Percutaneous coronary intervention in the current era compared with 1985-1986: the National Heart, Lung, and Blood Institute Registries.

BACKGROUND: Although refinements have occurred in coronary angioplasty over the past decade, little is known about whether these changes have affected outcomes. METHODS AND RESULTS: Baseline features and in-hospital and 1-year outcomes of 1559 consecutive patients in the 1997-1998 Dynamic Registry who were having first coronary intervention were compared with 2431 patients in the 1985-1986 National Heart, Lung, and Blood Institute Registry. Compared with patients in the 1985-1986 Registry, Dynamic Registry patients were older (mean age, 62 versus 58 years; P:<0.001) and more often female (32.1% versus 25.5%; P:<0.001). In the Dynamic Registry, procedures were more often performed for acute myocardial infarction (22.9% versus 9.9%; P:<0.001) and treated lesions were more severe (84.5% versus 82.5% diameter reduction; P:<0.001), thrombotic (22.1% versus 11.3%; P:<0.001) or calcified (29.5% versus 10.8%; P:<0.001). Stents were used in 70.5% of Dynamic Registry patients, whereas 1985-1986 patients received balloon angioplasty alone. Procedural success was higher in the Dynamic Registry (92.0% versus 81.8%; P:<0.001) and the rate of in-hospital death, myocardial infarction, and emergency coronary bypass surgery combined was lower (4.9% versus 7.9%; P:=0.001) than in the 1985-1986 Registry. The 1-year rate for CABG was lower in the Dynamic Registry (6.9% versus 12.6%; P:<0.001). CONCLUSIONS: Although Dynamic Registry patients had more unstable and complex coronary disease than those in the 1985-1986 Registry, their rate of procedural success was higher whereas rates of complications and subsequent CABG were lower. Results of percutaneous coronary intervention have improved substantially over the past decade.

Silent ischemia: evaluation by exercise and redistribution tomographic thallium-201 myocardial imaging.

UNLABELLED: To compare the amount of myocardium jeopardized during silent ischemia and painful ischemia, 112 consecutive patients undergoing coronary arteriography with ischemia demonstrated by exercise and redistribution tomographic thallium-201 myocardial imaging (SPECT) were divided into two groups: 84 patients without anginal pain (silent ischemia) and 28 with pain (painful ischemia). The SPECT apical, mid and basal ventricular levels of the short-axis view and the apical portion of the long-axis view were divided into 20 segments. The results were 1) 7.4 +/- 4.7 ischemic segments in silent ischemia and 7.6 +/- 3.7 in painful ischemia (p = NS) with 4.7 +/- 3.6 segments in silent ischemia undergoing total redistribution compared with 5.4 +/- 3.4 in painful ischemia (p = NS); 2) no difference in the incidence of single, double or triple vessel disease between silent and painful ischemic groups; 3) similar anatomic distribution of ischemic segments between the two groups; 4) more positive exercise electrocardiographic (ECG) changes in painful ischemia (70%) than in silent ischemia (32%) (p less than 0.001) with equal amounts of ischemia associated with positive and negative exercise ECG findings. CONCLUSIONS: 1) Patients with silent and painful ischemia during exercise have similar amounts of ischemic myocardium demonstrated by tomographic thallium-201 imaging and similar extent of angiographically documented coronary artery disease despite the absence of pain and the lower incidence of positive exercise ECG findings in silent ischemia. 2) Positive and negative exercise ECG findings were associated with similar amounts of ischemic myocardium.

Digital supine bicycle stress echocardiography: a new technique for evaluating coronary artery disease.

