenoses. Follow-up lasted a median of 85 months (range 0 to 137) and was 100% complete. The angiographic success rate was 90.9%. The clinical success rate was 86.3%. Nine patients (2.6%) died, 17 (4.8%) needed emergency coronary artery bypass graft surgery, and 10 (2.8%) developed a myocardial infarction. Several patients had subsequent complications. The success and complication rates were not significantly different for patients with ostial and nonostial stenoses. Ten years after balloon angioplasty, freedom from mortality was 80%, freedom from cardiac death was 87%, freedom from myocardial infarction was 84%, freedom from vessel-related reinterventions was 66%, and freedom from angina pectoris was 33%. There were more reinterventions for ostial stenoses, with a 1-year relative risk of ostial versus nonostial stenoses for related reinterventions of 1.7 (95% confidence interval 1 to 2.8, p = 0.049).Conclusions. More than 10 years ago, balloon angioplasty for stenoses in the proximal left anterior descending coronary artery, either ostial or nonostial, had a high success rate. Although the long-term results are satisfactory, ostial stenoses are associated with a higher early clinical restenosis rate requiring more reinterventions.     

Clinical outcome 5 years after attempted percutaneous transluminal coronary angioplasty in 427 patients

This study was performed to define the 5 year clinical status of 427 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in 1981. Their mean age was 54 +/- 10 years (+/- 1 SD). Sixty-one percent had unstable angina, 23% had prior myocardial infarction, 86% had one-vessel disease, and 92% had normal left ventricular function. Sixty-seven percent of patients had left anterior descending artery stenosis. Angiographic success was achieved in 84% of patients. Coronary bypass surgery was required in 9.6% of patients, in 5.9% as an emergency procedure. There were no in-hospital deaths. Follow-up at 5 years was 100% complete. There were 15 late deaths (96.3 +/- 1.0% survival), including seven of cardiac cause (98.1 +/- 0.7% cardiac survival). Myocardial infarction occurred in 24 patients (94% freedom from myocardial infarction), coronary bypass surgery was required in 63 (84% freedom from bypass surgery), and 365 patients (85%) were asymptomatic at follow-up. At 5 years, 83 patients (20%) had required an additional PTCA. Unstable angina pectoris and proximal left anterior descending coronary artery stenoses were present in 162 patients. The overall survival and cardiac survival in this subset was 94.4 +/- 1.8% and 98.1 +/- 1.1%, respectively. The excellent survival and low event rates over 5 years in this population support the concept that PTCA is safe and effective for patients with symptomatic angina pectoris, single-vessel disease, and normal left ventricular function.     

Late follow-up of 781 patients undergoing percutaneous transluminal coronary angioplasty or coronary artery bypass grafting for an isolated obstruction in the left anterior descending coronary artery

Seven hundred eighty-one patients with isolated left anterior descending coronary atherosclerosis treated with either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty between January 1980 and December 1984 were studied to determine late survival and event-free survival. Follow-up was complete in 775 patients (99.4%). Actuarial survival at 5 years was 98% for surgical patients and 95% for angioplasty patients (p = 0.02). Five-year event-free survival (freedom from myocardial infarction, bypass grafting, angioplasty, and death) was 93% for surgical patients and 62% for angioplasty patients. This study suggests that the higher initial cost and complexity of bypass surgery may be justified by superior long-term results.     

Long-term results of coronary angioplasty for single vessel, proximal, left anterior descending disease

The acute and long-term results of coronary angioplasty in 295 patients with isolated, proximal left anterior descending coronary stenosis are reported. The angiographic success rate was 83.4% overall, but 90.5% for non-occluded arteries treated since 1985. Clinical success at hospital discharge was achieved in 79.7%. The median duration of follow-up was 2.9 years and vital status was established in 99.7% at census. Cumulative 5-year cardiac survival was 96.2% after successful angioplasty and 95.6% for all patients. Five-year freedom from all cardiac events including cardiac death, myocardial infarction and repeat intervention was 73.8% amongst successfully treated patients, and 63.0% for all patients. After angioplasty, patients had less angina, required less anti-anginal medication and were more likely to be in gainful employment. Our data indicate that coronary angioplasty is an effective long-term treatment for selected patients with single vessel disease involving the proximal left anterior descending coronary artery.     

