Paul Teirstein MD

Paul Teirstein, MD 

Disclosures: 

Cordis, Boston, Medtronic, Abbott: 

Research Grants 

Consultant 

Speakers Bureau 

SCRIPPS CLINIC

Ahh….the benefit of hindsight 

Paul Teirstein, MD 

Chief of Cardiology 

Director of Interventional Cardiology 

Scripps Clinic 

La Jolla, California 

SCRIPPS CLINIC

A Bold New Era In Cardiovascular 

Disease 

We need bold new lectures. 

•Lectures that go deeper, ie “Ahh….the 

benefit of hindsight” 

•Modern speakers now stress EMOTION 

over CONTENT 

•They tell us how they feel, not what they 

think! 

SCRIPPS CLINIC

“Ahh….the benefit of hindsight” 

Ideas for future lectures: 

• Phew….that data smells awfully fishy to me 

• Expletive deleted! My hospital administrators are killing 

me 

• Blah…another one of my papers got rejected 

• Wow!...that was a great case 

• Yuck!.....got burned by another stent thrombosis 

• Ahhh….the benefit of foresight 

• Since foresight only becomes apparent in hindsight, 

you cant have foresight without hindsight. 

SCRIPPS CLINIC

“The farther backward you can look, the farther forward you are 

likely to see." 

---Winston Churchill 

SCRIPPS CLINIC

“Ahh….the benefit of 

hindsight” 

“Benefit of hindsight” is really a 

chance to talk about mistakes 

Mistakes: 

• Inadequate response to the COURAGE trial 

• Our erroneous referral of too many patients to bypass 

surgery 

• Mistakes I have made in the cath lab 

• Mistakes I have made in my career and my life 

SCRIPPS CLINIC

Mistake #1 

COURAGE trial results 

should have been more 

forcefully refuted 

SCRIPPS CLINIC

Homicide: n. The killing of one person by another 

• Criminal Homicide: 

• Murder first degree: Premeditation, intent 

• Murder Second degree: intent, no premeditation 

• Manslaughter 1 st degree (voluntary manslaughter): 

• Intent, heat of passion, a reasonable person is provoked to kill 

• Manslaughter 2 nd degree (involuntary manslaughter or negligent homicide): 

• No intent, but did not act with the care and caution of a reasonable 

person (ie kicking brick off bridge that hits someone below) 

• Reckless homicide – aware of risk but does not care, ie driving 

recklessly at 90 MPH 

• Non-Criminal homicide 

• Justifiable homicide – kill to protect yourself, police officer killing in the 

line of duty, 

• Accidental homicide: A lawful act done under a reasonable belief that no 

harm is possible

Harmonizing Outcomes with Revascularization and Stents in AMI 

≥3400* pts with STEMI with symptom onset ≤12 hours 

Aspirin, thienopyridine 

UFH + GP IIb/IIIa inhibitor 

(abciximab or eptifibatide) 

R 

1:1 

Bivalirudin monotherapy 

(± provisional GP IIb/IIIa) 

Emergent angiography, followed by triage to… 

CABG – 

Primary PCI 

– 

Medical Rx 

3000 pts eligible for stent randomization 

R 

1:3 

Bare metal stent 

TAXUS paclitaxel-eluting stent 

*To rand 3000 stent pts 

Clinical FU at 30 days, 6 months, 

1 year, and then yearly through 5 years

Mortality (%) 

1-Year Mortality: Cardiac and Non Cardiac 

Excess deaths 3 = 

2.9% 

30 

Number at risk 

Bivalirudin alone 

Heparin+GPIIb/IIIa 

5 

Mortality = 

4 

68 vs 38 pts 

2 

1 

0 

Bivalirudin alone (n=1800) 

Heparin + GPIIb/IIIa (n=1802) 

1.8% 

Time in Months 

HR [95%CI] = 

0.57 [0.38, 0.84] 

