Drug-eluting stent-supported percutaneous coronary intervention in high risk patients refused cardiac surgery

Randomized trials of drug-eluting stents (DES) have demonstrated their ability to improve clinical outcome in relatively simple lesion/patient subsets. Their potential in patients for whom the risk of coronary bypass grafting is judged prohibitive, remains largely unexplored. To investigate periprocedural and one-year outcome of percutaneous coronary intervention (PCI) using DES in patients refused for coronary artery bypass grafting (CABG).

At our institution, the therapeutic approach for all patients with multi-vessel disease is decided, by consensus at a conjoint session with the clinical cardiologist, interventionalist and cardiothoracic surgeon enabling unequivocal identification of patients, refused surgery, who were referred for PCI. The EuroSCORE was used to predict peri-operative mortality. From April 2002 to December 2003 we identified 84 such patients. The mean age was 70.9+/-10.1 years and 68% were men. More than one third had prior CABG. Most patients presented with stable or unstable angina pectoris. The reasons for refusal for CABG were: unsuitable coronary anatomy (37%), poor functional status (28%), patent grafts other than the culprit vessel (25%), prior CABG (28%), severe left ventricular dysfunction (13%), co-existing malignancy (18%), prior disabling stroke (12%) and morbid obesity (11%). Using the standard and logistic EuroSCORE methods, the predicted in-hospital mortality rates were 7.8+/-3.3% and 13.2+/-11.1% respectively. In this study, the actual mortality rate was 1.2% at 30 days, 3.6% at 6 months and 4.8% at 1 year follow-up.

PCI in high risk patients who were refused for CABG in the DES-era resulted in an early and 1-year mortality rate that was significantly lower than the predicted operative mortality.