Clinical outcomes and cost implications of routine early PCI after fibrinolysis: one-year follow-up of the Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) study.

Background: In patients with ST-elevation myocardial infarction treated with fibrinolysis, routine early percutaneous coronary intervention (r-PCI) improves clinical outcomes at 30 days compared with a more standard approach of performing early PCI only for failed fibrinolysis (s-PCI).

Methods: We report prespecified secondary clinical outcomes and cost implications of r-PCI compared with s-PCI from the Canadian TRANSFER-AMI trial. Average cost per patient in each arm was calculated based on a microcosting approach.

Routine early angioplasty after fibrinolysis for acute myocardial infarction.

Background: Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis have not been established.

Methods: We randomly assigned 1059 high-risk patients who had a myocardial infarction with ST-segment elevation and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI to either standard treatment (including rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis.

Economic evaluation of drug-eluting stents compared to bare metal stents using a large prospective study in Ontario.

Objectives: To determine the cost-effectiveness (CE) and cost-utility (CU) of drug-eluting stents (DES) compared to bare metal stents (BMS) in Ontario using a large prospective "real-world" cohort study and determine the extent to which results vary by patient risk subgroups.

Methods: A field evaluation was conducted based on all stent procedures in the province of Ontario between December 1, 2003, and March 31, 2005, with a minimum subject follow-up of 1 year. Effectiveness data from the study using a propensity-score matched cohort were combined with resource utilization and cost data and quality of life (QOL) data from the published literature in a decision analytic modeling framework to determine 2-year cost-effectiveness (cost per revascularization avoided) and cost-utility (cost per quality-adjusted life-year ([QALY] gained).

Rationale and design of the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).

Background: Most patients with ST-elevation myocardial infarction present to hospitals without percutaneous coronary intervention (PCI) facilities and receive fibrinolysis. The role of routine early PCI after fibrinolysis, using stents and contemporary pharmacotherapy, has not been studied in a large adequately powered randomized trial.

Objective: To compare a pharmacoinvasive strategy of transfer for routine PCI within 6 hours after fibrinolysis with standard treatment after fibrinolysis (including predefined criteria for rescue PCI and delayed cardiac catheterization for patients who do not require rescue PCI).

Effectiveness and safety of drug-eluting stents in Ontario.

Background: The placement of drug-eluting stents decreases the frequency of repeat revascularization procedures in patients undergoing percutaneous coronary intervention (PCI) in randomized clinical trials. However, there is uncertainty about the effectiveness of drug-eluting stents, and increasing concern about their safety, in routine clinical practice.

Methods: From the Cardiac Care Network of Ontario's population-based clinical registry of all patients undergoing PCI in Ontario, Canada, we identified a well-balanced cohort of 3751 pairs of patients, matched on the basis of propensity score, who received either bare-metal stents alone or drug-eluting stents alone during an index PCI procedure between December 1, 2003, and March 31, 2005.

Transfer for urgent percutaneous coronary intervention early after thrombolysis for ST-elevation myocardial infarction: the TRANSFER-AMI pilot feasibility study.

Background: Most hospitals in Canada do not have percutaneous coronary intervention (PCI) facilities and use thrombolysis as reperfusion therapy for ST-elevation myocardial infarction (STEMI). Urgent PCI after thrombolysis may optimize reperfusion and prevent reinfarction and recurrent ischemia.

Objective: To determine the feasibility of transferring high-risk STEMI patients from community hospitals in Ontario to PCI centres for urgent PCI within 6 h of thrombolysis.

Effect of percutaneous coronary intervention of nonacute total coronary artery occlusions on QT dispersion.

Background: Myocardial ischemia is one of several potential causes of increased QT dispersion (QTd) in patients with nonacute total coronary artery occlusions (TCOs). We sought to assess the effect of percutaneous revascularization (PCI) of TCO on QTd and the relationship between QTd and long-term vessel patency.

Methods: Seventy patients enrolled in the TOSCA were analyzed.

Randomized comparison of prasugrel (CS-747, LY640315), a novel thienopyridine P2Y12 antagonist, with clopidogrel in percutaneous coronary intervention: results of the Joint Utilization of Medications to Block Platelets Optimally (JUMBO)-TIMI 26 trial.

