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CLINICAL STUDIES

A comparison of systematic stenting and conventional balloon angioplasty during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction

Luc Maillard, MD, PhD^a, Martial Hamon, MD^*, Khalife Khalife, MD, Philippe Gabriel Steg, MD, FACC, Farzin Beygui, MD, Jean-Leon Guermonprez, MD^||, Christian M. Spaulding, MD^¶, Jean-Marc Boulenc, MD^#, Janusz Lipiecki, MD^**, Antoine Lafont, MD, PhD, Philippe Brunel, MD, Gilles Grollier, MD, Rene Koning, MD^||||, Pierre Coste, MD^¶¶, Xavier Favereau, MD^##, Bernard Lancelin, MD^***, Eric Van Belle, MD, PhD, Patrick Serruys, MD, PhD, FACC, Jean-Pierre Monassier, MD^*, Philippe Raynaud, MD^a for the STENTIM-2 Investigators

^a CHU Tours, Tours, France
^* CH Mulhouse, Mulhouse, France
CH Metz, Metz, France
CHU Bichat, Paris, France
CHU Necker, Paris, France
^|| CHU Broussais, Paris, France
^¶ CHU Cochin, Paris, France
^# Clinique St. Joseph, Colmar, France
^** CHU Clermont-Ferrand, Clermont-Ferrand, France
CHU Boucicaut, Paris, France
CHU Nantes, Nantes, France
CHU Caen, Caen, France
^|||| CHU Rouen, Rouen, France
^¶¶ CHU Bordeaux, Bordeaux, France
^## CMC Parly 2, Le Chesnay, France
^*** CC Marie Lannelongue, Le Plessis Robinson, France
CHU Lille, Lille, France
University Hospital Rotterdam Dijkzigt, Thorax Center, Rotterdam, The Netherlands

Manuscript received August 9, 1999; revised manuscript received December 10, 1999, accepted February 3, 2000.

Reprint requests and correspondence: Dr. Luc Maillard, Unité de Cardiologie Interventionnelle, Hôpital Trousseau, 37044 Tours Cedex, France
luc.maillard{at}med.univ-tours.fr

	Abstract

Top Abstract Methods Results Discussion Appendix References

 
OBJECTIVES

In a multicenter, randomized trial, systematic stenting using the Wiktor stent was compared to conventional balloon angioplasty with provisional stenting for the treatment of acute myocardial infarction (AMI).

BACKGROUND

Primary angioplasty in AMI is limited by in-hospital recurrent ischemia and a high restenosis rate.

METHODS

A total of 211 patients with AMI <12 h from symptom onset, with an occluded native coronary artery, were randomly assigned to systematic stenting (n = 101) or balloon angioplasty (n = 110). The primary end point was the binary six-month restenosis rate determined by core laboratory quantitative angiographic analysis.

RESULTS

Angiographic success (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3 and residual diameter stenosis <50%) was achieved in 86% of the patients in the stent group and in 82.7% of those in the balloon angioplasty group (p = 0.5). Compared with the 3% cross-over in the stent group, cross-over to stenting was required in 36.4% of patients in the balloon angioplasty group (p = 0.0001). Six-month binary restenosis (50% residual stenosis) rates were 25.3% in the stent group and 39.6% in the balloon angioplasty group (p = 0.04). At six months, the event-free survival rates were 81.2% in the stent group and 72.7% in the balloon angioplasty group (p = 0.14), and the repeat revascularization rates were 16.8% and 26.4%, respectively (p = 0.1). At one year, the event-free survival rates were 80.2% in the stent group and 71.8% in the balloon angioplasty group (p = 0.16), and the repeat revascularization rates were 17.8% and 28.2%, respectively (p = 0.1).

CONCLUSIONS

In the setting of primary angioplasty for AMI, as compared with a strategy of conventional balloon angioplasty, systematic stenting using the Wiktor stent results in lower rates of angiographic restenosis.

