- Email: [email protected]
The Incidence of Clinical Restenosis when the Choice Between Bare Metal Stents and Drug Eluting Stents is Based on the Calculated Risk of Restenosis
S152
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
Method: We compared baseline characteristics and 12month clinical outcomes in 2403 consecutive patients undergoing PCI whose smoking status was known at 30 days from April 2004 to November 2008. Results: Of the 2403 patients, 276 (11.5%) were current smokers 30 days post PCI. Compared to non-smokers, smokers were younger, had lower baseline creatinine and suffered more from airways disease (all p ≤ 0.001). Cardiovascular risk factor profile (hypertension, dyslipidaemia, diabetes, and family history) was not significantly different between the two groups other than smoking status. Smokers were less likely to have a history of heart failure, had less complex coronary lesions and lower DES use (all p < 0.05). At 12 months, mortality, myocardial infarction, target-vessel revascularization, stroke and MACE rates were similar between the groups. In a multivariate analysis, smoking status did not predict 12 month MACE. Conclusion: We did not detect a protective effect of smoking on outcomes in patients taking clopidogrel, as was recently reported by the CHARISMA investigators. That one in ten of our patients continue to smoke during follow up may represent therapeutic inertia.
kinase (CK) elevation (≥150 U/L) has been proposed as a better QA surrogate and marker of adverse long-term outcome after PCI. Objective: We therefore examined the use of post-PCI CK in our tertiary interventional centre, with a particular focus on the hard clinical end-points of mortality and need for coronary bypass grafting (CABG) by 5 years. Methods: Of 1500 patients from 2002 to 2004, we identified 398 patients (mean age 61; range 33–86) who had PCI then CK measurement the following day. Patients undergoing PCI for acute MI and those with elevated CK at the time of PCI were excluded. Patients were stratified according to (i) whether CK was checked routinely (n = 152) or on an operator-driven ad hoc basis because of some procedural problem arising (n = 246), and (ii) CK <150 (n = 329) or ≥150 (n = 69). Results: Overall, 11 patients (2.8%) needed CABG and 15 patients (3.8%) died. Only 22/152 (14.5%) routine and 47/246 (19.1%) ad hoc CK measurements were elevated. There was no difference in CABG or death rates between the routine and ad hoc groups, whether CK was elevated (P = 0.97, 0.77 respectively) or not (P = 0.14, 0.49 respectively). CK elevation did not predict CABG or death in the routine group (P = 0.72, 0.35 respectively), the ad hoc group (P = 0.23, 0.45 respectively) or the overall cohort ((P = 0.46, 0.27 respectively). Conclusions: From the prognostic perspective, it appears hard to justify checking CK after contemporary PCI, whether routinely or on an ad hoc basis. Our study further suggests that CK is not an ideal measure of quality assurance for PCI performed in experienced high-volume centres, and better surrogate markers should be explored.
R. Padang ∗ , B. Bailey, M. Adams, M. Ng, L. Pressley, P. Harris
doi:10.1016/j.hlc.2010.06.1026
Department of Cardiology, Royal Prince Alfred Hospital, NSW, Australia
360 The Effect of Smoking on Clinical Outcomes in Patients Taking Clopidogrel Following Percutaneous Coronary Intervention W. Chan 1,∗ , N. Andrianopoulos 2 , A. Ajani 3 , D. Clark 4 , R. Johnston 1 , A. Finlay 2 , A. Walton 1 , A. Brennan 2 , J. Shaw 1 , C. Reid 2 , A. Dart 1 , S. Duffy 1 1 Alfred
Hospital, Australia of Epidemiology and Preventive Medicine (DEPM), Monash University, Australia 3 Royal Melbourne Hospital, Australia 4 Austin Hospital, Australia 2 Department
Background: Smoking induces the cytochrome P450 enzyme CYP1A2, which participates in the conversion of clopidogrel to its active metabolite. Although pharmacokinetic and clinical interactions between clopidogrel and both statins and proton-pump inhibitors have been described, the clinical effects of smoking on clopidogrel metabolism have not been well studied. We investigated whether continued smoking impacts on clinical outcomes in patients with planned duration of clopidogrel use of ≥12 months post PCI in a multi-centre procedural registry.