Background: Despite the current standard antiplatelet regimen of aspirin and clopidogrel (with or without glycoprotein IIb/IIIa inhibitors) in percutaneous coronary intervention patients, periprocedural and postprocedural ischemic events continue to occur. Prasugrel (CS-747, LY640315), a novel potent thienopyridine P2Y(12) receptor antagonist, has the potential to achieve higher levels of inhibition of ADP-induced platelet aggregation than currently approved doses of clopidogrel.

Methods And Results: Joint Utilization of Medications to Block Platelets Optimally-Thrombolysis In Myocardial Infarction 26 (JUMBO-TIMI 26) was a phase 2, randomized, dose-ranging, double-blind safety trial of prasugrel versus clopidogrel in 904 patients undergoing elective or urgent percutaneous coronary intervention.

Same-day discharge after coronary stenting: a feasibility study using a hemostatic femoral puncture closure device.

A major limiting factor for percutaneous coronary interventions carried out via the femoral route is the time it takes to achieve femoral artery hemostasis and subsequent mobilization. Discharge from hospital usually occurs the following day. In this pilot study, we assessed the feasibility of mobilization at 4 hours and same-day discharge from hospital of selected elective patients undergoing intracoronary stenting using the Angio-Seal Vascular Closure device.

Low rates of angiographic and clinical restenosis with the new flexible MedStent for the treatment of single discrete coronary lesions.

The use of enhanced designs of new coronary stents continues to expand the spectrum of coronary anatomy and clinical settings amenable to nonsurgical revascularization. The objectives of this clinical trial were to demonstrate the safety and late angiographic restenosis rate of the new flexible MedStent. The study included 117 patients with stable or unstable angina pectoris and a discrete de novo lesion of a native coronary artery.

Successful treatment of a saphenous vein graft pseudoaneurysm with PTFE-covered JoStents.

A pseudoaneurysm of a saphenous vein bypass graft to a first diagonal coronary artery is reported. The patient presented with worsening angina symptoms 14 years after her first bypass surgery when this diagonal graft was implanted. Angiography revealed a 3 x 3 cm pseudoaneurysm of the graft.

Predictors of improvement in left ventricular function after percutaneous revascularization of occluded coronary arteries: a report from the Total Occlusion Study of Canada (TOSCA).

Background: The Total Occlusion Study of Canada (TOSCA) is a multicenter, randomized trial evaluating the effect of stenting with > =1 heparin-coated stent on long-term patency after percutaneous coronary intervention by balloon angioplasty of occluded coronary arteries. The purpose of the current study was to compare the effect of stenting and balloon angioplasty on global left ventricular ejection fraction (LVEF) and regional wall motion and to examine what clinical and angiographic factors may have an effect on left ventricular function in this setting.

Methods And Results: Analysis at the core angiographic laboratory of paired baseline and follow-up left ventricular angiograms, as well as target vessel patency, was possible in 244 of 410 cases.

Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up.

Objectives: To test the hypothesis that endovascular stents used with dilation of coarctation of the aorta (CoA) improve late outcomes. Balloon dilation for CoA has been limited by concerns over the risk for acute dissection, late restenosis, or aneurysm formation.

Design: All patients seen with CoA between November 1994 and September 1997 underwent attempted stent implantation.

Bleeding risks with abciximab after full-dose thrombolysis in rescue or urgent angioplasty for acute myocardial infarction.

Background: The bleeding risk associated with platelet glycoprotein IIb/IIIa inhibition in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) after full-dose thrombolysis for acute myocardial infarction (AMI) is unclear. We examined the risk and predictors of bleeding complications in patients with AMI who received abciximab during rescue or urgent PTCA after full-dose thrombolytic therapy.

Methods: A multicenter retrospective cohort of 147 consecutive patients who underwent PTCA within 48 hours after full-dose thrombolysis for AMI was studied.

Comparing angiographic coronary revascularization strategies: a 'natural' experiment.

Objective: To study the impact of intracoronary stents on clinical restenosis in the 'real world'.

Design: Retrospective comparison of the rates of clinical restenosis between two cohorts exposed to different strategies for percutaneous transcatheter intervention. The endpoint was the first of death, myocardial infarction, coronary artery bypass grafting, repeat percutaneous transluminal coronary angioplasty (PTCA) or repeat coronary angiography within nine months.