Repeat coronary angioplasty as treatment for restenosis.

Repeat coronary angioplasty has become the standard approach to a first restenosis. However, the long-term outcome of such a strategy is not well defined. In the present study, 465 patients (mean age 58 years [range 27 to 79], 53% with multivessel disease) underwent a second angioplasty procedure at the same site. The procedure was successful in 96.8% with a 1.5% rate of in-hospital bypass surgery, a 0.9% incidence rate of myocardial infarction and no procedural deaths. Four hundred sixty-three patients (99.6%) were followed up for a mean of 40.5 months. Forty-nine patients (10.6%) underwent a third angioplasty procedure at the same site, 55 (11.8%) had coronary bypass surgery and 33 (7.1%) underwent angioplasty at a different site. During follow-up, 12 patients (2.6%) sustained a myocardial infarction and 21 (4.5%) died including 13 (2.8%) with cardiac death. Of the 442 surviving patients, 88% experienced sustained functional improvement and 78% were free of angina. The actuarial 5-year cardiac survival rate was 96% and the rate of freedom from cardiac death and myocardial infarction was 92%. For the subgroup of 49 patients who had a third angioplasty procedure at the same site, the success rate was 93.9% with a 2% incidence rate of myocardial infarction. There were no in-hospital deaths or coronary artery bypass operations. The mean follow-up interval for this subgroup was 30.5 months with a 22.4% cross-over rate to coronary bypass surgery, a 4.1% incidence rate of myocardial infarction and a 2% cardiac mortality rate. At last follow-up, 89% of patients had sustained functional improvement and 76% were free of angina. The combined angiographic and clinical restenosis rate was 48%. Repeat angioplasty as treatment for restenosis is an effective approach associated with a high success rate, low incidence of procedural complications, and sustained functional improvement in combination with an acceptable rate of bypass surgery. However, there is a trend toward diminished angioplasty efficacy after a second restenosis. Thus, decisions for further revascularization should be made after careful review of available options.     

Long-term follow-up of patients with proximal left anterior descending coronary artery stenosis treated with stent

INTRODUCTION AND OBJECTIVE: Patients with lesions of the proximal left anterior descending coronary artery are a special high-risk group. In the present study we analyzed the efficacy and safety of coronary stenting in such lesions and the factors related to a less favorable prognosis in long-term follow-up. METHODS: Ninety-eight consecutive patients with severe left anterior descending artery stenosis were enrolled, all with coronary angioplasty and elective stenting. Clinical follow-up was carried out annually in all patients by personal interview or telephone contact. The incidence of death, new infarction, anginal status, and new revascularization procedures was registered. Clinical, angiographic, and procedural variables were analyzed to identify predictors of long term prognosis. RESULTS: Mean follow-up was 38 11 months. There was only one major periprocedural complication, which required urgent surgery. Five deaths were registered, 3 of non-cardiac and 2 of cardiac origin. Twenty-five patients developed angina and 11 underwent a new revascularization of the proximal left anterior descending coronary artery (6 surgical and 5 angioplasty). Two patients had new anterior myocardial infarction. At 60 months the major cardiac event-free rate was 83.7% and the cardiac death-free rate was 98%. The use of two stents and the association of diabetes-hypertension-hypercholesterolemia were associated with a less favorable prognosis in our population. CONCLUSIONS: Stenting of left anterior descending coronary stenosis was safe and effective in a long-term analysis. The survival rate was high and the incidence of new revascularization was low.     

Long-term outcome of unsuccessful percutaneous transluminal coronary angioplasty

We analyzed the long-term outcome of 198 patients after unsuccessful percutaneous transluminal coronary angioplasty. Forty-nine percent underwent emergency coronary artery bypass grafting surgery, 17% had elective bypass surgery, and 34% were treated medically. The in-hospital mortality rate was 4%, and myocardial infarction occurred in 36% of patients. Follow-up was completed in 100% of patients with a mean follow-up period of 35 +/- 22 months. Actuarial cardiac survival at 4 years was 97% in the emergency bypass surgery group, 100% in the elective bypass surgery group, and 86% in the medically treated group. Actuarial event-free survival (freedom from myocardial infarction, bypass surgery, coronary angioplasty, and cardiac death) at 4-year follow-up was 81% in 198 patients, 90% in the emergency bypass surgery group, 85% in the elective bypass surgery group, and 65% in the medically treated group. Results of multivariate analysis showed that emergency or elective bypass surgery after failed coronary angioplasty, normal or mildly impaired left ventricular function, and male sex were predictors of better outcome at 4 years.     