doi:10.1016/j.hlc.2010.06.1027 361 The Incidence of Clinical Restenosis when the Choice Between Bare Metal Stents and Drug Eluting Stents is Based on the Calculated Risk of Restenosis
In 2007 and 2008, 1256 patients underwent 1412 coronary angioplasty procedures in our hospital, at which a total of 1728 stents were deployed. The choice of bare metal (BMS) or drug eluting (DES) stent was based on a policy of limiting DES placement largely to patients with a predicted clinical restenosis rate of >15%. This was calculated from historical BMS restenosis data which took into account stent length, diameter and the presence or absence of diabetes. In all, 1328 (77%) BMS and 400 (23%) DES were deployed. We sought to determine whether this policy resulted in a reasonable compromise between the disadvantages and cost of using a high percentage of DES and the risk of clinical recurrence due to higher stent restenosis in BMS. From 2007 to 2009 inclusive, 222 of these patients (17.7% of the total study population) had 235 coronary angiograms for clinical indications beyond one month after stent placement. Among these, there were 74 instances (5.2 ± 1.2%) of primary restenosis, defined as ≥50% diameter stenosis in or adjacent to a stent. Rates of restenosis were similar for those with stable (5.7%) and unstable (5.2%) presentations, but higher (12.4%) in saphenous vein grafts. Even allowing for an underestimate owing to some patients having follow-up angiograms elsewhere, we think
the clinical restenosis rate resulting from this policy is acceptable. doi:10.1016/j.hlc.2010.06.1028 362 The Index of Microcirculatory Resistance, Measured Prior to Percutaneous Coronary Intervention, Predicts PeriProcedural Myocardial Infarction A. Yong 1,∗ , M. Shah 2 , M. Ho 2 , C. Chawantanpipat 1 , W. Fearon 2 , M. Ng 1 1 Department of Cardiology, Royal Prince Alfred Hospital, Syd-
ney, Australia 2 Department of Cardiology, Stanford University Medical Cen-
tre, Palo Alto, United States Due to a pending patent, the text of this abstract has been withheld from publication. doi:10.1016/j.hlc.2010.06.1029 363 The Initial 30-Day Australian and New Zealand Edwards Sapien Aortic Valve Replacement Experience D. Chew 1,∗ , S. Pasupati 2 , J. Bennetts 1 , D. Baron 3 , N. Kejriwal 2 , D. Walters 4 , A. Sinhal 1 1 Flinders
Medical Centre, Adelaide, Australia Hospital, Hamilton, New Zealand 3 St Vincents Hospital, Sydney, Australia 4 Prince Charles Hospital, Brisbane, Australia 2 Waikato
Transcatheter aortic valve replacement now presents a viable therapeutic strategy for patients deemed at highrisk for open aortic valve replacement (AVR). The Edwards Sapien Valve offers both transfemoral and trans-apical approaches to implantation. We report the initial Australian and New Zealand experience with this emerging valve technology. Method: A prospective registry of transcatheter aortic valve placement patients was initiated in November 2008. Consent provided by each patient. Permission to share clinical and outcome data with central data management was provided by each institutional ethics committee. Procedural success was defined as placement of the Sapien valve in the aortic area with ≤2+ aortic regurgitation. Outcomes at 30 days were assessed as survival and change in heart failure symptoms using the NYHA heart failure classification. Results: By March 2010, 30-day survival data were available on 39 patients from 3 hospitals, representing 39/68 (57.4%) of the total number of valves implanted. The logistic EuroSCORE predicted 30-day mortality was 24.1%. Procedural success was reported in 32/39 (82.1%) patients, while survival at 30 days reported in 34/39, (89.7%) patients, with 94.4% and 85.7% observed in transfemoral and transapical patients, respectively. Median NYHA heart failure classification improved from III to I among these patients. Access complications were observed in 4/39
Abstracts
S153
(10.3%) patients. Pacemaker implantation was required in 2/39 (5.1%) of patients. Conclusions: Initial local experience with Edwards Sapien valve demonstrates an acceptable procedural success rate and clinical outcomes at 30 days. Adverse outcomes are higher with trans-apical implantation reflecting a high-risk profile of these patients. doi:10.1016/j.hlc.2010.06.1030 364 The Use of Peri-Operative C-arm CT for the Accurate Placement of Percutaneous Aortic Valves J. Crowhurst 1,∗ , C. Aroney 1,2 , D. Walters 1 1 The
Prince Charles Hospital, Australia Spirit Northside Private Hospital, Australia
2 Holy
