Showing papers by "A. Pieter Kappetein published in 2019"

Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease

Abstract: Background Long-term outcomes after percutaneous coronary intervention (PCI) with contemporary drug-eluting stents, as compared with coronary-artery bypass grafting (CABG), in patients wit...

Heart Team decision making and long-term outcomes for 1000 consecutive cases of coronary artery disease.

Abstract: OBJECTIVES: The Heart Team has been recommended as standard care for patients with coronary artery disease (CAD). However, little is known about the real benefits, potential treatment delays and late outcomes of this approach. Our goal was to determine the safety and feasibility of multidisciplinary Heart Team decision making for patients with CAD. METHODS: We retrospectively assessed 1000 consecutive cases discussed by the Heart Team between November 2010 and January 2012. We assessed (i) time intervals between different care steps involving the Heart Team; (ii) the distribution of patients according to the complexity of their CAD; and (iii) the 5-year survival as estimated from Kaplan–Meier curves. RESULTS: Of 1000 case discussions, 40 were repeat cases, resulting in 960 unique cases. The mean age was 65 years, 73% were men, and 29% had diabetes. Native vessel disease was present in 86.4%, of which 69% had simple 1-vessel disease (1VD) or 2-vessel disease (2VD), and 31% had complex left main (LM) or 3-vessel disease (3VD). The time interval between referral by a community hospital and final treatment was less than 6 weeks for 90% of cases. Treatment decisions were delayed in 35% of cases due to a need for additional diagnostic information. For simple 1- or 2VD with or without proximal left anterior descending artery involvement, treatment was medical therapy in 6% and 12%, respectively; percutaneous coronary intervention (PCI) in 88% and 85%, respectively; and coronary artery bypass grafting (CABG) in 6% and 3%, respectively. For 3VD disease, treatment was equally split between CABG and PCI (46% for both). PCI was preferred for isolated LM or LM with 1VD (81% vs CABG 16%), whereas CABG was preferred in LM with 2- or 3VD (71% vs PCI 19%). The 5-year mortality rate was 16% for 1- or 2VD, 17% for 3VD, 3% for isolated LM or with 1VD and 27% for LM with 2- or 3VD. CONCLUSIONS: In this single-centre analysis, the Heart Team approach was feasible, with decision making and treatment by the Heart Team following within a short time after referral. However, the timing of treatment could be further optimized if adequate information and imaging were available at the time of the Heart Team meeting. The final treatment recommendation by the Heart Team was largely in accordance with clinical guidelines.

Comparison of Outcomes After Transcatheter vs Surgical Aortic Valve Replacement Among Patients at Intermediate Operative Risk With a History of Coronary Artery Bypass Graft Surgery: A Post Hoc Analysis of the SURTAVI Randomized Clinical Trial.

Abstract: Importance Surgical aortic valve replacement (SAVR) has increased risk for patients with aortic stenosis (AS) and a history of coronary artery bypass graft (CABG) surgery. Transcatheter aortic valve replacement (TAVR) may be an alternative. Objective To compare TAVR with SAVR outcomes in patients at intermediate operative risk with prior CABG surgery. Design, Setting, and Participants In this post hoc analysis of the Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) noninferiority randomized clinical trial, patients with severe, symptomatic AS at intermediate operative risk were enrolled from 87 centers across the United States, Europe, and Canada from June 2012 to June 2016 and followed-up with up to July 2017. Those with a history of CABG surgery were considered for analysis. Data were analyzed from September to December 2017. Interventions A total of 1746 patients were enrolled and randomized 1:1 to self-expanding TAVR or SAVR. An implant was attempted in 1660 patients, of whom 273 had prior CABG surgery, including 136 who underwent attempted TAVR and 137 who underwent attempted SAVR. Main Outcomes and Measures The primary outcome was all-cause mortality or disabling stroke at 1-year follow-up. Efficacy outcomes included quality of life, measured using the Kansas City Cardiomyopathy Questionnaire at 30 days, 6 months, and 1 year, and distance walked in 6 minutes, measured using the 6-minute walk test at 30 days and 1 year. Results Of the 136 patients in the TAVR cohort, 111 (81.6%) were male, and the mean (SD) age was 76.9 (6.5) years; of the 137 in the SAVR cohort, 117 (85.4%) were male, and the mean (SD) age was 76.6 (6.5) years. The mean (SD) Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.0% (1.6%) in the TAVR cohort and 5.2% (1.7%) in the SAVR cohort. All-cause mortality or disabling stroke at 1-year follow-up was 8.9% (95% CI, 5.2-15.2) in the TAVR cohort and 6.7% (95% CI, 3.5-12.8) in the SAVR cohort (log-rankP = .53). Compared with patients receiving SAVR, the mean (SD) Kansas City Cardiomyopathy Questionnaire summary score was significantly better among patients receiving TAVR at 30 days (81.4 [19.2] vs 69.7 [22.6];P Conclusions and Relevance Both TAVR and SAVR were safe for intermediate-risk patients with AS and prior CABG surgery. The transcatheter approach facilitated faster improvement in quality of life and better exercise capacity at 1-year follow-up. Trial Registration ClinicalTrials.gov identifier:NCT01586910

Life-long clinical outcome after the first myocardial revascularization procedures: 40-year follow-up after coronary artery bypass grafting and percutaneous coronary intervention in Rotterdam.

Abstract: OBJECTIVES: Our goal was to evaluate the outcomes of the first patients treated by venous coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCIs) with balloon angioplasty at a single centre who have reached up to 40 years of life-long follow-up. METHODS: We analysed the outcomes of the first consecutive patients who underwent (venous) CABG (n = 1041) from 1971 to 1980 and PCI (n = 856) with balloon angioplasty between 1980 and 1985. Follow-up was successfully achieved in 98% of patients (median 39 years, range 36–46) who underwent CABG and in 97% (median 33 years, range 32–36) of patients who had PCI. RESULTS: The median age was 53 years in the CABG cohort and 57 years in the PCI cohort. A total of 82% of patients in the CABG group and 37% of those in the PCI group had multivessel coronary artery disease. The cumulative survival rates at 10, 20, 30 and 40 years were 77%, 39%, 14% and 4% after CABG, respectively, and at 10, 20, 30 and 35 years after PCI were 78%, 47%, 21% and 12%, respectively. The estimated life expectancy after CABG was 18 and 17 years after the PCI procedures. Repeat revascularization was performed in 36% and 57% of the patients in the CABG and PCI cohorts, respectively. CONCLUSIONS: This unique life-long follow-up analysis demonstrates that both CABG and PCI were excellent treatment options immediately after their introduction as the standard of care. These procedures were lifesaving, thereby indirectly enabling patients to be treated with newly developed methods and medical therapies during the follow-up years.

Impact of Staging Percutaneous Coronary Intervention in Left Main Artery Disease: Insights From the EXCEL Trial.

Abstract: Percutaneous coronary intervention (PCI) is an acceptable alternative revascularization strategy to coronary artery bypass grafting for selected patients with unprotected left main coronary artery disease (LMCAD). Concomitant coronary artery disease (CAD) in other epicardial vessels is a frequent