Cardiac revascularization using both mammary arteries

Both internal mammary arteries in combination with veins were used for revascularization of the hearth in fifty Danish patients undergoing coronary artery bypass grafting (CABG) at Gentofte Hospital during the period 1994-1996. Patients with insulin-dependent diabetes mellitus, obesity, and age over 75 years were excluded. The patients were followed for at least one month after the operation. No patients died, and the complication rate was low and comparable to standard CABG using the left mammary artery and vein grafts. It is known from the literature that 10 years after CABG only 50% of vein grafts remain patent, and half of these have severe atherosclerosis. The mammary artery is far more resistant to atherosclerosis and 15 years after the procedure fewer patients have recurrent angina when both mammary arteries have been used. Bilateral mammary artery grafts can be used in half of CABG-procedures, and are especially indicated in younger patients.     

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery

OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.     

Use of an internal mammary artery graft in the revascularization of the myocardium. A ten-year follow up study

Between September 1986 and August 1996, 233 patients (187 males, 46 females) ranging in age from 32 to 81 (mean 54.7) years received at least one internal mammary artery (IMA) graft for coronary artery bypass procedures. The mean left ventricular ejection fraction was 55.1% (range, 17 to 75%). An average of 3.1 distal anastomoses per patient was constructed. Hospital mortality was 2.1%. Perioperative myocardial infraction was seen in 2.1%. The mean follow-up of hospital survivors was 39.2 (range, 4 to 123) months. Ten-year actuarial survival for patients discharged from the hospital was 96%. Recurrence of angina occurred in 18 patients and reoperation or PTCA was performed in 3 patients in the late follow-up period. These results support the continuing use of IMA grafts for myocardial revascularization.     

Long-term (10-year) outcome in patients with unstable angina pectoris treated by coronary balloon angioplasty

OBJECTIVES: We sought to examine completed 10-year survival and event-free survival in patients with stable and unstable angina pectoris treated by coronary balloon angioplasty. BACKGROUND: Patients with unstable angina are at increased risk for recurrent acute coronary events. METHODS: The study included 208 consecutive patients (133 with stable and 75 with unstable angina pectoris) undergoing angioplasty from 1984 to 1986. The balloon crossed the lesion in 185 patients (121 with stable and 64 with unstable angina pectoris). Angioplasty was performed in patients with unstable angina pectoris 12+/-15 days (median 8) after symptom onset. Patients with unstable angina pectoris were classified retrospectively into Braunwald class I (n=3), class II (n=20), class III (n=28), class B (n=52) and class C (n=12). Follow-up data were obtained from hospital charts, telephone interview and official death certificates where applicable. The study had >80% power to detect a clinically significant 20% difference in survival and a 20% difference in event-free survival between the stable and unstable patient groups. RESULTS: Despite similar baseline characteristics, early (40-day) mortality was slightly higher in patients with unstable angina (4.7% [3 of 64 patients] vs. 0.8% [1 of 121 patients], p=NS). Long-term outcome was not different, because survival curves were parallel thereafter (10-year survival was 83% for those with stable and 77% for those with unstable angina, p=NS). Survival free of myocardial infarction or coronary artery bypass graft surgery at 10 years was 53% in patients with stable and 47% in patients with unstable angina (p=NS), and survival free of infarction, bypass surgery or repeat angioplasty was 32% for both groups at 10 years. In patients with Braunwald class III unstable angina, 10-year survival was 80%, as compared with 85% in other patients with unstable angina, due to the early hazard (p=NS). Survival and event-free survival were similar in patients who had had a recent myocardial infarction (Braunwald class C) and in patients with acute electrocardiographic changes. Repeat hospital admissions were not more frequent in patients with unstable angina (3.1+/-3.5 vs. 3.0+/-2.6, p=NS). CONCLUSIONS: Ten-year survival and event-free survival were similar in patients with stable and unstable angina pectoris treated by coronary balloon angioplasty, with no evidence of an increased rate of recurrent cardiovascular events in the unstable group.     