Effect of coronary angioplasty on electrocardiographic changes in patients with unstable angina secondary to left anterior descending coronary artery disease

The effect of semiemergent percutaneous transluminal coronary angioplasty on clinical and electrocardiographic (ECG) variables was assessed in 76 patients with unstable angina secondary to an isolated severe proximal left anterior descending coronary artery stenosis. All patients manifested symmetric T wave inversion in two or more anterior ECG leads. Wall motion abnormalities were present in 37 patients on ventriculography before dilation. Angioplasty was successful in 70 patients (92%), resulting in a reduction in luminal diameter stenosis from 91 +/- 8% to 21 +/- 6%, with no major acute procedure-related complications observed. The other six patients underwent semiurgent (less than 48 h) coronary artery bypass surgery and three patients experienced a myocardial infarction (before bypass surgery in two). Serial ECGs revealed complete resolution of ST-T wave changes in 51% of patients at 14 weeks and in 90% at 28 weeks. In contrast, prolongation of the corrected QT interval, which was present in 16 patients (8%), normalized within 48 h of successful angioplasty. Twelve of these 16 patients with a prolonged QT interval had nonocclusive thrombus formation and poor collateral circulation on angiography. Patients were followed up for 6 to 43 months (mean 23 +/- 10). Angiographic evidence of restenosis was present in 34% of patients, all of whom underwent a successful second or third procedure. One death occurred at 8 months after successful angioplasty. Wall motion abnormalities had completely resolved in 13 of 15 patients who underwent repeat ventriculography, at which time 10 had a normal ECG. This study demonstrates that ECG changes may persist for up to 7 months in patients who undergo successful angioplasty for severe left anterior descending coronary artery disease and unstable angina. Semiemergent angioplasty was associated with a high initial success rate and excellent long-term outcome.     

Determinants of 2-year outcome after coronary angioplasty in patients with multivessel disease on the basis of comprehensive preprocedural evaluation. Implications for patient selection. The Multivessel Angioplasty Prognosis Study Group

BACKGROUND. To assess the likelihood of intermediate-term event-free survival (freedom from death, coronary artery bypass surgery, and myocardial infarction) in patients with multivessel coronary disease undergoing coronary angioplasty, 350 consecutive patients from four clinical sites were carefully evaluated and followed for 22 +/- 10 months. METHODS AND RESULTS. Eight clinical variables were evaluated at the clinical sites, and 23 angiographic variables describing the number, morphology, and topography of coronary stenoses were evaluated at a core angiographic laboratory. Most patients had Canadian Cardiovascular Society class III or IV angina (72%), two-vessel coronary disease (68%), and well-preserved left ventricular function (mean ejection fraction, 58 +/- 12%; range, 18-85%). Follow-up was complete in 99% of patients. At 2 years, event-free survival was 72%, overall survival was 96%, freedom from bypass surgery was 82%, and freedom from nonfatal myocardial infarction without surgery was 96%. Sequential Cox proportional hazards regression analyses allowing stepwise entry of variables prospectively coded as simple, as of intermediate complexity, or as complex found event-free survival to be independently predicted by low Canadian Cardiovascular Society angina class, no diabetes, no proximal left anterior descending stenoses, and the sum of stenosis simplified risk-territory scores of 15 or less. In the absence of class IV angina and these risk factors, 2-year event-free survival was 87% and overall survival was 100%. In the presence of two or more of these risk factors, event-free survival was less than 50%. CONCLUSIONS. Recognition of risk factors for poor long-term outcome in this setting may improve clinical decision making and provide a framework on which to base meaningful subgroup analyses in randomized trials assessing the efficacy of coronary angioplasty.     