OBJECTIVES: The objective of this study was to determine the accuracy of digital supine bicycle stress echocardiography, a new technique for evaluating coronary artery disease during peak exercise. BACKGROUND: Prior stress echocardiographic techniques have not utilized peak exercise imaging to determine the extent and location of coronary artery disease. METHODS: Two-hundred twenty-two patients were studied: 180 underwent both supine bicycle stress echocardiography and coronary arteriography; 42 had a < 5% likelihood of disease. Forty-three patients had normal coronary arteries, 55 had single-vessel, 42 had double-vessel and 40 had triple-vessel coronary artery disease. RESULTS: Supine bicycle stress echocardiography was 93% sensitive, 86% specific and 92% accurate for identifying patients with coronary artery disease irrespective of prior myocardial infarction or achievement of > or = 85% maximal predicted heart rate. The "normalcy" rate in the low probability group was 100%. Supine bicycle stress echocardiography was 87% sensitive, 89% specific and 88% accurate for specific vessel identification. The sensitivity was greatest for the left anterior descending compared with the right coronary artery and the left circumflex coronary artery (95% vs. 81% vs. 78%, p < 0.01) and for vessels in patients with double- and triple-vessel compared with single-vessel disease (90% vs. 89% vs. 78%, p < 0.05). The procedure was significantly more sensitive for detection of vessels with 90% to 100% compared with 50% to 70% diameter stenosis (91% vs. 81%, p < 0.05) and was 88% correct in the prediction of multivessel disease. CONCLUSIONS: Supine bicycle stress echocardiography is a highly accurate tool for evaluating coronary artery disease, identifying both the patient with coronary artery disease and the location and extent of disease.

Silent ischemia after coronary angioplasty: evaluation of restenosis and extent of ischemia in asymptomatic patients by tomographic thallium-201 exercise imaging and comparison with symptomatic patients.

One hundred sixteen patients were evaluated to determine the ability of single photon emission computed tomographic (SPECT) thallium-201 exercise and redistribution imaging to detect silent ischemia secondary to restenosis in asymptomatic patients after single and multiple vessel percutaneous transluminal coronary angioplasty and the findings were compared with SPECT imaging detection of restenosis in symptomatic patients. The value of exercise electrocardiography (ECG) and the amount of ischemic myocardium in symptomatic and asymptomatic patients were determined. Forty-one patients were asymptomatic after angioplasty; 77% of these had chest pain before angioplasty. Seventy-five patients had chest pain after angioplasty; 99% of these had chest pain before angioplasty. Restenosis occurred in 61% of asymptomatic and 59% of symptomatic patients and in 46% of the vessels in both asymptomatic and symptomatic patients. Sensitivity, specificity and accuracy for detection of restenosis by SPECT in individual patients were 96%, 75% and 88% versus 91%, 77% and 85%, respectively, in the asymptomatic versus symptomatic groups (p = NS). Sensitivity, specificity and accuracy for restenosis detection in individual vessels were 90%, 89% and 89% versus 84%, 77% and 84%, respectively, in the asymptomatic and symptomatic groups (p = NS), with similar results for the three major arteries. Sensitivity and accuracy of exercise ECG were significantly less than those of SPECT imaging for the patients with silent (40% and 44%) and symptomatic (59% and 64%) ischemia (p less than 0.001). Restenosis of vessels in the patients with silent and symptomatic ischemia was associated with an equal amount and degree of severity of ischemic myocardium in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty in young adults: initial results and late outcome.

The initial and late outcome of coronary angioplasty was studied in 148 patients less than 40 years of age (mean 36.4 +/- 3). Angioplasty was performed on a single vessel in 70% of patients and on multiple vessels in 30%; it was performed on a totally occluded vessel in 20%. Angioplasty was successful in 90.5% of patients, unsuccessful but uncomplicated in 7.4% and complicated by myocardial infarction in 0.7%, emergency bypass surgery in 0.7% and death in 0.7%. At late (mean 3.7 +/- 3 years; range 0.5 to 11.5) follow-up study after successful angioplasty, 94% of patients were alive, 79% were free of angina and 85% had returned to work; late myocardial infarction occurred in 4%. Actuarial survival at 5 years was 95%, and 85% of patients were free from death, infarction or bypass surgery. A second angioplasty was performed in 29 patients (22%) (mean 6.1 +/- 8.4 months) and was successful in 27 (93%), with no deaths. Elective coronary bypass surgery was performed in 8.5% of patients, with perioperative infarction in 9% and no deaths. By univariate analysis, late death was more likely to occur in hypertensive patients (15% versus 2.5%; p less than 0.01) and diabetic patients (21.4% versus 3.6%; p less than 0.01). Cox proportional hazard regression analysis identified hypertension (p = 0.007) and diabetes (p = 0.04) as independent time-related predictors of subsequent death. Thus, early and late results after coronary angioplasty in young adults are favorable, but certain risk factors are important predictors of outcome. Late revascularization procedures (repeat angioplasty or surgery) for restenosis or disease progression are common.