Revascularization in patients with prior coronary bypass surgery

Increasingly over the past several years, patients have returned after coronary surgery for reintervention procedures. This reflects immediate postsurgical complications and the relentless progression of coronary artery disease in the native circulation and in the bypass grafts. Although there are randomized comparative data for coronary bypass surgery (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) and medical therapy, these trials have always excluded patients with previous (GABG). OBJECTIVES: We attempted to compare the risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). METHODS AND RESULTS: This study examines follow up data (15.4 +/- 11.0 months) from 130 patients with previous CABG, who required either PTCA (Group A, n = 73) or re-CABG (Group B; n = 57) at a single center from 1994 to 1997. Follow up data were obtained from subsequent office visits and telephone calls. The PTCA and re-CABG groups were similar with respect to gender (86% vs 94% males), mean age (62 +/- 9 vs 59 +/- 10 years), angina CCS classes 3 and 4 (73% vs 69%), diminished left ventricular function (23% vs 26%), risk factors such as diabetes (19% vs 17%), hypercolesterolemia (49% vs 45%) and smoking (48% vs 39%) and three-vessel native coronary artery disease (67% vs 72%). The symptomatic status prior to the revascularization procedure was similar in both groups. Complete and functional revascularization was achieved in 85% of the PTCA group and in 92% of those with re-CABG (p = NS). During the hospital stay the complication rates were lower in the PTCA group. Actuarial survival was different at follow up (p = 0.04). Both PTCA and re-CABG groups resulted in equivalent event-free survival (freedom from death, myocardial infarction, unstable angina and urgent revascularization). The need for repeat revascularization at follow up was significantly higher in the PTCA group (PTCA 28% vs re-CABG 10%, p < 0.01). CONCLUSIONS: In this non-randomized study of patients with previous CABG requiring revascularization procedures, PTCA resulted in lower procedural morbidity and mortality risks. At follow up, both PTCA or CABG were similar for event-free survival; PTCA offered lower overall mortality, although it is associated to a greater need for subsequent revascularization procedures.     

Repeat coronary artery bypass grafting

Repeat coronary bypass grafting was performed in 19 patients. The mean age was 59.8 +/- 6.9 years, 26% being female. One or more coronary risk factors were observed in 10 to 37% and none in 37%. The mean interval from the initial procedure was 35.6 +/- 34.4 months, but 42% of patients were reoperated within one year. Eleven patients had unstable angina two requiring emergency surgery to achieve hemodynamic stabilization. A mean of 2.63 grafts/patient achieved 87.7% revascularization. Two patients died late postoperatively from surgical complications. Sixteen patients consented to have postoperative coronary angiography: IMA was used as conduit in one third of the grafts and had a patency of 100% (15/15), compared to 86.7% of the venous grafts (26/30), for an overall patency of 91%. Follow up for 1 to 65 months (28.2 +/- 20.1 months) showed that 75% (12/16) are asymptomatic, and 4 patients (25%) have mild angina (NYHA II). Three of these 4 patients with recurrent angina have evidence of incomplete revascularization. Thus, repeat coronary bypass operation can be offered with acceptably low risk, and the long term benefits are similar to those obtained with primary operation providing complete revascularization is achieved, preferably with multiple internal mammary artery grafting techniques.     

Survival 15 to 20 years after coronary bypass surgery for angina

OBJECTIVES: The aim of this study was to determine the 15- to 20-year outcome of coronary bypass surgery in patients with angina. BACKGROUND: Coronary bypass surgery has been performed for > 20 years; we need to know the expected outcome of a very long-term follow-up. METHODS: Using actuarial techniques, we determined the outcome of coronary bypass surgery performed for chronic stable and unstable angina in 7,529 patients from 1969 to 1988. RESULTS: The 5-, 10-, 15- and 20-year survival rates (mean +/- SE) were 88 +/- 1, 73 +/- 1, 53 +/- 1 and 38 +/- 3%, respectively, for the whole group. Compared with patients operated on in 1974 to 1988 (n = 7,026), patients operated on in 1969 to 1973 (n = 503) were younger and had less coronary artery disease but had a higher operative mortality rate and a shorter long-term survival time; 15- and 20-year survival of the 1969 to 1973 cohort was 47 +/- 2% and 33 +/- 3%, respectively. The 1974 to 1988 cohort of patients had a 2.1% operative mortality rate and a 10- and 15-year survival probability of 74 +/- 1% and 55 +/- 2%, respectively. For 2,128 patients with "normal" left ventricular function, the 10- and 15-year survival probability was 82 +/- 1% and 64 +/- 3%, respectively, and for 2,413 patients with "abnormal" left ventricular function, it was 66 +/- 1% and 47 +/- 3%, respectively (p < 0.0001); for men it was 74 +/- 1% and 56 +/- 2%, respectively, and for women, 70 +/- 2% and 52 +/- 5%, respectively, p < 0.05. The actuarial percentages of reoperation and myocardial infarction at 15 years were 33 +/- 2% and 26 +/- 2%, respectively; these values did not differ significantly between men and women. There was a significant (p < 0.001) difference between men and women in angina status; 81% of the men versus 74% of the women had no angina or mild angina at the most recent follow-up study. CONCLUSIONS: Coronary bypass surgery is an effective form of therapy for angina (for 15 to 20 years) in both men and women.     