P=0.005 

Cardiac 

Δ = 1.1% 

P=0.03 

Non Cardiac 

1.3% 

1.1% 

0 1 2 3 4 5 6 7 8 9 10 11 12 

1800 1705 1684 1669 1520 

1802 1678 1663 1646 1486 

3.8% 

Δ = 1.7% 

2.1%






• Intent, heat of passion, ie provoked to kill 

• Manslaughter 2 nd degree (involuntary manslaughter or negligent 

homicide): 


person (ie kick brick off bridge) 

• Reckless homicide – aware of risk but doesn‟t care,ie driving 



• Justifiable homicide – kill to protect yourself, police officer killing 

in the line of duty, 

• Accidental homicide: A lawful act done under a reasonable belief 

that no harm is possible

Hypothetical trial 

The HOLIE CHUTE trial 

Group A 

Group B 

Primary endpoint = Mortality 

Inexpensive trial 

Expected 90% relative risk; 40 pts provides power 0.90, alpha < 0.05 

DSMB halts trial early because of excess deaths in treatment group B






• Intent, heat of passion, ie provoked to kill 

• Manslaughter 2 nd degree (involuntary manslaughter or negligent 

homicide): 


person (ie kick brick off bridge) 

• Reckless homicide – aware of risk but doesn‟t care,ie driving 



• Justifiable homicide – kill to protect yourself, police officer killing 

in the line of duty, 

• Accidental homicide: A lawful act done under a reasonable belief 

that no harm is possible

COURAGE: Clinical Outcomes Utilizing 

Revascularization and Aggressive 

Guideline-Driven Drug Evaluation 

Boden W et al. NEJM 2007;356:1503-16.

COURAGE: Inclusion Criteria 

• Pts must have angiographically confirmed single 

or multivessel CAD (>70%) and objective 

evidence of ischemia 

• - LAD: prox or mid 

• - RCA: prox to PDA 

• - LCx: prox to PDA/PL 

• Pts with classic angina, >80% lesion, without 

documented objective ischemia

COURAGE: Exclusion Criteria 

The very highest CLINICAL risk patients were excluded 

• Unstable angina 

• CCS class IV angina refractory to medical therapy 

• Markedly abnormal stress test 

• Substantial STD or hypotensive response during Bruce I 

• Revascularization within the last 6 months 

• Unprotected LM stenosis (>50%) 

• Refractory heart failure or cardiogenic shock 

• Severe LV dysfunction (EF

52 year old 

business 

executive, 

diabetic with 

class II angina. 

Adenosine 

perfusion scan 

shows lateral 

wall ischemia. 

© Cordis Corporation 2007 19

55 yo male 

with class II 

angina and 

anterior 

ischemia

65 yo male 

with two 

episodes of 

angina; 

TMT found 

ST 

depression 

laterally

70 yo male 

with Class II 

angina, 

stress test: 

mild anterior 

ischemia 

and LAD 

lesions 60- 

70%; By IVUS 

they are both 

< 4.0 mm; 


77 yo male with 

class 3 angina, 

abnormal nuclear 

study 


Where high risk angiographic lesions included in 

COURAGE? 

Local Heart team (surgeon & 

interventional cardiologist) assessed 

each patient in regards to: 

Patient’s operative risk (EuroSCORE & Parsonnet 

score) 

Coronary lesion complexity (newly developed 

SYNTAX score) 

– The goal of the SYNTAX score is to provide a 

tool to assist physicians in their 

revascularization strategies for patients with 

high risk lesions 

Calcification 

Thrombus 

Dominance 

Bifurcation 

Tortuosity 

Number & 

location of 

lesions 

SYNTAX 

score 

Left Main 

3 Vessel 

Total 

Occlusion 

Sianos et al, EuroIntervention 2005;1:219-227 

Valgimigli et al, Am J Cardiol 2007;99:1072-1081 

Serruys et al, EuroIntervention 2007;3:450-459 

Coronary tree segments based on the classification proposed by the AHA 

and modified for the ARTS study Circulation 1975; 51:31-3 & Semin Interv 

Cardiol 1999; 4:209-19 

Leaman score, Circ 1981;63:285-299 

Lesions classification ACC/AHA , Circ 2001;103:3019-3041 

Bifurcation classification, CCI 2000;49:274-283 

CTO classification, J Am Coll Cardiol 1997;30:649-656

COURAGE: Enrollment 

35,539 pts screened 

3071 pts eligible 

784 (26%) consent not given by MD or patient 

2287 pts consented 

All patients had angiography. 

