Coronary Artery Disease: Hendler A

Lotan C, Rozenman Y, Hendler A, Turgeman Y, Ayzenberg O, Beyar R, Krakover R, Rosenfeld T, Gotsman MS. · Hadassah University Hospital, Jerusalem, Israel. · Eur Heart J. · Pubmed #11071802 links to  free full text

Abstract: AIMS: This multicentre randomized study set out to evaluate whether coronary stenting improves the results of successful balloon angioplasty for chronic total occlusion. Balloon angioplasty for chronic total occlusion has a high restenosis rate. Several reports have suggested that coronary stenting may decrease the likelihood of restenosis and reocclusion. METHODS AND RESULTS: Patients with total coronary artery occlusions who had an optimal PTCA result were randomized either to no further treatment or additional stent implantation. The AVE microstent was used and all patients were scheduled for a 1-, 3-, and 6-month clinical follow-up. Repeat coronary angiography to assess the rate and pattern of restenosis was performed at 6 months or earlier if clinically indicated. Ninety-six patients were enrolled in this study. The mean age was 59. 3+/-10.3 years and 15 were females. Forty-eight patients were randomized to the stent arm, receiving 52 stents (lengths 18-39 mm). Stent implantation was successful in all and there were no major procedure-related complications. Sixty-nine patients (72%) were restudied after 6 months. The binary restenosis rates (50%), in the PTCA arm were 70.9% with a minimal lumen diameter of 1.01+/-0.79 mm compared to 42.1% in the stent arm with a minimal lumen diameter of 1.63+/-1.02 mm (P=0.034). Reocclusion occurred in 7.9% in the stent group compared to 16.1% in the PTCA group. Restenosis in the PTCA group was focal in 88% of patients and occurred at the point of total obstruction (within 5 mm), compared to diffuse instent restenosis, which occurred in 54% of the patients in the stent group. CONCLUSION: Coronary stenting can significantly decrease the rate of restenosis and reocclusion of total occlusions. As restenosis in the stent group was more diffuse, care should be taken to implant short stents at the site of occlusion.

Uriel N, Moravsky G, Blatt A, Tourovski A, Gabara Z, Inna Y, Danicek V, Hendler A, Braunstein R, Krakover R, Vered Z, Kaluski E. · Department of Cardiology, Assaf Harofeh Medical Center, Zerifin, Israel. · Isr Med Assoc J. · Pubmed #17491214 links to  free full text

Abstract: BACKGROUND: Spontaneous coronary reperfusion occurs in 7-27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome. OBJECTIVES: To determine the optimal PCI time for patients admitted to the hospital due to STEMI with SCR. METHODS: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR. RESULTS: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2-3 was seen in > 95% in both groups. PCI was performed more frequently in the "early" group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the "late catheterization" group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 +/- 245 days). CONCLUSIONS: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive antiplatelet therapy, seems to result in an excess of early MACE without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.

Hendler A, Kaluski E, Blatt A, Gurevich Y, Zyssman I, Vered Z, Danicek V, Krakover R. · Department of Cardiology, Interventional Cardiology Unit, Assaf Harofeh Medical Center, Zerifin, Israel. · J Invasive Cardiol. · Pubmed #17476033 No free full text.

Abstract: BACKGROUND: Treatment of unprotected left main coronary disease by percutaneous interventions, even in the urgent setting, is still not an approved indication. However, the evolution of transcatheter technology and supporting devices, along with greater skill in high-volume centers, led the interventional community to deal with these cases. This study aimed to investigate whether the percutaneous approach in this cohort could be a viable alternative to coronary artery bypass graft (CABG) surgery in the urgent setting. METHODS: We enrolled 51 acute myocardial infarction patients with left main disease as the culprit lesion and treated them by percutaneous coronary intervention. This cohort was followed for major adverse cardiac and cerebrovascular events (MACCE) in-hospital and at 30 days, 6 months and 1 year, and was compared with a population of 35 CABG patients matched for clinical and angiographic characteristics. RESULTS: The estimated MACCE-free survival at 6 months and 1 year was 90% and 88%, respectively. The overall MACCE was 6%. Analysis of the surgical cohort showed an overall MACCE of 17%. In the final Cox model, significant predictors of MACCE were Parsonnet score for surgical risk (HR 1.93, 95% CI 1.15-7.3; p = 0.04) and diabetes mellitus (HR 1.73, 95% CI 1.03-3.8; p = 0.038). CONCLUSIONS: Angioplasty for unprotected left main coronary disease in the urgent clinical setting is feasible, showing a relatively low short- and long-term rate of MACCE.

Ben-Gal Y, Mohr R, Braunstein R, Finkelstein A, Hansson N, Hendler A, Moshkovitz Y, Uretzky G. · Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. · Ann Thorac Surg. · Pubmed #17126111 No free full text.

Abstract: BACKGROUND: The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB). METHODS: From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group. RESULTS: Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40). CONCLUSIONS: Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.

Herz I, Moshkovitz Y, Braunstein R, Uretzky G, Zivi E, Hendler A, Ben-Gal Y, Mohr R. · Department of Cardiology, Assuta Medical Center, Sheba, Israel. · Heart Surg Forum. · Pubmed #16401540 No free full text.