Percutaneous transluminal angioplasty of stenotic coronary artery bypass grafts: 5 years' experience.

In a 60 month period (January 1981 to December 1985), 82 patients (79% male with a mean age of 60 years) had 83 saphenous vein grafts and 5 internal mammary artery grafts with a total of 101 stenotic sites treated with percutaneous transluminal coronary angioplasty. The mean time between bypass surgery and angioplasty was 51.2 months. The procedure was technically successful in 85% of patients, 86% of grafts and 85% of the sites attempted. In these cases, the mean diameter stenosis was reduced from 77 +/- 14 to 27 +/- 20% (p less than 0.001), the mean pressure gradient from 49 +/- 16 to 7 +/- 6 mm Hg (p less than 0.001). Emergency coronary artery bypass graft surgery was necessary in one patient (1.2%) whereas myocardial infarction occurred in three patients (3.6%). There were no hospital deaths. Clinical follow-up was obtained in all 82 patients. Before angioplasty, 23% were in Canadian Cardiovascular Society functional class II, 60% in class III and 17% in class IV. With a mean clinical follow-up period of 21.4 +/- 2.3 months, 71% are in class I, 17% in class II and 12% in class III. There were two deaths, 3 months or more after angioplasty, one probably due to graft closure. So far, angiographic follow-up (at 7.9 +/- 2.1 months) has been available in 26 patients. Ten patients (with 10 grafts) exhibited graft restenosis; six of them have had second successful repeat angioplasty. Among the many variables analyzed, statistically significant predictors of success were a higher measured balloon/graft ratio (p less than 0.001), smaller diameter graft (p less than 0.001), and shorter lesion length (p less than 0.01). The only predictor of complication was diffuseness of disease in the graft (p less than 0.05). The statistically significant predictors of recurrence were the residual stenosis after the initial angioplasty (p less than 0.01) and the measured balloon/graft ratio (p less than 0.01). Angioplasty of coronary artery grafts appears to be a feasible and efficacious procedure with a low complication rate. The technique is a satisfactory alternative to repeat surgery in selected patients.

Coronary rotational ablation: initial experience in 302 procedures.

OBJECTIVES: The aim of this study was to assess the utility of percutaneous transluminal coronary rotational ablation in the treatment of coronary artery disease. BACKGROUND: Although numerous advances have been made in the treatment of coronary artery disease, there are lesions with complex morphology that are not amenable to current intravascular therapy. METHODS: A consecutive series of 242 patients having 302 coronary rotational ablation procedures was analyzed. One hundred nineteen (49%) of the patients had previously undergone attempted coronary angioplasty, which was unsuccessful in 31 patients (13%). The left ventricular ejection fraction was normal in 196 patients (81%). The ablation procedure was attempted in 308 vessels and 346 lesions. Of the 346 lesions treated, 26 (7.5%) were classified as American College of Cardiology/American Heart Association type A, and 320 (92.5%) as either type B or type C. RESULTS: Procedural success was achieved in 284 (94%) of the 302 procedures and 330 (95.4%) of the 346 lesions in which ablation was attempted. Five procedures (1.7%) were unsuccessful, but no cardiac event occurred during the hospital stay. A major cardiac event occurred in 13 cases (4.3%); 9 (3%) of these complications were due to the ablation procedure. Six patients sustained a Q wave myocardial infarction alone, two had a Q wave infarction and required emergency surgery and one needed emergency surgery but did not have a Q wave infarction. No procedural deaths were attributed to the ablation procedure. Follow-up has been obtained in 182 of the 242 patients at a mean interval of 9 +/- 5 months. Of the 182 patients, 174 (95.6%) were alive and free of myocardial infarction. Angiographic follow-up is available thus far in 87 patients. By combining angiographic and clinical outcome, an overall estimated restenosis rate of 37.4% (68 of 182) was calculated. CONCLUSIONS: These data suggest that coronary rotational ablation can be performed on lesions with a variety of morphologic features with high initial success rates. The overall rate of restenosis is similar to that of balloon angioplasty.