Sudden paradoxic clinical deterioration during angioplasty of the occluded right coronary artery in acute myocardial infarction

The beneficial versus detrimental effects of emergency coronary angioplasty for achieving myocardial reperfusion remain controversial. We studied 83 consecutive patients treated with angioplasty of occluded (Thrombolysis in Myocardial Infarction trial [TIMI] grade 0 or 1 flow) infarct-related arteries. Seventy patients had unsuccessful intravenous thrombolytic therapy and subsequently had rescue angioplasty and 13 patients had direct angioplasty without prior thrombolytic therapy. Forty-six patients had occlusion of the right coronary artery and 37 of the left anterior descending coronary artery. These two patient groups were similar with respect to age, percent of men, history of prior myocardial infarction, known cardiac risk factors and elapsed time from onset of chest pain to reperfusion. Angioplasty was initially successful in achieving TIMI grade 2 or 3 flow in 87% of right coronary artery occlusions and 92% of left anterior descending artery occlusions (p = 0.47). At 1 week follow-up catheterization, vessel patency was 63% for right coronary and 85% for left anterior descending infarct-related arteries (p = 0.03). Patients with right coronary artery occlusion had a higher incidence of life-threatening complications during angioplasty than did patients with left anterior descending artery occlusion (p = 0.002) including, respectively: 1) the need for cardiopulmonary resuscitation in 16% versus 0% (p = 0.02), 2) sustained ventricular tachycardia or ventricular fibrillation requiring electric cardioversion in 9% versus 3% (p = 0.33), and 3) sustained hypotension requiring inotropic agents or balloon pump therapy in 11% versus 3% (p = 0.16).(ABSTRACT TRUNCATED AT 250 WORDS)     

First time myocardial revascularization in patients younger than 70 years. Single versus double internal mammary artery.

BACKGROUND: We evaluated the early and late outcomes of bilateral internal mammary artery (BIMA) grafting, with or without saphenous vein grafts (SVGs), compared to single internal mammary artery and SVGs in patients < 70 years undergoing first myocardial revascularization. METHODS: From September 1986 to December 1999, 1389 patients underwent first myocardial revascularization using the left internal mammary artery (LIMA) to the left anterior descending artery and SVGs (n = 480) or BIMA (one internal mammary artery on the left anterior descending artery) with or without SVGs (n = 909). Propensity score analysis was used to select 952 (476 of each group) patients with the same preoperative and operative characteristics. Thirty-day outcome and 10-year freedom from all-cause death, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted artery, cardiac events and any events, were evaluated. Follow-up ranged from 3.5 to 16.8 years (mean 8.8+/-4.0 years). RESULTS: Thirty-day mortality was 2.9% in the LIMA group and 1.9% in the BIMA group, p = NS; the BIMA group showed a better 10-year freedom from all-cause death (92.4+/-2.1 vs 87.5+/-3.5%, p = 0.0216), cardiac death (97.4+/-0.9 vs 91.9+/-1.4%, p = 0.0042), AMI (98.7+/-0.5 vs 94.2+/-1.2%, p = 0.0034), AMI in a grafted area (98.9+/-0.5 vs 94.7+/-1.3%, p = 0.0017), cardiac events (95.4+/-1.2 vs 86.8+/-1.8%, p = 0.0026) and any events (88.8+/-2.2 vs 80.7+/-2.1%, p = 0.0124). Cox analysis confirmed that LIMA + SVGs was a risk factor independent of lower freedom from all the above-mentioned events. CONCLUSIONS: Double mammary artery in patients < 70 years who had a first time myocardial revascularization gives a better clinical outcome even 10 years after the operation.     

Clinical and arteriographic variables predictive of survival in coronary artery disease

Survival, subsequent myocardial infarction and current anginal status were determined for 90 nearly consecutive patients who underwent coronary arteriography at the Johns Hopkins Hospital between 1960 and 1967. All patients had at least one coronary arterial narrowing equal to or greater than 70 percent; 78 of 90 patients would be candidates for coronary bypass surgery by present criteria. Twenty-nine of the 78 surgically “suitable” patients died of cardiac causes; 7 of 49 survivors sustained an acute myocardial infarction (mean follow-up period 9.9 years). Patients with a 70 percent or greater narrowing proximal to the first septal branch of the left anterior descending coronary artery had a significantly greater mortality compared with patients with equivalent narrowing distal to the first septal branch or with patients without 70 percent or greater narrowing of the left anterior descending artery. The patients with a 70 percent or greater narrowing of the left anterior descending artery who died were those with a significant narrowing in at least one other major coronary artery. Multivariate stepwise discriminate function analysis of all clinical, electrocardiographic (except stress electrocardiographic) and arteriographic variables identified three independent predictors of mortality: (1) the simultaneous occurrence of a narrowing in left anterior descending and right coronary arteries, (2) prior myocardial infarction; and (3) 70 percent or greater narrowing proximal to the first anterior descending septal branch. When stress electrocardiographic findings were included, a “positive” stress electrocardiographic test was also an independent predictor of mortality.     