32,468 Were excluded 

8677 Did not meet inclusion criteria 

5155 Had undocumented ischemia 

3961 Did not meet protocol for vessels 

6554 Were excluded for logistic reasons 

18,360 Had one or more exclusions 

4513 Had recent (50% 

722 Had only restenosis (no new lesions) 

528 Had complications after MI 

A lot of patients were excluded. 

PCI (n=1149) 

Medical (n=1138) 

Were the patients who were at high risk for death 

and MI Mean excluded? follow-up 4.6 yrs

% of Patients 

Hard Endpoints at 4.6 Years 

40% 

P

COURAGE Myths 

Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying 

COURAGE QOL manuscript in NEJM 

• „COURAGE trial patients were not low risk.‟ 

•Diabetics 34% 

•Heart failure 5% 

•Multivessel disease 70% 

• No, no, no…….this is high risk 

....yada, yada, yada 

SCRIPPS CLINIC

Courage Myths 

Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying 

COURAGE QOL manuscript in NEJM 

• “Although the majority of patients who received 

optimal medical therapy alone had improved 

symptoms within 3 months, 21% crossed over and 

received PCI.” 

•Actually, 32.6% of OMT patients crossed over to PCI 

• “Thus, a very reasonable „take-home‟ message from 

the COURAGE trial is to pursue optimal medical 

therapy initially and if this is ineffective, turn to PCI” 

• No mention of importance of angiography to risk stratify 

• 1/3 patients will get an extra procedure 

SCRIPPS CLINIC

Courage Myths 

Cost-Effectiveness of Percutatneous Coronary Intervention in Optimally 

Treated Stable Coronary Patients 

---Weintraub et al Circ Cardiovasc Qual Outcomes. 2008;1:12-30 

Item PCI + medical Medical only PCI - Medical 

Initial Cost $12,162 $752 $11,410 

Lifetime Cost $99,820 $90,370 $9,451 

But…the cost of diagnostic angiography was not included in the 

medical only arm. 

If the cost of the qualifying angiogram where included in the medical 

arm, the cost differences would be mitigated. 

Thus, the myth of COURAGE is perpetuated , i.e: “Angiography is not 

required for patients with stable angina” 

SCRIPPS CLINIC

How Has the COURAGE Trial Changed 

My Practice? 

LESSONS I HAVE LEARNED: 

• You don‟t have to stent every little blockage in every 

little vessel 

• Fix the major, ischemia producing lesions 

• Leave the small, distal, sidebranch vessels alone 

unless the patient has recalcitraint angina 

SCRIPPS CLINIC

Why such controversy? Are there two 

different cardiologist phenotypes? 

• We all agree medical therapy should be used in 

most patients to reduce death and MI 

• Anti-thrombotics, lipid lowering, beta blockers and ACE 

inhibitors 

• We disagree about how to control angina. Here, 

cardiologists have emotionally charged differences 

of opinion: 

•Aggressive anti-anginal medications versus 

revascularization 

SCRIPPS CLINIC

an oxygen molecule: O 2

Revascularization Therapy For Angina: 

Open the artery 

Stents increase oxygen supply 

YOUR HEART VESSELS EXPAND! 

The Liberated Heart

Medical Therapy For Angina: 

Beta-blockers, Nitrates, 

Decrease Oxygen Demand 

YOUR HEART IS 

IN 4 POINT 

RESTRAINTS! 

The Repressed Heart 

42

Think About It! Are you… 

• Are you a demand cutting cardiologist who wants 

to repress the heart? 

• Or 

• Are you a supply expanding cardiologist who wants 

to liberate the heart? 

SCRIPPS CLINIC

What‟s Your Phenotype? 

THE HEART 

REPRESSOR? 

•THE HEART 

LIBERATOR? 