Abbreviations and Acronyms   AMI = acute myocardial infarction   ECG = electrocardiogram or electrocardiographic   LV = left ventricle or ventricular   PTCA = percutaneous transluminal coronary angioplasty   STENTIM-2 = second STENTing In acute Myocardial infarction study   TIMI = Thrombolysis In Myocardial Infarction trial

	Methods

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STENTIM-2 is a multicenter, randomized trial comparing systematic coronary stenting using the Wiktor stent to conventional balloon angioplasty with provisional stenting for the treatment of AMI. The study was designed and powered to compare the rates of binary angiographic restenosis at systematic six-month angiographic follow-up.

The primary end point was binary angiographic restenosis, defined as 50% residual stenosis on the follow-up angiogram. Secondary end points included procedural success, defined as residual stenosis <50%, associated with Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 (17,18) and a composite end point combining either: 1) death; 2) recurrent myocardial infarction, defined as recurrent symptoms lasting >30 min despite nitrate therapy with new electrocardiographic (ECG) changes and either recurrent elevation of cardiac enzymes or emergency angiographic confirmation of an occluded culprit vessel; or 3) repeat revascularization of the target lesion, which included either repeat angioplasty or bypass surgery of the target vessel for restenosis with objective myocardial ischemia. This composite end point was evaluated at 6- and 12-month follow-up.

Secondary end points also included 1) recurrent ischemia, defined as recurrent symptoms consistent with angina and ECG changes sensitive to nitroglycerin and lasting <30 min, with no recurrent elevation of cardiac enzymes; and 2) reocclusion of the infarct-related artery, defined as TIMI flow grade 0 or 1 with >50% residual diameter stenosis on the follow-up angiogram of a previously patent vessel.

Additional end points included cerebrovascular accidents, access site bleeding, need for vascular repair or transfusion. Revascularization of other lesions was not considered an end point.

Patient selection.   Patients >18 years old with prolonged nitrate-resistant chest pain seen within 12 h of onset and ST segment elevation were selected. Exclusion criteria included participation in another study in the last month; thrombolytic therapy; cardiogenic shock; history of coronary artery bypass graft surgery; percutaneous transluminal coronary angioplasty (PTCA) within the previous six months; contraindications to heparin, aspirin or ticlopidine, such as allergy, thrombocytopenia or hemorrhagic diasthesis; severe renal or liver failure; and weight <40 or >100 kg. All patients had ECG and enzyme confirmation of an AMI.

Emergency management and catheterization.   Patients received a 500-mg intravenous bolus of aspirin and at least 5,000 IU of intravenous heparin (additional boluses were given as appropriate, according to the duration of the procedure). Coronary and left ventricular (LV) angiography was performed with the femoral approach using standard techniques. Angiographic inclusion criteria included 1) vessel diameter <3.00 mm by local on-line quantitative coronary analysis after maximal dilation induced by intracoronary nitroglycerin; 2) TIMI flow grade <3; and 3) culprit lesion diameter stenosis >70%. Bifurcation lesions involving a major side branch, left main coronary artery disease (stenosis >50%) and massively calcified lesions were excluded. Patients were also excluded if the infarct-related artery could not be identified or if they presented with severe multiple-vessel disease requiring emergency bypass surgery.

After coronary angiography and before crossing the lesion with a guide wire, the patients were randomly assigned by computer to either conventional balloon angioplasty or stent placement. The randomization sequence was designed to ensure balanced randomization at each center. Recruitment was limited to 25 patients per center.

Procedure.   Angioplasty was performed using standard techniques. The 6F guiding catheters were recommended. Operators were instructed to attempt to achieve a residual stenosis <30%. Stenting was performed using the Wiktor GX stent (Medtronic), which is a 16-mm-long coil stent. Expansion is obtained by inflating the balloon catheter at 12 atm (19–21). Additional stents were placed according to operator judgment to treat residual dissections. In the balloon angioplasty group, cross-over to stent placement was allowed for occlusive (bail-out) or nonocclusive extensive (type C or more) dissections that could not be successfully treated by repeated prolonged balloon inflations (22), a suboptimal result with residual stenosis of >50% or persistent slow flow (TIMI flow grade <3) (23).

The femoral sheath was removed, and hemostasis was obtained by manual compression as soon as the activated partial thromboplastin time was <60 s. All patients then received 100 international U of activity of low molecular weight heparin subcutaneously twice daily for at least 48 h, as well as 160 to 300 mg/day of aspirin (24). In addition, ticlopidine (500 mg/day) was prescribed for one month to all patients with stents. Angiotensin-converting enzyme inhibitors and beta-blockers were administered according to established guidelines.

