ABSTRACT: We report the incidence, management and clinical outcome of coronary perforations in 39 of 12,658 patients (0.3%) undergoing percutaneous coronary intervention (PCI). Coronary perforation occurred more frequently with debulking techniques than with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques (1% versus 0.2%; p < 0.001). There were 8 type I (20.5%), 15 type II (38.5%) and 16 type III (41%) perforations. Importantly, fifty-one percent of the coronary perforations were guide-wire related. Major adverse clinical outcomes occurred more frequently in patients who experienced type III perforations. Conventional strategies to treat perforations (i.e., prolonged balloon inflation and reverse of the anticoagulated state) were used. There was one death (2.6%), two emergency surgeries (5.2%) and no Q-wave myocardial infarctions. Pericardial effusion occurred in 18 of 39 patients (46.2%), with cardiac tamponade occurring in 7 patients.

Coronary perforation remains one of the most serious complications in the catheterization laboratory, with multiple studies demonstrating very poor outcomes, particularly in relationship to myocardial infarction and death. Angiographic evidence of perforation has been reported in 0.1% to 3.0% of lesions treated with various intervention techniques^1–8 and even today accounts for 20% of referrals for emergency by-pass surgery.9 Patients who are especially at risk are elderly, female patients, those with calcified and tortuous arteries^1,5,6,8 and those in whom atheroablative devices are used.^{3,4,6,8,10,11}

In our own series, we noted an 8% incidence of death, 18% incidence of MI, and a 13% need for emergency coronary bypass surgery.⁸

ABSTRACT: Purpose. This study was designed to compare the rates of subacute stent thrombosis (SAT) among patients receiving heparin-coated stents to patients receiving bare-metal stents in real world, contemporary coronary interventions. Background. Controlled trials with heparin-coated coronary stents have shown a trend toward decreased rates of SAT. Methods and Results. The data in this study were collected from a single, large cardiac center over a period of 9 months. All patients who underwent coronary stent implantation during this 9-month period were included in the study (1,288 patients; 1,366 procedures; 2,231 stents). All patients were treated with aspirin and clopidogrel (or ticlopidine) after stenting. Primary thrombotic outcome was defined as angiographically documented SAT and/or sudden unexplained cardiac death (SCD) within 30 days of the procedure. Follow-up data (1,264/1,276 patients) were obtained in 99% of patients.

ABSTRACT: Objectives. A discrepancy exists in the medical literature as to what effect intravascular ultrasound (IVUS)-guided stent deployment has on target vessel revascularization (TVR) at 6 months. The major endpoints of this study are the need for TVR, defined as clinically driven repeat interventional or surgical therapy of the index vessel at 6 months and major adverse cardiac events. Methods. One hundred interventional stent cases (50 IVUS-guided, 50 non-IVUS guided) were randomly selected in a 6-month period (January to June 2001) for review by measurement of minimal luminal diameter (MLD) pre- and post-intervention. Seventy males and 30 females were distributed among the 2 groups. There were a total of 135 lesions (70 IVUS-guided, 65 non-IVUS guided) in the 2 groups. A 6-month follow-up chart review was performed following the initial stenting. Results.

The study by Faulknier and colleagues evaluates the clinical impact of intravascular ultrasound (IVUS) on stent deployment, using bare-metal stents.¹ These investigators retrospectively evaluated the clinical outcomes of 50 stent cases where IVUS was used, and compared the subsequent clinical events with 50 randomly selected cases wherein IVUS was not employed. Clinical outcomes tended to favor the group not receiving intravascular ultrasound guidance. This led to the conclusion by the authors that “the added expense of intravascular ultrasound does not appear to be warranted.” This is a conclusion many will accept at face-value, as it is consistent with perhaps the most-commonly prevailing attitude towards the use of IVUS. However, it may be appropriate to ask if this type of research is helpful or harmful to those who read this journal.

See Faulknier, et al. on pages 311–315

ABSTRACT: Background. There is little consensus regarding the use of functional testing after percutaneous transluminal coronary angioplasty (PTCA). Some physicians employ a routine functional testing strategy, and others employ a symptom-driven strategy. Objective. To examine the effects of routine post-PTCA functional testing on the use of follow-up cardiac procedures and clinical events. Methods. The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) Registry is a prospective multicenter observational study examining the use of functional testing after PTCA. A total of 788 patients (pts) were enrolled in the ROSETTA Registry at 13 clinical centers in 5 countries. The frequencies of functional testing, cardiac procedures and clinical events were examined during the first 6 months following a successful PTCA. Results.

Approximately one million percutaneous coronary interventions are performed annually in the United States.¹ There are conflicting opinions and no good consensus as to whether or not patients should undergo routine stress testing post PCI.² The charge for a treadmill stress test with myocardial perfusion imaging (MPI) is approximately $1000 (technical and professional fee). This equates to one billion dollars per year for stress testing alone in this group of patients, assuming each patient were to have only one stress test in follow-up. Whether or not to perform routine stress tests with MPI post coronary intervention is, therefore, not only an important clinical question but a major health-care economic issue as well.

ABSTRACT: Background. Clopidogrel combined to aspirin reduces the early risk of stent thrombosis and a clopidogrel pre-treatment strategy is associated with a better outcome. However, in clinical practice such pre-treatment strategy is not always feasible and clopidogrel is frequently not administered until the time of intervention. Aim of the study was to compare platelet function profiles in patients undergoing coronary stenting receiving clopidogrel pre-treatment (75 mg x 2 daily at least 48 hours before intervention) compared to that of patients receiving a 300 mg loading dose at intervention time. Methods: A total of 50 patients were included in whom patients’ platelet aggregation (using light transmittance aggregometry) and platelet activation (P-selectin and PAC-1 expression by whole blood flow cytometry) were assessed following ADP stimuli at baseline, and 4 hours and 24 hours following coronary stenting.

ABSTRACT: We describe a 64-year-old male with severe hemophilia A (factor VIII-dependent), acute myocardial infarction (MI) and congestive heart failure (CHF) who underwent successful multi-vessel percutaneous coronary intervention (PCI). The patient was administered factor VIII transfusion to maintain activity levels between 60–80%. Anticoagulation during the PCI procedure was maintained with the direct thrombin inhibitor, bivalirudin. There were no procedural complications and the patient was discharged home the following day. These results suggest that bivalirudin may be used effectively in patients at very high risk of bleeding with enhanced procedural safety.

J INVAS CARDIOL 2004;16:330–332

Key words: percutaneous coronary intervention, hemophilia, bivalirudin, acute myocardial infarction

Dear Readers,

This issue of The Journal of Invasive Cardiology includes original research articles, case reports, case reports with brief literature reviews, and articles from the journal’s special sections “Electrophysiology Corner,” “Clinical Decision Making” and “Clinical Images.”

In the first original research article, Dr. Christian Witzke and associates from the Cardiac Catheterization Laboratory at the Massachusetts General Hospital in Boston, Massachusetts,
present their analysis of the changing pattern of coronary perforation in the era of new coronary devices, indicating that the rate continues to be low but is most often associated with debulking devices. They also offer valuable insights into the management of patients who develop perforation. Drs. Antonio Colombo and Goran Stankovic have provided a commentary to accompany the Witzke et al. article.