SCRIPPS CLINIC

Mistake #2 

We should be more 

aggressively against CABG, 

especially when it involves 

SVGs 

SCRIPPS CLINIC

PCI Vs CABG: New Vs Old Technology 

1,100,000 

800,000 

500,000 

920,000 

770,000 810,000 850,000 

542,000 

514,000 

485,000 

1,092,000 

1,030,000 1,037,000 

980,000 

Angioplasty 

Bypass Surgery 

200,000 

395,000 

305,000 299,500 296,000 289,000 

2000 2001 2002 2003 2004 2005 2006 2007 

© Cordis Corporation 2007 46 

Sources: Cordis Database, Morgan Stanley

POD #1 after multi vessel revascularization: 

OLD technology 

POD #1 after multi vessel revascularization: 

NEW technology 

47

The Interventionalist‟s View of Bypass Surgery 

What do I like about bypass surgery? 

• Left internal mammary 

What do I dislike about bypass surgery? 

• Morbidity of the procedure 

• Saphenous vein grafts 

• Acceleration of underlying native coronary disease 

SCRIPPS CLINIC

Impact of increased sheer 

stress on native disease 

progression 

52

Percent of Native Arteries with Progression 

----- Cosgrove et al. Cleveland Clinic; J Thorac and Cardiovasc Surg 82:520-530, 1981 

100 

80 

60 

Less than 1 year 

1 to 2 years 

Greater than 2 years 

40 

20 

0 

20% decrease in MLD) of atherosclerosis in native vessels was 

accelerated by vein grafts and occurred in over 50% of native vessels within 2 years 53 

of surgery

Effect of Coronary Artery Bypass Grafting on Native 

Coronary Artery Stenosis 

----Hamada, Y. et al. Journal of Cardiovascular Surgery 2001; 42: 159-164 

40% 

30% 

20% 

p = 0.016 

35% 

10% 

0% 

8% 

IMA 

SVG 

35% of native coronaries bypassed with a vein graft 

progressed to total occlusion by 5 month angiography

Risk Factors for 

Acceleration of Coronary Disease 

• Smoking 

• Hypertension 

• LDL cholesterol 

• Obesity 

• Sedentery life style 

• Bypass surgery 

•especially saphenous vein graft implantation 

SCRIPPS CLINIC

The most frequently implanted 

surgical graft in the U.S. is still a 

saphenous vein… 

and after a few years, it‟s not a pretty 

site!

2006 Isolated CABG Data: 

Society of Thoracic Surgeons STS 

• 156,128 patients with isolated CABG 

•LIMA = 88.2% 

•Bilateral IMA = 4.4% 

•Radial artery = 7.7% 

---- 2006 STS database 

Bilateral IMA = 27.6% 

---- SYNTAX 

SCRIPPS CLINIC

By 5 years, vein graft patency was less than 40%. It was even worse for radial 

artery conduits and not much better for RIMAs! 

----Khot UN et al. Cleveland Clinic, Circulation. 2004;109:2086-91. 

Cumulative patency (

A contemporary study (2002-2003), 73% 

received statins, 90% received aspirin!

1,820 (81%) patients underwent 12 month angiography

By 12 months ¼ of SVG‟s are occluded; 40% of 

patients had at least one occluded SVG 

At 1 year ITA failure was less frequent than SVG failure 8% Vs 29%

Vein graft failure profoundly increased death, MI 

and revascularization 

Saphenous vein graft failure 

+ Native disease acceleration 

= A very difficult day for the 

Interventional cardiologist!

Example: The Graft Dependent Patient 

• The graft dependent patient was not graft 

dependent before surgery. 

• He is graft dependent because of surgery

Three Great Myths of Cardiac Surgery 

• Myth # 1: “Cardiologists do not obtain informed consent 

from patients prior to multivessel PCI.” 

•No surgical consultation obtained 

•Risk of restenosis not disclosed 

• How many cardiac surgeons do you know who inform 

patients that their saphenous vein graft only have about a 

50% chance of patency within 5 years? 

• How many cardiac surgeons do you know who inform 

patients that their underlying native vessel disease will 

accelerate due to SVG bypass, making their overall 

coronary diseased burden much worse when the SVG 

occludes? 