Desirability of immediate surgical standby for coronary angioplasty

OBJECTIVE--To assess the value of emergency surgical standby for percutaneous transluminal coronary angioplasty. DESIGN--Retrospective review of the major complications of coronary angioplasty in a regional cardiac centre. SETTING--All angioplasties were performed in the cardiac catheterisation laboratory of Wythenshawe Hospital with surgical standby in an adjoining operating theatre. PATIENTS--1262 vessels were dilated in 1032 patients (mean age 53 years) between 1984 and 1989. MAIN OUTCOME MEASURES--In-hospital mortality from emergency surgical revascularisation after angioplasty; the rate of myocardial infarction and overall morbidity. RESULTS--Coronary angioplasty achieved primary success in 90% of cases. Thirty eight (3.7%) patients (five women (mean age 55.8) and 33 men (mean age 53.0] were referred for urgent surgical revascularisation--36 direct to operation and two within 24 hours. All patients survived surgery. Five of the 38 had had a previous angioplasty to the same vessel and one had had previous coronary artery grafts. Four of the 38 had an angioplasty for unstable angina. Eighteen had single, 13 double, and seven triple vessel coronary artery disease. The target vessel was the left anterior descending in 25, right coronary artery in nine, circumflex in three, and the left anterior descending and circumflex coronary arteries in one. Five required external cardiac massage on the way to the operating theatre; two of them had a left main stem occlusion. Four internal mammary artery and 60 reversed saphenous vein grafts were implanted (1.6 per patient). Complete revascularisation was achieved in 36 (94.7%) patients. Q wave myocardial infarction occurred in six (15.8%). The final outcome was: none dead, three patients with angina, one late death, one cerebrovascular accident, one late operation for a new left anterior descending lesion, two patients on diuretics with or without an angiotensin converting enzyme inhibitor. One orthotopic transplant was performed in a patient in whom cardiogenic shock developed after the left anterior descending coronary artery became occluded 72 hours after angioplasty. CONCLUSION--There was no surgical mortality and low morbidity among patients for whom immediate surgical cover was requested.     

Usefulness of coronary angioplasty in asymptomatic patients

Of 6,545 patients who had elective coronary angioplasty procedures performed over a 7.5-year period from June 1980 through December 1987, 114 (1.7%) never had symptoms of myocardial ischemia. Exercise-induced silent myocardial ischemia was documented before angioplasty in 94% of these asymptomatic patients. Angioplasty was successful in 87%, whereas emergency coronary artery bypass grafting was required in 4%, and a further 2% had myocardial infarctions after the procedures. The remaining 7% had unsuccessful angioplasty procedures but experienced no in-hospital cardiac events. The follow-up period after hospital discharge averaged 43 +/- 20 months (range 5 to 93). There were no deaths. In the group of 99 patients with initially successful angioplasty procedures the follow-up interval ranged from 5 to 92 months. During that period, 7 patients underwent coronary bypass surgery, 4 patients had myocardial infarction and 30 patients had repeat angioplasty procedures for restenosis. The cumulative probability of event-free survival over 5 years for the group with successful angioplasty was: 100% freedom from death, 95% freedom from myocardial infarction, 87% freedom from myocardial infarction or coronary bypass surgery and 61% freedom from myocardial infarction, coronary bypass surgery or repeat angioplasty. Thus, coronary angioplasty performed in 114 asymptomatic patients, most with exercise-induced silent myocardial ischemia, achieved very good primary success and was accompanied by low cardiac event rates and no deaths over several years of patient follow-up.     

Desirability of immediate surgical standby for coronary angioplasty.