Abstract: BACKGROUND: Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting. METHODS: From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities. RESULTS: The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015). CONCLUSIONS: Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

Herz I, Moshkovitz Y, Loberman D, Uretzky G, Braunstein R, Hendler A, Zivi E, Ben-Gal Y, Mohr R. · Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. · Ann Thorac Surg. · Pubmed #16305850 No free full text.

Abstract: BACKGROUND: Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI), including drug-eluting stents (Cypher; Cordis, Miami Lakes, FL). This study compares results of multivessel Cypher stenting with those of bilateral internal thoracic artery (BITA) grafting. METHODS: From January 2002 to June 2004, 768 consecutive patients underwent multivessel myocardial revascularization; 138 by PCI including Cyphers and 630 by BITA. After matching for age, sex, ejection fraction, extent of coronary disease, and congestive heart failure, two groups (113 patients each) were used to compare the two revascularization modalities. RESULTS: Both groups were similar; however, left main and intraaortic balloon were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.87 vs 2.22, p < 0.001). Follow-up ranged between 6 and 34 months. Thirty-day mortality was 0.9% in the BITA and zero in the PCI group (p = 0.32). There were no late deaths in the BITA and three (2.7%) in the Cypher group (p = 0.08). Angina returned in 28.3% of the Cypher and 12.4% of the BITA group, p = 0.003. A Cox proportional hazard model revealed assignment to the Cypher group to be the only predictor of angina recurrence (odds ratio 2.78, 95% confidence interval 1.46-2.56). There were 16 (14.2%) reinterventions in the Cypher group compared with six (5.3%) in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA was 96% compared with 86.6% in the Cypher group (p = 0.005, log-rank test). CONCLUSIONS: Despite improved results of PCI with Cyphers, midterm clinical outcome of multivessel patients treated with BITA is still better.

Herz I, Moshkovitz Y, Hendler A, Adam SZ, Uretzky G, Ben-Gal Y, Mohr R. · Department of Cardiology, The Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Israel. · Ann Thorac Surg. · Pubmed #15620921 No free full text.

Abstract: BACKGROUND: This study compares early results of left anterior descending coronary artery stenting using drug-eluting stents (Cypher) with off-pump coronary artery bypass grafting (OPCAB). METHODS: From June 2002 to June 2003, 386 consecutive patients underwent myocardial revascularization of the left anterior descending coronary artery territory, 130 by Cypher and 256 by OPCAB. After matching for age, sex, and extent of coronary artery disease, two groups (each with 94 patients) were used to compare the two revascularization modalities. The two groups were similar; however, old myocardial infarction and intraaortic balloon pump were more prevalent in the OPCAB group, and prior percutaneous transluminal coronary angioplasty was more prevalent in the Cypher group. RESULTS: The number of coronary vessels treated per patient in the two groups was similar (1.54 versus 1.34, OPCAB and Cypher, respectively; not significant). Mean follow-up was 18 months. Thirty-day mortality was 1% in the OPCAB group and 0% in the Cypher group. There was one late death in each group. Angina returned in 31% of the Cypher group and in 11% of the OPCAB group (p = 0.001). There were nine reinterventions in the Cypher group: seven coronary angioplasties (including two to the left anterior descending coronary artery) and two surgical interventions. There were two reinterventions (percutaneous transluminal coronary angioplasty) in the surgical group (p = 0.042). CONCLUSIONS: Despite the higher risk profile of patients treated with OPCAB, their clinical outcome is better. A longer and more complete angiographic follow-up is required to determine the role of drug-eluting stents in left anterior descending coronary artery revascularization.

Ben-Gal Y, Moshkovitz Y, Nesher N, Uretzky G, Braunstein R, Hendler A, Zivi E, Herz I, Mohr R. · Department of Cardiologu, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. · Ann Thorac Surg. · Pubmed #17062230 No free full text.

Abstract: BACKGROUND: Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI) with drug-eluting stents (Cypher). This study compares results of Cypher (Cordis, Miami Lakes, FL) stenting and surgical revascularization in diabetic patients. METHODS: From January 2002 to January 2005, 518 consecutive diabetic patients underwent myocardial revascularization; 176 by PCI incorporating Cyphers and 342 treated surgically. Single-vessel patients in the surgical group were treated with the left internal thoracic artery (ITA) and most multivessel patients were treated with two ITAs. After matching for age, sex, right system revascularization, and extent of coronary disease, two groups (86 patients each) were used to compare the two revascularization modalities. RESULTS: Both groups were similar; however, left main, poor ejection fraction, total occlusion, and bifurcation lesions were more prevalent in the surgical group, and in-stent restenosis in the PCI group. The mean number of coronary vessels treated was higher in the surgical group (2.05 vs 1.6, p < 0.001). Mean follow-up was 18 months. Overall mortality (early and late) was 2.3% and 3.5% in the Cypher and surgical groups, respectively (p = 0.65). Angina returned in 39.5% of the Cypher group and 15.1% of the surgical group, p < 0.001. There were 25 reinterventions in the Cypher group compared with five in the surgical group (p = 0.010). The Cox proportional hazard model revealed assignment to the Cypher group to be the only independent predictor of reangina (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.63 to 6.53) and reintervention (OR 4.17, 95% CI 1.92 to 20.83). CONCLUSIONS: Despite improved results of PCI with Cyphers, midterm clinical outcome of diabetic patients treated surgically is better.