A case against low-volume percutaneous coronary intervention centers.

Since the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial1 in April 2007, percutaneous coronary intervention (PCI) has received harsh scrutiny in both the scientific and lay press.2,3 The COURAGE investigators concluded that PCI did not reduce chances of death or myocardial infarction (MI) in patients with stable coronary artery disease and mild symptoms. At the same time, enormous controversy and media attention turned to a concern about late stent thrombosis in patients treated with drugeluting stents. Studies suggested that an excess of deaths occurred 1 to 3 years after drug-eluting stent implantation.4,5 More recently, Tonino et al6 demonstrated in the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) trial that the risk of MI could be reduced by use of fractional flow reserve measurements during PCI. The FAME trial suggested that patients were benefited by deployment of fewer stents. In 2008, Hannan et al7 found that risk-adjusted mortality was less for coronary artery bypass grafting (CABG) than PCI with drug-eluting stents in the New York State registry. In March 2009, the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial was published, and Serruys et al8 concluded that PCI with drug-eluting stents was inferior to CABG in patients with multivessel or left main coronary disease. In June 2009, the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) investigators reported that patients with treated diabetes mellitus had no improvement in survival when they were revascularized with PCI; however, an improvement in survival occurred when patients were treated with CABG.9