OBJECTIVE--To assess the value of emergency surgical standby for percutaneous transluminal coronary angioplasty. DESIGN--Retrospective review of the major complications of coronary angioplasty in a regional cardiac centre. SETTING--All angioplasties were performed in the cardiac catheterisation laboratory of Wythenshawe Hospital with surgical standby in an adjoining operating theatre. PATIENTS--1262 vessels were dilated in 1032 patients (mean age 53 years) between 1984 and 1989. MAIN OUTCOME MEASURES--In-hospital mortality from emergency surgical revascularisation after angioplasty; the rate of myocardial infarction and overall morbidity. RESULTS--Coronary angioplasty achieved primary success in 90% of cases. Thirty eight (3.7%) patients (five women (mean age 55.8) and 33 men (mean age 53.0] were referred for urgent surgical revascularisation--36 direct to operation and two within 24 hours. All patients survived surgery. Five of the 38 had had a previous angioplasty to the same vessel and one had had previous coronary artery grafts. Four of the 38 had an angioplasty for unstable angina. Eighteen had single, 13 double, and seven triple vessel coronary artery disease. The target vessel was the left anterior descending in 25, right coronary artery in nine, circumflex in three, and the left anterior descending and circumflex coronary arteries in one. Five required external cardiac massage on the way to the operating theatre; two of them had a left main stem occlusion. Four internal mammary artery and 60 reversed saphenous vein grafts were implanted (1.6 per patient). Complete revascularisation was achieved in 36 (94.7%) patients. Q wave myocardial infarction occurred in six (15.8%). The final outcome was: none dead, three patients with angina, one late death, one cerebrovascular accident, one late operation for a new left anterior descending lesion, two patients on diuretics with or without an angiotensin converting enzyme inhibitor. One orthotopic transplant was performed in a patient in whom cardiogenic shock developed after the left anterior descending coronary artery became occluded 72 hours after angioplasty. CONCLUSION--There was no surgical mortality and low morbidity among patients for whom immediate surgical cover was requested.     

Off-pump coronary endarterectomy in high-risk patients

The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% - 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 +/- 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.     

Repeat coronary angioplasty for restenosis: results and predictors of follow-up clinical events

To determine the predictors of long-term outcome after repeat percutaneous transluminal coronary angioplasty (PTCA), we analyzed the immediate and follow-up results of 144 patients who underwent a second PTCA procedure for restenosis of a previously successfully dilated lesion. Clinical success was obtained in 94% of patients. Emergency coronary bypass graft surgery was required in two patients (1%). Of the 136 successfully treated patients, 126 were followed for a duration of 6 to 36 months (mean 16, median 12 months). The follow-up coronary events (mutually exclusive) included cardiac death (2%), nonfatal myocardial infarction (2%), coronary bypass surgery (15%), and third PTCA (9%). According to results of Cox regression analysis, the independent variables associated with an increased risk of recurrent coronary events after repeat PTCA were: dilatation of a proximal left anterior descending artery stenosis at both initial and second PTCA (p = 0.001), time interval between the initial and the second PTCA less than or equal to 3 months (p = 0.001), multiple versus single-lesion redilatation at the time of repeat PTCA (p = 0.002), and the presence of diabetes mellitus (p = 0.005). Thus repeat PTCA for restenosis is a safe and efficacious procedure, and it provides excellent long-term outcome in the majority of patients. Dilatation of a proximal left anterior descending artery lesion, a short time interval between the first and second PTCA procedures, diabetes mellitus, and redilatation of multiple lesions are predictors of recurrent clinical events after a second PTCA. Repeat PTCA should be considered carefully for patients falling within a high-risk profile for recurrent events after the procedure.     

Preponderance of acute proximal left anterior descending coronary arterial lesions in fatal myocardial infarction: A clinicopathologic study

To determine whether an acute lesion in a specific segment of the cororiary tree is more likely than other obstructions to cause fatal myocardial infarction, 77 autopsy patients Who died of acute myocardial infarction were studied. Multiple coronary stenoses were present in 92 percent of these patients, arid the proximal left anterior descending coronary artery before the first septal perforator accounted for only 23 percent of the critical narrowings (greater than 70 percent of luminal diameter). In contrast, acute thrombotic coronary events associated with fatal myocardial infarction occurred most often in the proximal left anterior descending artery, accounting for 61 percent of acute lesions; this rate compared with 8 percent of acute lesions occurring in the mid or distal left anterior descending artery, 18 percent of those in the right, 6 percent of those in the left circumflex and 7 percent of those in the left main coronary artery. Of the autopsy patients, 32 (40 percent) had 77 prior nonfatal myocardial infarcts of which only 17 (22 percent) were anteroseptal infarcts related to occlusion of the proximal left anterior descending coronary artery. The amount of infarcted myocardium in the hearts with acute proximal left anterior descending coronary arterial lesions was somewhat more extensive but not significantly different from that of hearts with other acute coronary lesions.