SCRIPPS CLINIC

AWESOME 454 5 

MASS-II* 408 1 

SOS 988 2 

ARTS 1,205 1 

ERACI-II* 450 2.5 

BARI* 1,829 10 

EAST 392 8 

CABRI 1,054 4 

GABI 359 1 

ERACI* 127 3 

RITA* 1,011 6.5 

Total 8,258 

PCI vs CABG 

Mortality 

Pt F-U Odds ratio 

(no.) (yr) 95% Cl 

.1 1 10 

PCI 

CABG 

better 

Hazard*/risk ratios 

better 

Holmes DR Jr., Berger PB: Complex Intervention. Textbook of Interventional Cardiology, 4th 

Edition, Topol EJ, editor. 2003:201-22.

One-year Rates of Repeat Revascularization in 4 

CABG vs. Stent Assisted PCI Trials 

Mercado et al, J thoracic Cardiovasc Surg, 2005

Rate (%) 

SYNTAX 

One Year Clinical Outcomes 

20 

15 

10 

5 

0 

P=0.0015* 

12.1 

17.8 

P=0.98 

7.7 

CABG (N=897) 

7.6 

P=0.11 

P=0.37 

4.3 4.8 

3.5 3.2 

TAXUS (N=903) 

P=0.003 

2.2 

0.6 

P


• Myth # 2: Target vessel revascularization rates are much 

higher following PCI compared to CABG 

SCRIPPS CLINIC

Repeat Revascularization Following CABG: 

Interpreting Clinical Trial Results 

• Several years post CABG, both the native vessel and SVG often 

progress to a total occlusion or diffuse disease resulting in limited 

options for PCI. 

• Given the high threshold for repeat bypass surgery (particularly in 

the presence of a patent LIMA graft), many post CABG patients are 

not offered repeat revascularization; not because they wouldn‟t 

benefit from re-intervention, but because the risks are prohibitive 

and the likelihood of success is low. 

• Thus, much of the relative increase in repeat revascularization 

following PCI observed in clinical trials is because the post PCI 

patient, in contradistinction to the post CABG patient, remains a 

good candidate for further revascularization. 

SCRIPPS CLINIC

What‟s missing from the PCI vs 

CABG trial data discussion? 

• Why does the debate seem to always focus on mortality 

and repeat revascularization? 

• Shouldn‟t we include morbidity endpoints? 

SCRIPPS CLINIC

Any above complication 53% 1% 

53% of CABG patients had a morbid complication compared to only 1% 

of DES patients

PREVENT 4 

JAMA 2005 

CABG + CABG +

Risk of Procedural Stroke 

PCI Vs CABG = 0.6% vs 1.2%, p = 0.002 

73

Rate (%) 

SYNTAX 


20 

15 

10 

5 

0 

P=0.0015* 

12.1 

17.8 

P=0.98 

7.7 

CABG (N=897) 

7.6 

P=0.11 

P=0.37 

4.3 4.8 

3.5 3.2 

TAXUS (N=903) 

P=0.003 

2.2 

0.6 

P


• Myth # 3: Given differences in morbidity, bypass 

surgery can even be compared to PCI. 

• If my PCI patient has a pseudo aneurysm requiring 

surgical repair of the femoral artery, it is considered a 

major complication that I have to defend at M&M and QA 

committee. The untoward event is a small surgical 

incision in the groin. 

•All CABG patients have a major surgical incision in the 

chest. Therefore 100% of all CABG patients, by this 

definition, suffer a major complication as a result of 

their care plan. 

SCRIPPS CLINIC

Survival (%) 

3 VD with Disease of the Proximal LAD Artery 

100 

A thought experiment! 

95 

90 

85 

94.3 

92.0 

Number needed to treat = 20 pts 

91.5 

Start with 20 pts 

3 yrs post CABG = 18 pts left 

3 yrs post stenting = 17 pts left 

88.1 

CABG 

Stenting 

89.3 

84.4 

80 

0 1 2 3 

Hannan EL: NEJM, 2005 

Years 

CP1190491-7

Original Article 

Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting 

in Multivessel Coronary Disease 

Edward L. Hannan, et al N Engl J Med, Volume 358(4):331-341 Jan 24, 2008 

Mortality (after adjustment) 7.3% for DES Vs. 6.0% for CABG 

This 1.3% absolute difference (p=0.03) yields a NNT of 77 

If we need to do 77 bypasses to save one life, I believe the 

mortality benefit is clinically meaningless! 