Introduction: Both ‘Corevalve’ and the ‘Edwards’ valve require the prosthesis to be accurately placed in the proximal ascending aorta. The valve must be profiled perfectly perpendicular to the X-ray beam before deployment. This requires multiple aortograms being performed. This is time consuming, inaccurate and uses significant contrast media volumes. Performing a Pre-operative or peri-operative CT scan can demonstrate the correct C-arm angle for placement of the valve. This study compares the effectiveness of pre-operative CT against peri-operative C-arm CT for these procedures. Method: Seventeen re-valving procedures performed at The Prince Charles Hospital between 08/2008 and 02/2010 were included in the study. Ten patients underwent pre-operative CT scans (Siemens Somatom Definition) and seven underwent peri-operative C-arm CT (Siemens Cardiac DynaCT). Predicted C-arm angulations from both groups were decided using Siemens inspace 3D software. In all cases, the C-arm (Siemens Axiom Artis Zee) was positioned using the CT scan’s predicted angle. An aortogram was performed to confirm the accuracy. Total contrast volume was noted for the re-valving procedure including C-arm CT. Results: In the pre-operative CT group, the correct Carm angulation was demonstrated in 1 of 10 cases, versus 6 of 7 cases in the peri-operative C-arm CT group (p = 0.002). The average re-valving procedural contrast volume for the pre-operative CT group was 256 ml and the peri-operative group used a total of 251 ml of contrast (p = 0.909). Conclusion: For the accurate placement of percutaneous Aortic Valves, peri-operative C-arm CT demonstrates the correct C-arm angle more accurately, when compared to traditional pre-operative CT, with no significant difference in procedural contrast volume. doi:10.1016/j.hlc.2010.06.1031
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
Method: We compared baseline characteristics and 12month clinical outcomes in 2403 consecutive patients undergoing PCI whose smoking status was known at 30 days from April 2004 to November 2008. Results: Of the 2403 patients, 276 (11.5%) were current smokers 30 days post PCI. Compared to non-smokers, smokers were younger, had lower baseline creatinine and suffered more from airways disease (all p ≤ 0.001). Cardiovascular risk factor profile (hypertension, dyslipidaemia, diabetes, and family history) was not significantly different between the two groups other than smoking status. Smokers were less likely to have a history of heart failure, had less complex coronary lesions and lower DES use (all p < 0.05). At 12 months, mortality, myocardial infarction, target-vessel revascularization, stroke and MACE rates were similar between the groups. In a multivariate analysis, smoking status did not predict 12 month MACE. Conclusion: We did not detect a protective effect of smoking on outcomes in patients taking clopidogrel, as was recently reported by the CHARISMA investigators. That one in ten of our patients continue to smoke during follow up may represent therapeutic inertia.
kinase (CK) elevation (≥150 U/L) has been proposed as a better QA surrogate and marker of adverse long-term outcome after PCI. Objective: We therefore examined the use of post-PCI CK in our tertiary interventional centre, with a particular focus on the hard clinical end-points of mortality and need for coronary bypass grafting (CABG) by 5 years. Methods: Of 1500 patients from 2002 to 2004, we identified 398 patients (mean age 61; range 33–86) who had PCI then CK measurement the following day. Patients undergoing PCI for acute MI and those with elevated CK at the time of PCI were excluded. Patients were stratified according to (i) whether CK was checked routinely (n = 152) or on an operator-driven ad hoc basis because of some procedural problem arising (n = 246), and (ii) CK <150 (n = 329) or ≥150 (n = 69). Results: Overall, 11 patients (2.8%) needed CABG and 15 patients (3.8%) died. Only 22/152 (14.5%) routine and 47/246 (19.1%) ad hoc CK measurements were elevated. There was no difference in CABG or death rates between the routine and ad hoc groups, whether CK was elevated (P = 0.97, 0.77 respectively) or not (P = 0.14, 0.49 respectively). CK elevation did not predict CABG or death in the routine group (P = 0.72, 0.35 respectively), the ad hoc group (P = 0.23, 0.45 respectively) or the overall cohort ((P = 0.46, 0.27 respectively). Conclusions: From the prognostic perspective, it appears hard to justify checking CK after contemporary PCI, whether routinely or on an ad hoc basis. Our study further suggests that CK is not an ideal measure of quality assurance for PCI performed in experienced high-volume centres, and better surrogate markers should be explored.