Fifty survivors of myocardial infarction who underwent cardiac catheterization were studied for comparison. In those patients, proximal left anterior descending coronary disease accounted for 17 percent of critical narrowings and only 22 percent of nonfatal infarcts. These findings suggest that an acute proximal left anterior descending coronary arterial lesion is more likely to result in fatal myocardial infarction than are critical obstructions elsewhere in the coronary arterial tree. Because the quantity of the infarct does not appear to be sufficient to explain these differences, qualitative differences in anteroseptal myocardium are suggested.     

Elective Coronary Stenting as an Adjunct to Balloon Angioplasty in Stable Coronary Artery Disease: No Association with Incidence of Acute Complications. Results of the PTCA Registry of the German Community Hospitals

Background: Elective coronary stenting has hem shown to reduce the rate of recurrent stenoses after angioplasty but no firm data are available on its possible association with in-hospital ischemic complications . Methods: We analyzed the data of the registry of the German community hospitals covering approximately one quarter of all interventions in Germany. We included all angioplasty procedures performed in patients with stable coronary artery disease in 1996. Interventions with elective coronary stenting were compared to those with conventional balloon angioplasty. Interventions with bailout stenting were excluded . Results: Of 19,170 angioplasty procedures, 32.2% included elective coronary stenting. The immediate angiographic success rate (residual stenosis < 50%) was 90.6% of the procedures with stents versus 86.3% of those without stents (P < 0.001). The overall incidence of complications (death, myocardial infarction, bypass surgery, vessel closure, reintervention) was 3.9% and 3.8% (NS). Major events (death, myocardial infarction, bypass surgery) were more common in the stent-treated group (1.8% vs 1.4%, P = 0.027). In multivariate analysis, the following factors were significantly associated with complications: residual stenosis ≥ 50%, female gender, angioplasty of proximal left anterior descending coronary artery, morphological fype of lesion B2 or C, and multivessel disease. Angioplasty of restenoses after previous angioplasty was associated with significantly less risk than of de novo lesions. Stents were neutral with respect to the overall incidence of complications . Conclusions: Complications after elective coronary angioplasty remain largely unpredictable in individual patients despite the identification of several clinical and procedural risk factors. Elective coronary stenting is not associated with the immediate therapeutic risk of angioplasty in stable coronary artery disease .     

Increased exercise thallium-201 lung uptake: a noninvasive prognostic index in two-vessel coronary artery disease

To determine the physiologic impact of two-vessel coronary artery disease and its effect on prognosis, a series of clinical, angiographic, exercise and quantitative thallium-201 (Tl-201) imaging parameters were analyzed in 85 consecutive two-vessel coronary artery disease patients followed for 52 +/- 27 months after coronary angiography and Tl-201 scintigraphy. End points were cardiac death (n = 3), myocardial infarction (n = 6) and coronary bypass graft surgery more than three months after testing (n = 16). Using Cox Hazards survival analysis, early cardiac events were not predicted by: myocardial infarction or anginal history; resting left ventricular function; exercise blood pressure response; angina or severity of ECG ST segment depression (mm); Tl-201 defect size; redistribution or clearance; angiographic patterns; or the presence of proximal left anterior descending disease. Significant predictors of adverse cardiac events were: increased exercise lung to heart Tl-201 ratio (0.59 +/- 0.12 versus 0.46 +/- 0.1; P less than 0.0001); ECG lead extent of ST segment depression (P less than 0.03); and exercise heart rate response (P less than 0.047). Event-free survival for patients with normal and abnormally increased lung to heart Tl-201 ratios at 48 months was 76% versus 63% (P less than 0.003). It was concluded that two-vessel coronary artery disease survival correlates with exercise Tl-201 uptake which reflects exercise induced left ventricular dysfunction.