Lesion morphology and coronary angioplasty: current experience and analysis.

From July 1, 1990 to February 28, 1991, 533 consecutive patients with 764 target vessels and 1,000 lesions underwent coronary angioplasty. Procedural success was achieved in 92.3%, untoward (major cardiac) events occurred in 3% (0.8% myocardial infarction, 1.3% emergency coronary bypass grafting and 0.9% both; there were no deaths). An unsuccessful uncomplicated outcome occurred in 4.7%. Lesion analysis using a modified American College of Cardiology/American Heart Association classification system showed that 8% were type A, 47.5% were type B and 44.5% were type C (36% of type B and 11% of type C were occlusions). Angioplasty success was achieved in 99% of type A, 92% of type B and 90% of type C lesions (A vs. B, p less than 0.05; B vs. C, p = NS; A vs. C, p less than 0.01). Untoward events occurred in 1.2% of type A, 1.9% of type B and 2% of type C lesions (p = NS). An unsuccessful uncomplicated outcome occurred in 0% of type A, 6% of type B and 7% of type C lesions (A vs. B, p less than 0.05; B vs. C, p = NS; A vs. C, p less than 0.05). Among the unsuccessful uncomplicated outcome group, occlusion occurred in 49%: 38% of type B and 59% of type C lesions. With B1 and B2 subtypes, success was obtained in 95% and 89.5% and untoward events occurred in 1.5% and 2.3% and an unsuccessful uncomplicated outcome in 3.7% and 8%, respectively. C1 and C2 subtyping showed success in 91% and 86%, untoward events in 1.3% and 6% and an unsuccessful uncomplicated outcome in 7.5% and 8.5%, respectively. Among the 764 vessels, success was obtained in 89.5% and untoward events occurred in 2.5% and an unsuccessful uncomplicated outcome in 8%. Assessment of lesion-vessel combinations showed a less favorable outcome with type C lesions and combinations of A-B, B-C and multiple (more than three lesions) type B and C vessels. Statistical analysis of morphologic factors associated with angioplasty success included absence of (old) occlusion (p less than 0.0001) and unprotected bifurcation lesion (p less than 0.001), decreasing lesion length (p less than 0.003) and no thrombus (p less than 0.03). The only significant factor associated with untoward events was the presence of thrombus (p less than 0.003). Predictors of an unsuccessful uncomplicated outcome included old occlusion (p less than 0.0001) and increasing lesion length (greater than 20 mm) (p less than 0.001), unprotected bifurcation lesion (p less than 0.05) and thrombus (p less than 0.03).

In-hospital cardiac mortality after acute closure after coronary angioplasty: analysis of risk factors from 8,207 procedures.

Cardiac death consequent to acute vessel closure after coronary angioplasty occurred in 13 of 294 closures from 8,207 consecutive procedures performed at two centers since 1981 (0.16% cardiac mortality rate). To determine the predictors of cardiac death after acute coronary closure, 50 clinical, angiographic and procedural variables were analyzed by an observer unaware of the clinical outcome for each of the 13 patients who died and also 100 patients randomly chosen, in whom vessel closure after angioplasty did not result in death during hospitalization. Univariate analysis found female gender (p less than 0.0001), collateral channels from the vessel dilated (p less than 0.0001), use of balloon counterpulsation (p less than 0.0002), pre- and postprocedural hypotension (p = 0.0003 and p = 0.003, respectively), jeopardy score greater than or equal to 2.5 (p = 0.003), left ventricular hypertrophy (p = 0.013), hypertension (p = 0.02), diabetes (p = 0.02) and multivessel disease (p = 0.03) to be predictive of death. Multivariate analysis found collateral vessels, female gender and multivessel disease to be independent predictors of death. Thus, cardiac death after elective coronary angioplasty is very rare in experienced centers and occurs most often in women with a large amount of potentially ischemic myocardium. Hypotension often precedes the fatal closure event. Close attention to the amount of potentially ischemic myocardium and to the fluid volume status of these patients would seem to be especially warranted.