This point was completely missed by the lay press 

78

The TVR Trade-off: 

Good data – Bad interpretation 

• The clinician‟s perspective 

•Most of my patients tell me they would rather go through 3, 4 or 

even 5 PCI procedures rather than go through one bypass surgery 

• Yet some are using SYNTAX data to say exactly the 

opposite 

SCRIPPS CLINIC

Rate (%) 

SYNTAX 


20 

15 

10 

5 

0 

P=0.0015* 

12.1 

17.8 

P=0.98 

CABG (N=897) 

P=0.11 

P=0.37 

4.3 4.8 

3.5 3.2 

TAXUS (N=903) 

Number needed to prevent analysis 

Number of CABGs needed to 

prevent one re-PCI = 13 

At the cost 7.7of 7.6almost 4 times as 

many strokes 

P=0.003 

2.2 

0.6 

P

Adverse Events to 12 Months 

Stent (N=357) 

Left Main Subset 

CABG (N=348) 

All-Death 

P=0.88* 

CVA (Stroke) 

P=0.009* 

Number Needed to Prevent 



Myocardial Infarction 

This means 18 P=0.97* of every 19 

CABGs were unnecessary! 

At the cost of 9 times as many 

strokes 

4.4% 

4.2% 

4,1% 

4.3% 

Revascularization 

P=0.02* 

2.7% 

0.3% 

12.0% 

6.7%

54 yo business man 

with angina, 

dyspnea on exertion 

and ischemic 

dilatation on nuclear 

study 

82

After long 

discussion, patient 

requests stents 

85

Three stents to RCA two weeks later 

89

Single DES “crossover” 

circumflex with 

final kissing balloon 

inflation. 

Will stage RCA chronic 

occlusion. 

69 yo male with class III angina, anterolateral 

ischemia on cardiolyte scan, new 

decrease in EF on stress echo. Angio finds 

CTO of RCA with bridging collaterals and 

high grade distal LM and ostial LAD. 

Patient requests stents. 

90

Patients (%) 

USVC.TBD.October 2007.Page 91 of 157 

Safety at 12 Months (Death/CVA/MI) 


CABG TAXUS ® Express ® Stent 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

9.2 

ITT population 

Presented by Dr. Serruys; TCT 2008 

P>0.99 P=0.29 P=0.72 P=0.57 P=0.11 

7.0 

2.1 

0 

7.4 7.7 

4.5 

9.9 

14.5 

8.1 

LM all LM only LM+1VD LM+2VD LM+3VD 

(n=705) (n=91) (n=138) (n=218) (n=258) 

The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery 

or patients with multi-vessel disease.

Patients (%) 

USVC.TBD.October 2007.Page 92 of 157 

Revascularizations * at 12 Months 


CABG TAXUS ® Express ® Stent 

ITT population 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

*Any revascularization (PCI or CABG) 

P=0.02 P=1.0 P=0.68 P=0.08 P=0.02 

11.8 

15.3 

7.7 

6.5 

7.1 

6.4 5.9 

6.0 

3.0 

Number Needed to Prevent 

LM + 3VD Patients 



14.8 

LM all LM only LM+1VD LM+2VD LM+3VD 

(n=705) (n=91) (n=138) (n=218) (n=258) 

Presented by Dr. Serruys; TCT 2008 

The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery 

or patients with multi-vessel disease.

Who would I send CABG Surgery? 

