A Short Success Story

I was assisting Dr. Kang W. Lee at our hospital with a diagnostic coronary angiogram on a patient with whom I was familiar. The patient was Dr. Julius Gray, a very popular OB/GYN that has delivered countless babies in the southern California area for the last thirty-odd years. Dr. Gray is in excellent condition, as well as being very active. He hikes, golfs, and has an extremely successful practice. The reason for his angiogram was for some discomfort in his chest, which he described as tight and pressure-like in character. The attacks usually occurred upon exertion and sometimes even at rest. The angiogram revealed a dominant left coronary artery with an ostial lesion in the circumflex artery, which is supplying not only the posterior wall of the left ventricle, but the inferior wall as well. This was an eccentric lesion that actually extended 2 millimeters into the left main. Dr. Gray now had a dilemma, and a great decision to make. Either he should go in for coronary artery bypass grafting, or take the 25-30% chance of restenosing a stent that would have to be implanted at that site. After some discussion with Dr. Lee, it was decided that it wasn’t necessary to rush into anything. As I was wheeling Dr. Gray back to his room, I mentioned that there was another option that had just occurred to me, a drug-eluting stent made by Cordis Corporation (Miami Lakes, FL), called the Cypher stent. This particular stent is a BX Velocity rapamycin (sirolimus) eluting stent. Rapamycin prevents proliferation of T cells, but also proliferation and migration of smooth muscle cells. Furthermore, rapamycin has been shown to diminish smooth muscle cell hyperproliferation. The Cypher stent is only available in Europe and will not be available to the United States for approximately another year. RAVEL was a multicenter prospective, double-blind clinical trial comparing bare metal and sirolimus-eluting stents. Two hundred thirty-eight patients were randomized to a single rapamycin-coated versus a bare metal Bx velocity stent. At six months follow-up, the restenosis rate of the treated group was zero, the loss in minimal lumen diameter was zero, there was no target lesion reintervention, and the event-free survival was 96.5%. After I shared these statistics, Dr. Gray asked me if I could help him get the contacts needed to be able to go to Europe and get this stent. I contacted Julie Logan at Scripps and sent her the films. Within days, Dr. Buchbinder decided that Dr. Gray’s lesion would be a perfect intervention for the Cypher stent exhibition at the EuroPCR, which was to take place in two weeks. Dr. Gray made an appointment with Dr. Buchbinder, and they discussed the red tape and the travel plans. The next day, Dr. Gray walked into our cath lab and informed me that if I could attend the EuroPCR on such short notice that he would pay for my round-trip airfare to Paris. I called a friend of mine, Mark Young from Cordis, and with his connections, I was able to enroll immediately. The EuroPCR is a world conference, presented in English, that took place May 21-24, 2002. Lectures were given by renowned interventionalists from all over the world. The convention center is located at the World Congress Center (Palais des Congres) in Paris. It is the most magnificent conference center I have ever visited (and I have attended a lot of cardiovascular conventions all around the United States). The lectures and live case presentations were via satellite from twelve different countries and were viewed on two giant screens by over 2000 scientists, cardiologists, nurses, technologists and vendors. The seats were comfortable and we had the ability to vote using a push-button remote on the armrest. The results would end up on one of the screens as part of the presentation. For example, there might be a complex bifurcation lesion on the LAD diagonal, and we would be asked, What size French would you use in this procedure? Or, Would you you a IIb/IIIa during this intervention? It was amazing to instantly see statistics on the screen that reflected the opinions of everyone in the room. I realized just how subjective this field can be! The EuroPCR is actually a balance between evidence-based medicine and new technologies. All lecturing scientists and physicians were required to state their own conflicts of interests before their lecture. I thought this was brilliant. If I heard a particular doctor mention a piece of equipment or technology from a company that he didn’t endorse, it would make quite an impression on me as to whether I wanted to consider purchasing this product or not. Another thing that impressed me was how the cardiologists in Europe were very cost-conscious as to where or when they would use a drug-eluting stent. Currently in Europe, drug-eluting stents are being used for high-risk restenosis lesions or in diabetic patients. New methods of percutaneous intervention are being developed for valve repair and even valve replacement. The whole of valve replacement will someday be accomplished entirely through a catheter! I was able to witness the future of imaging, checking out technologies like magnetic resonance imaging (MRI) and Multisplice CT coronary angiography, which demonstrates amazing coronary imaging quality. These technologies will be available starting in the next three or four years. This is a milestone, as it will signal the end of invasive diagnostic procedures and an increase in invasive interventional procedures. New techniques and technologies are also being developed for detecting vulnerable plaques, as well as new prevention techniques and treatments of plaque events that cause acute coronary syndromes. I witnessed Dr. Julius Gray’s drug-eluting stent procedure via satellite, as he was in Toulouse, France. On a giant screen in Paris, Dr. Maurice Buchbinder performed a pristine procedure on Dr. Gray, documented by intravascular ultrasound and witnessed by thousands of physicians in countries worldwide. We arrived back in southern California a week later, and I’m still on a natural high, not only from being able to attend the EuroPCR, but from having been in Paris in the springtime. The validation one can get for doing a great job is a wonderful feeling, but it’s really all about the patient. If it weren’t for Dr. Lee, who always keeps an open mind, respects the cath lab staff and allows us to voice our opinions, none of this would have been possible. This is the sum of teamwork.

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