Coronary angioplasty after coronary bypass surgery: initial results and late outcome in 422 patients.

From 1978 to 1988, coronary angioplasty was performed in 422 patients with prior coronary artery bypass surgery (264 patients with native coronary artery angioplasty and 158 patients with graft angioplasty). Angioplasty was successful in 84%, unsuccessful but uncomplicated in 11% and complicated by one or more major cardiac events in 5% (myocardial infarction 5%, emergency bypass surgery 2% and death 0.2%). Follow-up data were obtained in 99% of 356 patients with successful angioplasty. At a mean of 33 +/- 26 months, 92% were alive, 73% had improvement in angina and 61% were free of angina. One or more of the following late events occurred in 67 patients (19%): myocardial infarction (6%), elective reoperation (13%) and cardiac death (6%). Repeat angioplasty was performed in 27%, with a success rate of 89% and no deaths. Initial success rates were equal in native vessel versus graft angioplasty, but late outcome was less favorable with the latter because of a higher rate of infarction (11% versus 4%, p less than 0.05) and need for reoperation (19% versus 10%, p less than 0.05). The initial success rate was higher in vein grafts less than 1 year old compared with grafts 1 to 4 years or greater than 4 years after operation (92% versus 85% versus 83%, respectively) and adverse late events were less frequent after angioplasty in recent vein grafts (less than 1 year 13%, 1 to 4 years 35%, greater than 4 years 29%; less than 1 versus greater than 1 year, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Bidirectional crossover and late outcome after coronary angioplasty and bypass surgery: 8 to 11 year follow-up.

Between March 1978 and July 1981, 217 symptomatic patients underwent coronary angioplasty as an alternative to coronary bypass surgery. Angioplasty was successful in 143 patients (66%), unsuccessful but uncomplicated in 65 (30%) and complicated in 9 (4%) by one or more of the following criteria: Q wave myocardial infarction (2%), emergency surgery (4%) or death (0.5%). Late follow-up evaluation was obtained in 213 patients at a mean of 9 +/- 1 years. Of patients in whom angioplasty was successful, 59 (42%) of 140 required another revascularization procedure (repeat angioplasty in 26% and bypass surgery in 16%). The actuarial survival rate at 5, 9 and 10 years after successful angioplasty was 98%, 93% and 92%, respectively. Of the 65 patients with unsuccessful and uncomplicated angioplasty (usually as a result of technical factors), 58 underwent elective bypass surgery within 2 months and 56 survived. These 56 surgical patients were compared with the 140 patients with successful angioplasty. Univariate analysis of prognostic factors did not reveal significant differences between these two groups. At late follow-up study, the successful angioplasty and the successful surgical groups had similar rates of survival (93% versus 95%, p = NS) and of death or infarction, or both (11% versus 12.5%, p = NS). Repeat revascularization was required more frequently after successful angioplasty than after surgery (42% versus 18%, p less than 0.001). Crossover from angioplasty to surgery occurred slightly more often than from surgery to angioplasty (16% versus 12.5%, p = NS). The time to crossover from angioplasty to surgery occurred earlier than from surgery to angioplasty (mean 21 versus 76 months, p less than 0.001).

Multicenter study of percutaneous transluminal angioplasty for right coronary artery ostial stenosis.