R. Padang ∗ , B. Bailey, M. Adams, M. Ng, L. Pressley, P. Harris
doi:10.1016/j.hlc.2010.06.1026
Department of Cardiology, Royal Prince Alfred Hospital, NSW, Australia
360 The Effect of Smoking on Clinical Outcomes in Patients Taking Clopidogrel Following Percutaneous Coronary Intervention W. Chan 1,∗ , N. Andrianopoulos 2 , A. Ajani 3 , D. Clark 4 , R. Johnston 1 , A. Finlay 2 , A. Walton 1 , A. Brennan 2 , J. Shaw 1 , C. Reid 2 , A. Dart 1 , S. Duffy 1 1 Alfred
Hospital, Australia of Epidemiology and Preventive Medicine (DEPM), Monash University, Australia 3 Royal Melbourne Hospital, Australia 4 Austin Hospital, Australia 2 Department
Background: Smoking induces the cytochrome P450 enzyme CYP1A2, which participates in the conversion of clopidogrel to its active metabolite. Although pharmacokinetic and clinical interactions between clopidogrel and both statins and proton-pump inhibitors have been described, the clinical effects of smoking on clopidogrel metabolism have not been well studied. We investigated whether continued smoking impacts on clinical outcomes in patients with planned duration of clopidogrel use of ≥12 months post PCI in a multi-centre procedural registry.
doi:10.1016/j.hlc.2010.06.1027 361 The Incidence of Clinical Restenosis when the Choice Between Bare Metal Stents and Drug Eluting Stents is Based on the Calculated Risk of Restenosis
In 2007 and 2008, 1256 patients underwent 1412 coronary angioplasty procedures in our hospital, at which a total of 1728 stents were deployed. The choice of bare metal (BMS) or drug eluting (DES) stent was based on a policy of limiting DES placement largely to patients with a predicted clinical restenosis rate of >15%. This was calculated from historical BMS restenosis data which took into account stent length, diameter and the presence or absence of diabetes. In all, 1328 (77%) BMS and 400 (23%) DES were deployed. We sought to determine whether this policy resulted in a reasonable compromise between the disadvantages and cost of using a high percentage of DES and the risk of clinical recurrence due to higher stent restenosis in BMS. From 2007 to 2009 inclusive, 222 of these patients (17.7% of the total study population) had 235 coronary angiograms for clinical indications beyond one month after stent placement. Among these, there were 74 instances (5.2 ± 1.2%) of primary restenosis, defined as ≥50% diameter stenosis in or adjacent to a stent. Rates of restenosis were similar for those with stable (5.7%) and unstable (5.2%) presentations, but higher (12.4%) in saphenous vein grafts. Even allowing for an underestimate owing to some patients having follow-up angiograms elsewhere, we think
the clinical restenosis rate resulting from this policy is acceptable. doi:10.1016/j.hlc.2010.06.1028 362 The Index of Microcirculatory Resistance, Measured Prior to Percutaneous Coronary Intervention, Predicts PeriProcedural Myocardial Infarction A. Yong 1,∗ , M. Shah 2 , M. Ho 2 , C. Chawantanpipat 1 , W. Fearon 2 , M. Ng 1 1 Department of Cardiology, Royal Prince Alfred Hospital, Syd-
ney, Australia 2 Department of Cardiology, Stanford University Medical Cen-
tre, Palo Alto, United States Due to a pending patent, the text of this abstract has been withheld from publication. doi:10.1016/j.hlc.2010.06.1029 363 The Initial 30-Day Australian and New Zealand Edwards Sapien Aortic Valve Replacement Experience D. Chew 1,∗ , S. Pasupati 2 , J. Bennetts 1 , D. Baron 3 , N. Kejriwal 2 , D. Walters 4 , A. Sinhal 1 1 Flinders
Medical Centre, Adelaide, Australia Hospital, Hamilton, New Zealand 3 St Vincents Hospital, Sydney, Australia 4 Prince Charles Hospital, Brisbane, Australia 2 Waikato