Primary stenting versus balloon angioplasty in occluded coronary arteries: the Total Occlusion Study of Canada (TOSCA).

Background: Balloon angioplasty (PTCA) of occluded coronary arteries is limited by high rates of restenosis and reocclusion. Although stenting improves results in anatomically simple occlusions, its effect on patency and clinical outcome in a broadly selected population with occluded coronary arteries is unknown.

Methods And Results: Eighteen centers randomized 410 patients with nonacute native coronary occlusions to PTCA or primary stenting with the heparin-coated Palmaz-Schatz stent.

Stenting of coronary artery stenosis in Kawasaki disease.

Coronary artery lesions can develop in Kawaski disease as a major complication, and result in aneurysm formation and stenosis. Reported is the evolution of important coronary artery stenosis in a pediatric patient managed with an endovascular stent.

Failed coronary stent deployment.

Background: Coronary stent deployment failure may be more common in clinical practice than generally appreciated. The incidence of failed deployment in routine clinical practice and the clinical sequelae have not been described. This study sought to determine the incidence and consequences of failed coronary stent deployment and to identify clinical and angiographic characteristics associated with deployment failure.

Coronary 'Y' stenting: a technique for angioplasty of bifurcation stenoses.

This report describes a case of successful percutaneous coronary transluminal angioplasty (PTCA) of a coronary artery bifurcating lesion using multiple intracoronary stents in an inverted 'Y' configuration. Balloon angioplasty of bifurcation coronary stenoses has a lower procedural success rate, higher restenosis rate and potential for side branch occlusion compared with nonbifurcation lesions. Numerous techniques, including two ('kissing') angioplasty balloons, have been used to overcome these problems.

Percutaneous catheter closure of the persistently patent ductus arteriosus in the adult.

The USCI patent ductus occluder has been shown to be an effective nonsurgical technique for closure of the persistently patent ductus in a primarily pediatric population. Its clinical impact in the adult has been reported only within small subgroups of larger pediatric studies or for a small population. This study was conducted to determine the feasibility, success rate, and complications of device closure for the persistently patent ductus arteriosus (PDA) in the adult.

Stenting for pulmonary artery stenosis following the Ross procedure.

A 34-year-old woman showed the development of significant main pulmonary artery obstruction along the supravalvar suture line 18 months following a Ross procedure. The patient underwent unsuccessful balloon angioplasty, followed by successful stent implantation. The angiographic narrowing disappeared postprocedure, and the excellent hemodynamic result maintained at 4 month follow-up.

Impaired vascular reactivity following angioplasty is mainly due to endothelial injury.

Vasoconstriction occurs frequently following coronary angioplasty and is implicated in the pathogenesis of abrupt closure and restenosis. Control of vasomotor tone is regulated in part directly by smooth muscle cells and indirectly through the endothelium. To study the mechanisms underlying vasoconstriction, the effect of angioplasty and endothelial denudation on endothelium-dependent and -independent relaxation was examined in 15 mongrel dogs.

Predictors of survival of in-hospital cardiac arrest.

A prospective study was conducted of all cases of attempted resuscitation following cardiac arrest occurring over a period of one year in a tertiary care teaching hospital. Analysis was made of the effects on survival of preselected variables of patients and circumstances of arrest. In 125 cases for which resuscitation was attempted, 49 attempts (39%) were initially successful.

Isolated chronic mitral regurgitation with preserved systolic left ventricular function and severe pulmonary hypertension.

Pulmonary hypertension in chronic mitral valve disease has been related most commonly to left ventricular dysfunction or mitral stenosis; its association with chronic, isolated mitral regurgitation and preserved left ventricular systolic function is unclear. In 41 catheterized patients with chronic mitral regurgitation (known history of mitral regurgitation for greater than 18 months) and preserved left ventricular systolic function (ejection fraction greater than 0.55), historic, electrocardiographic, echocardiographic and hemodynamic variables were analyzed.

Angiosarcoma of the left atrium mimicking myxoma: case report.

The case of a 65-year-old female patient with a pedunculated left atrial angiosarcoma is presented. Histologically, the tumor was composed of vascular spaces lined by atypical cells with similar cells in the solid portion of the tumor. Immunohistochemical stain for factor VIII-related antigen was positive in the cells forming vascular spaces.