•Several restenoses, large territory at risk 

•Diabetics with diffuse disease, particularly if small vessels but 

usually these are poor targets for CABG 

•Total occlusions with large and important territory at risk, not 

amenable to PCI or failed PCI 

•Excessive proximal tortuosity, particularly if calcified with good 

distal targets 

SCRIPPS CLINIC

You Can Call Me Now… 

…Or You Can Call Me Later 

But Remember: 

• Bypass surgery is very hard to go through more than 

once 

– Your saphenous vein grafts will likely close down 

– Your native vessels will likely shrivel up 

– Your subsequent PCI will likely be more difficult 

• But, PCI can be repeated as often as you like 

– And you can always have a bypass 

– Sometime in the future 

– Or, maybe never 

95

Bypass the Bypass! 

96

Mistake #3 

Mistakes I have made in the 

cath lab 

SCRIPPS CLINIC

Top Ten Things Not to Say 

in the Cath Lab 

6) Can I get a nurse in here who knows what she's 

doing. 

7) I just can't understand this anatomy. 

It’s really weird. Where's the LAD? 

8) This room is horrible...I can’t see anything I’m 

doing! Can you see anything? 

9) Stop that!...your killing my patient. 

10) Wow! I've never done that before... lets give it a 

try!

Top Ten Things Not to Say 

in the Cath Lab 

1) Ugh! This is the worst case I've ever had in my 

entire life! 

2) You smell really nice. What are you wearing? 

3) I’ve got to get out of here, lets hurry up! 

4) Huh? Where’d the stent go. Can anyone find the 

stent? 

5) No, I have no idea what vessel that is! Our job is 

to fix vessels, not name them.

The Cardiovascular 

Research Foundation 

Lenox Hill Heart and Vascular 

Institute of New York





































"A smart person learns from his own mistakes, 

a brilliant person learns from the mistakes of 

others" 

--- Bill Collins (Mike's father)

Beep…Beep…Beep…Beep…Beep…Be 

4-4701 911

113

114

115

116

“Success is going from failure to 

failure with no loss of 

enthusiasm” 

--Winston Churchill 

SCRIPPS CLINIC 

1 800 Fix A Stent 

117

Stranger Then Fiction 

69 yo female, fell in bathtub and hit her head. 

Went to ER, CT was obtained and something 

“unusual” observed. 

Due to stent procedure 8 years previously at 

another hospital, patient referred to cardiology 

for evaluation 

Cine images of chest obtained 

118

119

Lesson 

Learned: 

Always do a 

“wire out” 

shot 

120

80 yo female, no 

grafts, s/p double 

barrel DES with 

LAD in-stent 

restensosis and 

angina 

136

Mid LAD Cypher ISR 

Simple re-stent with 

Taxus for Cypher 

ISR 

A humbling 

experience 

137

Re-stent with TAXUS 

2.5 mm followed by 

non-compliant 2.5 

mm balloon @ 20 atm 

138

Some “plaque shift” 

into proximal LAD. 

After “discussion” 

decision to deploy 

second stent 

….hmmmm 

139

Position second 

2.5 mm stent 

140

Deploy second 

stent at 18 atm 

141

!!!!!!!!!!!!!!!!!!!!!!!!!!!! 

142

Tamponade with 

stent delivery 

balloon at 4 atm. 

But….patient is 

receiving AngioMax 

Patient tolorates 

inflation well, insert 

IABP. 

Need to wait 45 min 

for AngioMax to 

wear off 

How to pass the 

time? 

143

144

Question 30 

Which one of the following statements is true regarding echocardiography with 

dobutamine administration in comparison with exercise echocardiography? 

End of text 

(A) Sensitivity and specificity are lower 

(B) Oxygen demand is greater 

(C) The incidence of procedural complications is lower 

(D) It provides superior assessment of myocardial viability 

(E) It is less desirable for assessment of risk prior to noncardiac surgery 

145

Much improved. 

Lets wait another 15 

minutes. 

146

Re-inflate balloon 

for another 15 

minutes 

How should we 

pass the time? 

147

Question 31 

In patients over age 60, which of the following characterizes cardiovascular risk for those 

who have elevated systolic blood pressure, in comparison with those who have elevated 

diastolic blood pressure? 