Clinical and angiographic follow-up.   Clinical follow-up was obtained at six months and one year. Six-month repeat coronary angiography was performed after a routine stress test. Angiography performed before four months was allowed on the basis of clinical indications. If restenosis was not found, a new angiogram was required after four months. All angiograms were sent to a core laboratory (Cardialysis, Rotterdam, the Netherlands) for analysis using the Cardiovascular Angiography Analysis System and previously described methods (25). The TIMI frame count was performed on all angiograms (23).

Clinical and angiographic data were forwarded to the Data Coordinating Center at the University of Tours, France for statistical analysis. All adverse events were analyzed by the members of the Critical Events Committee. Analysis was done on an intention-to-treat basis.

Participating centers.   Study centers and investigators were selected on the basis of their experience with primary angioplasty for AMI. A yearly case load of >150 per center and >50 per investigator was required.

The study protocol was approved by the Institutional Review Board of the Tours Hospital according to French law, and written consent was obtained from all patients. The study was conducted according to the Declaration of Helsinki.

Statistical analysis.   Sample size estimates (n = 180) were based on an assumed rate of restenosis of 50% (including a 10% occlusion rate) in the angioplasty group and a 50% relative reduction in the stent group (two-sided test with an alpha error of 0.025 and a power of 0.95). To compensate for unsuccessful interventions and losses to follow-up, the sample was enlarged by 10% (n = 200). Results are expressed as the mean value ± SD for continuous variables. The two-tailed t test was used to assess differences between the treatment groups. Categoric data are presented as rates and were compared using the chi-square test or the Fisher exact test. Freedom from clinical end points was analyzed using Kaplan-Meier survival curves. Differences between the treatment groups were compared using the log-rank test.

	Results

Top Abstract Methods Results Discussion Appendix References

 
Between September 1997 and September 1998, 216 patients were randomly assigned to either balloon angioplasty (n = 112) or systematic stent implantation (n = 104). Of these 216 patients, five successfully treated patients were excluded by the Critical Events Committee because of major protocol violations. The final study group comprised 211 patients, with 101 and 110 patients in the stent and balloon angioplasty groups, respectively (Fig. 1). Baseline clinical (Table 1) and angiographic characteristics (Table 2) were similar between the groups.

View larger version (37K): [in this window] [in a new window]   Figure 1 Trial flow chart. pts = patients.

View larger version (17K): [in this window] [in a new window]   Figure 2 Cumulative frequency distribution curves for the two groups for minimal lumen diameter (MLD) at baseline, after the procedure and at six-month follow-up. There was no difference at baseline between the groups. After the procedure and at follow-up, minimal lumen diameter was larger in the stent group (solid line) than in the balloon angioplasty group (dashed line).

View larger version (14K): [in this window] [in a new window]   Figure 3 Kaplan-Meier survival curves for major adverse cardiac events (MACE). At one year, 80.2% of the patients in the stent group (solid line) were event free. Dashed line = balloon angioplasty group.

View larger version (15K): [in this window] [in a new window]   Figure 4 Kaplan-Meier curves for second revascularization. There were less patients in the stent group (solid line) than in the balloon angioplasty group (dashed line) requiring a second revascularization procedure.

	Discussion

Top Abstract Methods Results Discussion Appendix References

Use of ticlopidine and aspirin.   Systematic stenting in the setting of primary angioplasty was feasible and safe (13–15), as demonstrated by the high success rate for stent deployment (97%) and the low in-hospital mortality and morbidity rates. This may be partially ascribed to the adjunctive prescription of ticlopidine and aspirin, which has been shown to reduce major events after elective coronary stenting (24,26–29), and to the selection of experienced centers and operators.