Over a 5 year period at three centers, 53 patients underwent percutaneous transluminal angioplasty of a right coronary artery ostial stenosis. The procedure was successful in 42 patients (79%) and unsuccessful in 11, of whom 5 (9.4%) required emergency coronary artery bypass grafting because of abrupt closure. The right coronary ostial lesion had distinctive technical requirements to achieve success, including high pressure balloon inflation (10 +/- 4 atm) and the need for unconventional right coronary guide catheters. Technical factors that account for increased difficulty in these patients include: problems with guide catheter impaction and ostial trauma; inability to inflate the balloon with adequate guide catheter support; and need for increased intracoronary manipulation. The stenoses were quite discrete (4 +/- 5 mm) and calcified in the majority (40) of the 53 patients. Long-term follow-up (mean 12.5 months, range 4 to 60) of these patients demonstrated clinical recurrence of angina in 20 patients (48%) and angiographically proved restenosis in 16 (38%). Repeat coronary angioplasty was successful in three of six patients for relief of symptoms for over 6 months. In conclusion, angioplasty of the right coronary ostial lesion compared with nonostial dilation leads to a suboptimal early success rate; an apparent high risk of emergency bypass surgery; and a high restenosis rate. Careful assessment of the patient with this lesion and improved technology appear to be warranted.

Complex coronary angioplasty: multiple coronary dilatations.

Selected patients underwent PTCA of multiple stenoses in different vessels or in the same vessel. Three hundred nine patients underwent 685 PTCA procedures in various combinations of arterial and vein graft stenoses. A multiple dilatation procedure was defined as successful when all lesions attempted were successfully dilated, or when the considered-critical-stenosis was successfully dilated and this resulted in a patient clinical improvement. Angiographic success was achieved in 599 of 685 lesions attempted (87.4%) and in 285 of 309 patients (92.2%). Complications included a mortality rate of 1.0%, an MI rate of 4.2% per patient and 1.9% per lesion attempted, and a 3.6% incidence of emergency CABG. Follow-up data show that 58 patients (20.4%) had clinical evidence of a lesion recurrence, and that 92.5% (37 of 40 patients) who underwent repeat angioplasty had a successful procedure. A sustained clinical improvement was obtained in 264 of 309 patients (85.4%). The data indicate that multiple dilatations are feasible with good success rates and acceptable complication rates. Further evaluation of this extended application of PTCA is needed to clearly establish its role in the therapy of CAD.

Baseline characteristics of patients in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

The efficacy of PTCA was evaluated in several subgroups of patients. Of special clinical interest were the comparisons between subgroups of patients with multivessel disease vs 1-vessel disease, unstable angina vs stable angina, older age vs younger age, and female sex vs male sex. As a prerequisite for such comparisons, baseline characteristics of patients in the subgroups were examined. Compared with the subgroup with 1-vessel CAD, the subgroup with multivessel CAD had more elderly patients (age 65 years and older) and more of these patients had previous MI or CABG. PTCA was more often unsuccessful in patients with multivessel CAD because of inability to pass the catheter across the lesion. The subgroup of women tended to be older than men, and more women had severe and unstable angina, although fewer had multivessel CAD, previous MI or previous CABG. The PTCA success rate was 5% lower in women because of a greater frequency of inability to pass the lesion. Compared with younger patients, older patients had a higher prevalence of severe angina, multivessel CAD and lesions with larger diameters. The older patients had a 5% lower PTCA success rate, once again because of a greater frequency of inability to pass the lesion. The learning experience with PTCA was measured by the overall success rate as well as by the rate of ability to pass the lesion and the rate of dilating it once it was passed. These rates improved significantly by the investigators' case accumulations and independently by calendar year. Multivariate prediction of crossing the lesion and of overall success showed that favorable lesion characteristics and increasing physician experience were more important than the patient characteristics just discussed, although both female sex and multivessel CAD remained significant independent risk factors.

Usefulness of supine bicycle stress echocardiography for detection of restenosis after percutaneous transluminal coronary angioplasty.

The role of supine bicycle stress echocardiography (SBSE) for detecting restenosis after percutaneous transluminal coronary angioplasty (PTCA) was evaluated in 80 patients: 41 (51%) with single and 39 (49%) with multivessel PTCA (total 129 dilated vessels). Total revascularization was performed in 54 (68%) and partial revascularization in 26 (32%) patients. Restenosis was angiographically demonstrated in 60 patients (75%) and in 72 vessels (56%) 6.1 +/- 2.9 months after PTCA. The results for detecting restenosis were: (1) SBSE versus exercise electrocardiographic sensitivity, 87 versus 55% (p < 0.001); (2) specificity, 95 versus 79%; and (3) accuracy, 89 versus 61% (p < 0.001). SBSE was 83% sensitive, 95% specific and 88% accurate for restenosis detection in specific vessels with comparable results for single versus multivessel PTCA and total versus partial revascularization. Sensitivity, specificity and accuracy were: 91, 93 and 91% for the left anterior descending coronary artery; 77, 94 and 85% for the right coronary artery; and 76, 96 and 88% for the left circumflex coronary artery. Ninety-four percent of the nondilated diseased vessels were correctly identified. It is concluded that SBSE is an excellent tool for identifying restenosis after PTCA.