End of text 

(A) Lower 

(B) Equivalent 

(C) Higher 

148

Question 36 

A 60-year-old man is admitted to the hospital for treatment of atrial fibrillation, 

associated with dyspnea and orthopnea, of two weeks' duration. He has had a heart 

murmur for many years. Physical examination reveals pulse rate of 108 per minute 

with irregularly irregular rhythm. Vital signs are otherwise normal. Cardiac examination 

reveals a grade 3/6 holosystolic murmur at the apex and an S 3 

followed by a short 

low-frequency murmur at the apex. 

Electrocardiogram reveals atrial fibrillation. Chest radiograph shows moderate cardiac 

enlargement and prominent vascular markings. 

Therapy with digoxin, atenolol, furosemide, and potassium chloride results in marked 

improvement of the patient's symptoms and slowing of the ventricular rate to 76 beats 

per minute at rest. Doppler echocardiogram reveals nearly normal left ventricular 

function, severe mitral regurgitation without evidence of mitral stenosis, and left atrial 

dimension of 5.5 cm. Estimated left ventricular ejection fraction is 55%. 

End of text 

149

Which of the following is most appropriate at this time? 

(A) Start warfarin therapy, and schedule semiannual evaluations including Doppler 

echocardiography 

(B) Start warfarin therapy, and perform direct-current cardioversion in three to four 

weeks; then schedule semiannual evaluations including Doppler echocardiography 

(C) Start heparin therapy, and schedule coronary angiography and mitral valve surgery 

(D) Start heparin and warfarin therapy, and order transesophageal echocardiography; if 

no clot is present, perform direct-current cardioversion; then schedule semiannual 

evaluations including Doppler echocardiography 

(E) Start warfarin and angiotensin-converting enzyme inhibitor therapy, and schedule 

semiannual evaluations including Doppler echocardiography 

150

After another 15 

minutes of balloon 

tamponade, (total 

inflation time 1 

hour) perforation 

is a bit worse. 

151

Remove IABP, 

exchange for 

second guide 

catheter. 

152

Deflate balloon for a 

few seconds to allow 

passage of second 

guidewire 

Then, reinflate 

balloon! 

153

Bring Jo-stent 

through proximal 

double barrel 

stents down LAD 

right up to inflated 

balloon 

154

Position 3.0 x 12 mm 

Jo-stent across 

perforation 

155

Deploy Jo-stent @ 16 

atm 

156

Final result 

Echo: minimal 

pericardial effusion 

ReoPro bolus plus 

infusion 

Discharge next 

morning: no CPK 

rise, no pericardial 

effusion. 

157

Emergency Angiogram for a 83 y.o Man Admitted 

with Episodic Angina and Hypotension 

The left main 

coronary artery 

has a 99% 

stenosis, and is 

intermittently 

obstructing! 

Patient requests 

stents 

158

Sudden Cardiac Arrest Due to Complete 

Closure of Left Main Artery – CPR! 

159

Emergency Balloon Inflation in Left Main Artery 

160

A Little More Flow but CPR Continues 

161

More Balloon Inflations 

162

Better Flow but CPR Continues! 

163

Now the Flow is Increasing and Cardiac 

Contraction is Improving 

164

More Balloon Inflations 

165

Position Stent in Left Main Artery 

166

Deploy Stent in Left Main Artery 

167

Final Result – Normal Flow! 

168

3 Months Later: Asymptomatic 

169

“Good judgement comes 

from experience . . . 

and experience comes from 

bad judgement” 

Lillehei 

SCRIPPS CLINIC 

1 800 Fix A Stent 

170

Mistake #4 

Mistakes I have made in my 

career and in my life 

SCRIPPS CLINIC

Top 10 mistakes I have made in my career 

and in my life 

10) I did not invent the coronary stent 

9) My first automobile was a Renault...sorry 

8) I took singing lessons in medical school…pointless! 

7) I recently drilled a small hole in the trunk of my 

Mercedes…right into the fuel tank…it‟s a long 

story…I‟ll tell you at the break 

6) Sending emails when upset 

5) Sending emails when intoxicated 

4) Thinking I could think of 10 mistakes, when all I 

could come up with is 8 mistakes 

1)…Not marrying my wife about 10 years sooner 

SCRIPPS CLINIC

Paul Teirstein MD

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