Clinical implications.   In contrast to other trials of stenting in primary angioplasty (30–32), in STENTIM-2 randomization was performed before attempted recanalization, avoiding a bias toward selection of "ideal" lesions for stenting. Our results are therefore relevant to daily clinical practice. Despite these broad angiographic inclusion criteria, the in-hospital rates of occlusion and the need for repeat revascularization appear to be low in both groups, in comparison to previously reported reocclusion rates up to 15% after balloon angioplasty for AMI (4,5), and are comparable to those of nonrandomized trials of stenting for AMI (16). The cross-over rate to provisional stenting (36.4%) was higher than previously reported (30–32) and probably reflects the current momentum of clinical practice toward wider indications for stenting after incomplete or unsatisfactory balloon angioplasty results (33). This may in part explain the very low rate of in-hospital deaths and complications.

Restenosis rate and event-free survival.   This study was designed and powered to evaluate the six-month angiographic restenosis rate. Systematic stenting, compared with balloon angioplasty, significantly reduced the restenosis rate. This was associated, at six-month follow-up, with a 31.3% relative reduction in coronary ischemic events and a 36.8% relative reduction in the need for target vessel revascularization in the stent group versus the balloon angioplasty group, even though the protocol mandated that revascularization be driven by noninvasive demonstration of ischemia. At one-year follow-up, 80.2% of patients in the stent group were event free. The study was not powered to detect differences in clinical outcome or LV ejection fraction, although there appears to be an interesting and consistent improved event-free survival in the stent group at six- and 12-month follow-up. The similar event-free survival rates between the groups during the hospital period and the benefit in the stent group at both six and 12 months are likely due to the reduction in restenosis rates, as suggested by similar survival and revascularization rates at six months. A larger sample may have yielded a greater clinical benefit of systematic stenting.

Study limitations.   The results of the study must be interpreted with caution given the sample size and the exclusion of high risk patients, such as those with hemodynamic compromise or failed thrombolysis. In addition, the protocol did not mandate adjunctive use of glycoprotein IIb/IIIa inhibitors. Recent studies have suggested benefit in terms of procedural and short-term results with abciximab during primary PTCA (34–36), although this benefit was not sustained at six months (35). Only a small fraction of the patients enrolled in STENTIM-2 received abciximab (3% in each group). Ongoing randomized trials are currently evaluating the association between abciximab and primary stenting for AMI. One of the limitations of the present study was that only patients with stents received ticlopidine. However, in this open trial, it was deemed unethical by the Institutional Review Board to administer ticlopidine to the patients not receiving stents, considering the potential for severe, life-threatening hematologic complications, even though these are rare. In addition, ticlopidine has not been shown to have any impact on restenosis, which was the primary end point of the trial. Despite these potential limitations, STENTIM-2 involved randomization of unselected lesions and incorporated rigorous and blinded adjudication of clinical and angiographic end points. Our results are therefore clinically relevant.

Conclusions.   Systematic stenting during primary angioplasty for AMI is safe and feasible. It is associated with a reduction in six-month restenosis and fewer clinical events and target vessel revascularization at six months and one year. This suggests that systematic stenting may be of benefit for patients with AMI treated with primary PTCA.

	Appendix

Top Abstract Methods Results Discussion Appendix References

 
STENTIM-2.   Institutions and investigators
CHU Tours (n = 25): L. Maillard, B. Desveaux, L. Quilliet, G. Pacouret, B. Charbonnier and Ph. Raynaud; CH Mulhouse (n = 25): J.-P. Monassier and M. Hamon; CH Metz (n = 25): K. Khalife, F. Aboujaoude, J.-P. Rinaldi, F. Benhamed, M. Boursier and S. Alsagher; CHU Bichat, Paris (n = 23): P. G. Steg, H. Benamer, L. Feldman, D. Himbert, P. Aubry and J.-M. Juliard; CHU Necker, Paris (n = 17): F. Beygui, C. Le Feuvre, D. Catuli and J.-P. Metzger; CHU Broussais, Paris (n = 14): J.-L. Guermonprez, S. Battaglia, K. Boughalem and P. Henry; CHU Cochin, Paris (n = 13): C. Spaulding, R. Cador, J. Monsegu, A. Py, K. Benhamda, P. Richard and F. Belaouchi; Clinique St. Joseph, Colmar (n = 13): J.-M. Boulenc, A. Verdun, O. Katz, Y. Gottwalles, P.-L. Clermont and P. Valentin; CHU Clermont-Ferrand (n = 10): J. Lipiecki, B. Citron and L. Sarfati; CHU Boucicaut, Paris (n = 10): A. Lafont, S. Rahal, P. Durand, K. Bougrini, F. Addad and F. Labarthe; CHU Nantes (n = 10): Ph. Brunel and D. Crochet; CHU Caen (n = 10): G. Grollier, E. Lecluse, R. Sabatier, B. Valette, J. C. Potier and M. Hamon; CHU Rouen (n = 9): R. Koning, H. Eltchaninoff, C. Tron, B. Baala and A. Cribier; CHU Bordeaux (n = 4): P. Coste, S. Sempe, P. Jais and P. Besse; CC Marie Lannelongue, Le Plessis Robinson (n = 4): B. Lancelin, S. El Hadad, C. Caussin and C.-Y. Angel; CMC Parly 2, Le Chesnay (n = 4): X. Favereau, Y. Guerin and T. Corcos; CHU Lille (n = 1): E. Van Belle, E. McFadden and M. E. Bertrand. (The number of patients enrolled at each center is given in parentheses.)