Usefulness of tomographic thallium-201 imaging for detection of restenosis after percutaneous transluminal coronary angioplasty.

The role of tomographic thallium-201 exercise and redistribution imaging in the detection of restenosis after percutaneous transluminal coronary angioplasty (PTCA) was evaluated in 116 patients: 61 (53%) with 1- and 55 (47%) with multivessel PTCA, with a total of 185 dilated vessels. Complete revascularization was performed in 89 (77%) and partial revascularization in 27 (23%) of the patients. Restenosis was angiographically demonstrated in 69 (60%) of the patients and 85 (46%) of the vessels 6.4 +/- 3.1 months after PTCA. Disease progression in previously normal vessels was noted in 11 patients. The results were: (1) for detection of restenosis in the group of patients, single-photon emission computed tomographic (SPECT) versus exercise electrocardiographic sensitivity was 93 vs 52% (p less than 0.001), specificity 77 vs 64%, and accuracy 86 vs 57% (p less than 0.001). The results were similar in the complete and partial revascularization groups. (2) SPECT was 86% sensitive, specific and accurate for restenosis detection in specific vessels with comparable results for 1-versus multivessel PTCA and complete versus partial revascularization. Sensitivity, specificity and accuracy were: 89, 95 and 92% for the left anterior descending coronary artery; 88, 79 and 82% for the right coronary artery; and 76, 83 and 85% for the left circumflex coronary artery. Eighty-one percent of the diseased nondilated vessels were correctly identified. (3) Disease progression to greater than 50% stenosis was detected with 91% sensitivity, 84% specificity and 85% accuracy. SPECT thallium-201 imaging is an excellent tool for the detection of restenosis and disease progression after PTCA in the settings of 1- and multivessel angioplasty and complete and partial revascularization.

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

To better understand the factors predisposing a patient to death after elective percutaneous transluminal coronary angioplasty (PTCA) and to gain insight into indications for high-risk PTCA both with and without adjunctive use of support devices, the outcomes of 8,052 consecutive procedures were reviewed. Death occurred after 32 procedures (0.4%) and was directly related to coronary artery closure in 26 (81%) of these cases. Left ventricular failure due to vessel closure at the dilated site, the most common cause of death, was independently correlated with female sex (p less than 0.001), "jeopardy score" (p less than 0.001) and PTCA of a proximal right coronary artery site (p = 0.002), but not with left ventricular ejection fraction or presence of multivessel disease. Right ventricular failure after closure of the proximal right coronary artery, and left main coronary dissection accounted for the majority of the remaining deaths. Systolic blood pressure immediately after coronary artery closure was also closely correlated with jeopardy score, and cardiogenic shock was frequent in women with scores greater than or equal to 3.5 and in men with scores greater than or equal to 5.0. These data highlight the superiority of the jeopardy score versus ejection fraction in the determination of risk, stress the importance of gender in determining outcome and point to the need for better means of right ventricular protection from severe ischemia. Therefore, an initial framework for rational use of PTCA and support devices in the high-risk setting is established.

Risk factors, time course and treatment effect for restenosis after successful percutaneous transluminal coronary angioplasty of chronic total occlusion.

