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(Circulation. 2007;116:232.)
© 2007 American Heart Association, Inc.

Editors' Note

Gregg W. Stone, MD; Patrick W. Serruys, MD, PhD; Antonio Colombo, MD

Series Editors, Advances in Interventional Cardiology, Circulation

September 16, 2007, marks the 30th anniversary of the first percutaneous coronary balloon angioplasty procedure by Andreas Gruentzig, a seminal event that has forever altered the therapeutic landscape for patients with coronary artery disease. From its initial application, restricted to patients with a single obstructive lesion in the proximal coronary tree, angioplasty rapidly spread to higher-risk and more complex patients, such as those with multivessel disease, chronic total occlusions, and acute myocardial infarction. Physicians and patients rapidly embraced this newer, less invasive technique. However, it quickly became evident that balloon angioplasty was severely limited by acute and subacute vessel closure in 5% to 10% of patients and by restenosis in as many as 50% of cases. The introduction of the bare metal stent in the mid 1980s virtually eliminated acute closure and further reduced restenosis rates by one third, but these stents were not without their own issues. Vascular injury produced by stents resulted in excessive neointimal hyperplasia with in-stent restenosis in approximately one third of patients, which was occasionally refractory to repeat angioplasty (necessitating vascular brachytherapy and other arcane approaches). Moreover, the stainless steel implant elicited subacute thrombosis with resultant death or myocardial infarction in as many as 16% of patients in the early reports, which has gradually been reduced to 1% with improved stent technique and adjunct pharmacology. Finally, the site-specific delivery of antiproliferative agents to the region of vascular injury with drug-eluting stents has further lowered restenosis to <10% in most patients, though the infrequent but concerning occurrence of late stent thrombosis necessitates prolonged dual antiplatelet therapy, in some cases complicating management decisions.

Improved interventional devices and adjunct pharmacological agents, coupled with performance of an extraordinary volume of clinical research, have established the safety and efficacy of percutaneous coronary intervention in numerous clinical settings, resulting in widespread adoption with more than 2 million procedures annually performed worldwide. Angioplasty has been demonstrated to save lives and reduce heart attacks in patients with acute coronary syndromes and myocardial infarction and alleviate ischemia and improve quality of life in patients with stable coronary artery disease, clearly contributing to the marked improvement in prognosis that has been well documented in patients with coronary atherosclerosis. Moreover, the success of percutaneous coronary intervention has encouraged the development of device-based approaches to treat vascular lesions beyond the heart (such as carotid, femoral, and aortic disease), and the fostered the emerging subspecialties of structural heart disease and interventional heart failure, encompassing less invasive therapies for septal defects and shunts, valvular stenosis and insufficiency, and myocardial dysfunction and cardiomyopathy.

Despite this explosive growth of knowledge and capability, numerous questions remain regarding the optimal performance of and appropriate applications for the interventional approach to heart disease. For example, should drug-eluting stents be used in high-risk patients and lesions as compared with bare metal stents, medical therapy, or surgery? How long of a transfer delay to perform primary angioplasty for acute myocardial infarction rather than administering fibrinolytic therapy is excessive? When will closure of a patent foramen ovale prevent stroke? Do asymptomatic patients with extracranial carotid stenoses benefit from stenting?

It is thus appropriate as we celebrate the 30th anniversary of the birth of angioplasty that these and related issues be explored in a series of articles in Circulation highlighting the expanding subspecialty of Interventional Cardiology. Over the next 6 months, in-depth review articles will describe the current status and future directions for the stent-based treatment of coronary artery disease, angioplasty strategies in acute myocardial infarction, endovascular therapies for peripheral arterial disease, the pathophysiology and management of congenital heart disease in the adult, and emerging percutaneous valve therapies. It is our hope that these reports will provide insight and guidance for the practitioner confronting complex management decisions in patients with coronary, endovascular, and structural heart disease and offer a broad platform for understanding emerging breakthroughs in transcatheter cardiovascular therapeutics.

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