Steering committee
D. Blanchard, A. Cribier, J.-P. Metzger and P. G. Steg

Critical events committee
J. Boschat, P. Joly, J. Puel and B. Valeix

Writing committee
M. Hamon, E. McFadden, A. Lafont, L. Maillard, C. Spaulding and P. G. Steg

Statistical analysis
Medtronic Bakken Research Center, Maastricht, the Netherlands: M. Janssen and E. Kerkhofs; CHU Tours, France: P. Ardwidson

Core angiographic laboratory
Cardialysis, Rotterdam, the Netherlands: P. W. Serruys

Coordination committee
M. Hamon, L. Maillard, J.-P. Monassier and Ph. Raynaud

	Acknowledgments

 
We are indebted to C. Cassiram and C. Aublant for their technical assistance.

	Footnotes

 
This study was supported in part by a grant from the Medtronic Corporation, France.

The remaining investigators in the STENTing In acute Myocardial infarction (STENTIM-2) study group are listed in the Appendix.

	References

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				K D Dawkins, T Gershlick, M de Belder, A Chauhan, G Venn, P Schofield, D Smith, J Watkins, H H Gray, and Joint Working Group on Percutaneous Coronary Inter Percutaneous coronary intervention: recommendations for good practice and training Heart, December 1, 2005; 91(suppl_6): vi1 - vi27. [Abstract] [Full Text] [PDF]

				T. P. Wharton Jr, E. C. Keeley, C. L. Grines, T. P. Wharton Jr, E. C. Keeley, and C. L. Grines The Case for Community Hospital Angioplasty Circulation, November 29, 2005; 112(22): 3509 - 3534. [Full Text] [PDF]

				A. K. Bilge, Y. Nisanci, E. Yilmaz, B. Ozben, A. Oncul, F. Mercanoglu, and M. Meric Effects of Percutaneous Coronary Thrombectomywith the X-Sizer Catheter on Epicardial Flow and Microvascular Function in Acute Coronary Syndromes Clinical and Applied Thrombosis/Hemostasis, October 1, 2005; 11(4): 461 - 466. [Abstract] [PDF]

				K. Huber, R. D. Caterina, S. D. Kristensen, F. W.A. Verheugt, G. Montalescot, L. B. Maestro, F. V. d. Werf, and for the Task Force on Pre-hospital Reperfusion The Pre-hospital reperfusion therapy: a strategy to improve therapeutic outcome in patients with ST-elevation myocardial infarction Eur. Heart J., October 1, 2005; 26(19): 2063 - 2074. [Full Text] [PDF]

				G. De Luca, H. Suryapranata, R. Grimaldi, and M. Chiariello Coronary stenting and abciximab in primary angioplasty for ST-segment-elevation myocardial infarction QJM, September 1, 2005; 98(9): 633 - 641. [Abstract] [Full Text] [PDF]

				P M Schofield Acute myocardial infarction: the case for pre-hospital thrombolysis with or without percutaneous coronary intervention Heart, June 1, 2005; 91(suppl_3): iii7 - iii11. [Full Text] [PDF]