Transcatheter aortic valve replacement now presents a viable therapeutic strategy for patients deemed at highrisk for open aortic valve replacement (AVR). The Edwards Sapien Valve offers both transfemoral and trans-apical approaches to implantation. We report the initial Australian and New Zealand experience with this emerging valve technology. Method: A prospective registry of transcatheter aortic valve placement patients was initiated in November 2008. Consent provided by each patient. Permission to share clinical and outcome data with central data management was provided by each institutional ethics committee. Procedural success was defined as placement of the Sapien valve in the aortic area with ≤2+ aortic regurgitation. Outcomes at 30 days were assessed as survival and change in heart failure symptoms using the NYHA heart failure classification. Results: By March 2010, 30-day survival data were available on 39 patients from 3 hospitals, representing 39/68 (57.4%) of the total number of valves implanted. The logistic EuroSCORE predicted 30-day mortality was 24.1%. Procedural success was reported in 32/39 (82.1%) patients, while survival at 30 days reported in 34/39, (89.7%) patients, with 94.4% and 85.7% observed in transfemoral and transapical patients, respectively. Median NYHA heart failure classification improved from III to I among these patients. Access complications were observed in 4/39
Abstracts
S153
(10.3%) patients. Pacemaker implantation was required in 2/39 (5.1%) of patients. Conclusions: Initial local experience with Edwards Sapien valve demonstrates an acceptable procedural success rate and clinical outcomes at 30 days. Adverse outcomes are higher with trans-apical implantation reflecting a high-risk profile of these patients. doi:10.1016/j.hlc.2010.06.1030 364 The Use of Peri-Operative C-arm CT for the Accurate Placement of Percutaneous Aortic Valves J. Crowhurst 1,∗ , C. Aroney 1,2 , D. Walters 1 1 The
Prince Charles Hospital, Australia Spirit Northside Private Hospital, Australia
2 Holy
Introduction: Both ‘Corevalve’ and the ‘Edwards’ valve require the prosthesis to be accurately placed in the proximal ascending aorta. The valve must be profiled perfectly perpendicular to the X-ray beam before deployment. This requires multiple aortograms being performed. This is time consuming, inaccurate and uses significant contrast media volumes. Performing a Pre-operative or peri-operative CT scan can demonstrate the correct C-arm angle for placement of the valve. This study compares the effectiveness of pre-operative CT against peri-operative C-arm CT for these procedures. Method: Seventeen re-valving procedures performed at The Prince Charles Hospital between 08/2008 and 02/2010 were included in the study. Ten patients underwent pre-operative CT scans (Siemens Somatom Definition) and seven underwent peri-operative C-arm CT (Siemens Cardiac DynaCT). Predicted C-arm angulations from both groups were decided using Siemens inspace 3D software. In all cases, the C-arm (Siemens Axiom Artis Zee) was positioned using the CT scan’s predicted angle. An aortogram was performed to confirm the accuracy. Total contrast volume was noted for the re-valving procedure including C-arm CT. Results: In the pre-operative CT group, the correct Carm angulation was demonstrated in 1 of 10 cases, versus 6 of 7 cases in the peri-operative C-arm CT group (p = 0.002). The average re-valving procedural contrast volume for the pre-operative CT group was 256 ml and the peri-operative group used a total of 251 ml of contrast (p = 0.909). Conclusion: For the accurate placement of percutaneous Aortic Valves, peri-operative C-arm CT demonstrates the correct C-arm angle more accurately, when compared to traditional pre-operative CT, with no significant difference in procedural contrast volume. doi:10.1016/j.hlc.2010.06.1031
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268