Advances in technology and operator experience, and increased use of angiography early after myocardial infarction have led to greater use of percutaneous transluminal coronary angioplasty (PTCA) for chronic, total coronary artery occlusions. To better assess long-term outcome, 257 consecutive patients with successful PTCA of a total occlusion with late angiographic follow-up from 484 patients (53%) with PTCA success were reviewed. The mean +/- standard deviation patient age was 54 +/- 10 years, 79% were men, the duration of total occlusion was 11 +/- 15 weeks and the post-PTCA diameter stenosis was 24 +/- 12%. Eighty-two, 27 and 63% of patients received long-term aspirin, dipyridamole and warfarin therapy, respectively. Angiography at 8 +/- 8 months demonstrated restenosis (greater than or equal to 50% diameter stenosis) in 41% of patients restudied within 6 months and in 66% of patients restudied within 12 months by life table analysis. In multivariate regression analysis of 19 variables, 2 were independently correlated with the occurrence of restenosis: post-PTCA diameter stenosis greater than 30% (p = 0.02) and coronary artery dilated (left anterior descending and right coronary arteries greater than the left circumflex coronary artery) (p = 0.05). In log rank analysis that also considered the timing of angiographic detection of restenosis, dilatation of a proximal left anterior descending stenosis was also a significant predictor of restenosis (p = 0.01), and dilatation within 4 weeks of the presumed time of occlusion was only weakly predictive (p = 0.11).(ABSTRACT TRUNCATED AT 250 WORDS)

Relative cost of coronary angioplasty and bypass surgery in a one-vessel disease model.

A national study was carried out to determine the relative costs of PTCA and CABG. Baseline clinical criteria for the 2 groups were similar. Data were collected in 186 sets for the PTCA group and 175 sets for the CABG group. Male patients make up 81% of the PTCA group and 80% of the CABG group. Mean hospital stay was 12 +/- 5 days in the CABG group, compared with 4 +/- 2 days in the PTCA group (p less than 0.001). The base charges for hospital and professional components of the CABG procedure were $15,580 +/- $2,159, whereas the same charges for the PTCA procedure were $5,315 +/- $2,159 (p less than 0.001). With an 80% primary success rate, which was the group mean success rate, the average dollar savings per PTCA procedure would be $7,149, or $7,149,000 per 1,000 cases. Thus, PTCA for revascularization in 1-vessel CAD is significantly more cost-effective than CABG in the short term.

Documentation of decline in morbidity in women undergoing coronary angioplasty (a report from the 1993-94 NHLBI Percutaneous Transluminal Coronary Angioplasty Registry). National Heart, Lung, and Blood Institute.

To determine whether there has been an improvement in the relatively unfavorable outcome of percutaneous transluminal coronary angioplasty (PTCA) in women, the 1993 to 1994 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry collected data from 12 clinical centers that participated in the earlier registries. We compared 274 consecutive women in 1993 to 1994 with 545 consecutive women in 1985 to 1986 undergoing PTCA. Women in the 1993 to 1994 registry were older (64.3 vs 61.0 years, p <0.001) with more diabetes mellitus (34.3% vs 19.9%, p <0.001), congestive heart failure (13.7% vs 8.6%, p <0.05), and comorbid disease (19.5% vs 9.3%, p <0.001). Left ventricular function and multivessel coronary artery disease were similar between groups. Angiographic success (90.9% vs 85.1%, p <0.05) and clinical success (89.4% vs 79.4%, p <0.001) were higher in women undergoing PTCA in 1993 to 1994 than in 1985 to 1986. Whereas there was no difference in in-hospital mortality (1.5% vs 2.6%), the incidence of nonfatal myocardial infarction (1.8% vs 4.6%, p <0.05), emergency coronary artery bypass graft surgery (1.8% vs 4.6%, p <0.05), and the combined end points of death, myocardial infarction, and emergency coronary artery bypass grafting (4.4% vs 9.7%, p <0.01) were lower in women in 1993 to 1994 than in women in 1985 to 1986, respectively. Multivariate analysis revealed an odds ratio of 0.36 (95% confidence interval 0.18 to 0.72) for major complications and of 2.34 (95% confidence interval, 1.49 to 3.69) for clinical success in the 1993 to 1994 versus 1985 to 1986 registry. Therefore, despite a higher risk profile, women undergoing PTCA in 1993 to 1994 have a higher clinical success and lower major complication rate than women treated with PTCA in 1985 to 1986.