				H Suryapranata, G De Luca, A W J van 't Hof, J P Ottervanger, J C A Hoorntje, J-H E Dambrink, A T M Gosselink, F Zijlstra, and M-J de Boer Is routine stenting for acute myocardial infarction superior to balloon angioplasty? A randomised comparison in a large cohort of unselected patients Heart, May 1, 2005; 91(5): 641 - 645. [Abstract] [Full Text] [PDF]

				J.-Y. Dupuis and M. Labinaz Noncardiac surgery in patients with coronary artery stent: what should the anesthesiologist know?/La chirurgie non cardiaque chez des patients porteurs d'une endoprothese coronaire : que devraient savoir les anesthesiologistes ? Can J Anesth, April 1, 2005; 52(4): 356 - 361. [Full Text] [PDF]

				E. C. Keeley and C. L. Grines Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way? Ann Intern Med, August 17, 2004; 141(4): 298 - 304. [Abstract] [Full Text] [PDF]

				Writing Committee Members, E. M. Antman, D. T. Anbe, P. W. Armstrong, E. R. Bates, L. A. Green, M. Hand, J. S. Hochman, H. M. Krumholz, F. G. Kushner, et al. ACC/AHA guidelines for the management of patients with ST-Elevation myocardial infarction--executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction) J. Am. Coll. Cardiol., August 4, 2004; 44(3): 671 - 719. [Full Text] [PDF]

				E. M. Antman, D. T. Anbe, P. W. Armstrong, E. R. Bates, L. A. Green, M. Hand, J. S. Hochman, H. M. Krumholz, F. G. Kushner, G. A. Lamas, et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) Circulation, August 3, 2004; 110(5): 588 - 636. [Full Text] [PDF]

				G Montalescot, H R Andersen, D Antoniucci, A Betriu, M J de Boer, L Grip, F J Neumann, and M T Rothman Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction Heart, June 1, 2004; 90(6): e37 - e37. [Abstract] [Full Text] [PDF]

				R. H. Mehta, K. J. Harjai, D. Cox, G. W. Stone, B. Brodie, J. Boura, W. O'Neill, C. L. Grines, and Primary Angioplasty in Myocardial Infarction (PAMI Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1739 - 1746. [Abstract] [Full Text] [PDF]

				S. Sakai, K. Mizuno, S. Yokoyama, J. Tanabe, T. Shinada, K. Seimiya, M. Takano, T. Ohba, M. Tomimura, R. Uemura, et al. Morphologic changes in infarct-related plaque after coronary stent placement: A serial angioscopy study J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1558 - 1565. [Abstract] [Full Text] [PDF]

				D. A. Cox, G. W. Stone, C. L. Grines, T. Stuckey, D. J. Cohen, J. E. Tcheng, E. Garcia, G. Guagliumi, R. S. Iwaoka, M. Fahy, et al. Outcomes of optimal or "stent-like"balloon angioplasty in acutemyocardial infarction: the CADILLAC trial J. Am. Coll. Cardiol., September 17, 2003; 42(6): 971 - 977. [Abstract] [Full Text] [PDF]

				D. J. Moliterno and A. W. Chan Glycoprotein IIb/IIIa inhibition in early intent-to-stent treatment of acute coronary syndromes: EPISTENT, ADMIRAL, CADILLAC, and TARGET J. Am. Coll. Cardiol., February 19, 2003; 41(4_Suppl_S): 49S - 54S. [Abstract] [Full Text] [PDF]

				F Beygui, C Le Feuvre, G Helft, C Maunoury, and J P Metzger Myocardial viability, coronary flow reserve, and in-hospital predictors of late recovery of contractility following successful primary stenting for acute myocardial infarction Heart, February 1, 2003; 89(2): 179 - 183. [Abstract] [Full Text] [PDF]

				F. Beygui, C. Le Feuvre, C. Maunoury, G.e. Helft, and J. P. Metzger Coronary vasodilator reserve: a clue to the explanation of 201Tl redistribution patterns early after successful primary stenting for acute myocardial infarction J. Am. Coll. Cardiol., September 4, 2002; 40(5): 877 - 881. [Abstract] [Full Text] [PDF]

				M. Singh, H. H. Ting, P. B. Berger, K. N. Garratt, D. R. Holmes Jr, and B. J. Gersh Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1881 - 1889. [Abstract] [Full Text] [PDF]