Intra-arterial blood pressure during exercise and left ventricular indices in normotension and borderline and mild hypertension

OBJECTIVE: To determine whether a sex-related difference in outcome is present among patients who undergo percutaneous transluminal coronary angioplasty (PTCA) for unstable angina. DESIGN: We retrospectively analyzed the results after PTCA was performed between January 1981 and June 1993 in a series of 2,073 men and 941 women with unstable angina and rest pain. RESULTS: The success rates of PTCA were similar for women and men (87.9% and 87.2%, respectively), as were the in-hospital mortality rates (4.1% and 3.2%, respectively) and the need for emergency coronary artery bypass operation (3.1% and 3.5%, respectively). Fewer women than men had Q-wave myocardial infarction (0.5% versus 1.6%; P = 0.02). During the follow-up period (mean, 4 years), no significant differences were noted between women and men in overall survival (81% and 85% at 6 years, respectively) or survival free of Q-wave myocardial infarction (81% and 83% at 6 years, respectively) with use of the Kaplan-Meier method. Women were less likely than men to have had coronary artery bypass grafting (19% versus 22% at 6 years; P = 0.02), and the occurrence of severe angina was higher in women than in men (52% versus 44% at 6 years; P = 0.001). A subgroup analysis of patients who had myocardial infarction within 7 days preceding PTCA showed a similar pattern of results. CONCLUSION: After PTCA performed for unstable angina and rest pain, survival rates were excellent in both women and men, and no difference was observed in subsequent myocardial infarction rates. During follow-up, however, women were more likely to have severe angina and were less likely to have had coronary artery bypass grafting. Concerns about possible sex-related complications should not dissuade physicians from performing PTCA when clinically indicated for unstable angina and rest pain.     

Paradigms and expectations: the nature of research and diagnostics

OBJECTIVES: Our purpose was to evaluate the long-term benefit of myocardial viability assessment for stratifying risk and selecting patients with low ejection fraction for coronary artery bypass grafting and to determine the relation between the severity of anginal symptoms, the amount of ischemic myocardium, and clinical outcome. METHODS: We studied 93 consecutive patients with severe coronary artery disease and low ejection fraction (median, 25%) who underwent positron emission tomography to delineate the extent of perfusion-metabolism mismatch (reflecting hibernating myocardium) for potential myocardial revascularization. Median follow-up was 4 years (range, 0 to 6.2 years). RESULTS: Fifty patients received medical therapy, and 43 patients underwent bypass grafting. In Cox survival models, heart failure class, prior myocardial infarction, and positron emission tomographic mismatch were the best predictors of survival. Patients with positron emission tomographic mismatch receiving bypass grafting had improved 4-year survival compared with those on medical therapy (75% versus 30%; P =.007) and a significant improvement in angina and heart failure symptoms. In patients without positron emission tomographic mismatch, bypass grafting tended to improve survival and symptoms only in those patients with severe angina (100% versus 60%; P =.085), whereas no survival advantage was apparent in patients with minimal or no anginal symptoms (63% versus 52%; P =.462). CONCLUSIONS: Patients with low ejection fraction and evidence of viable myocardium by positron emission tomography have improved survival and symptoms with coronary bypass grafting compared with medical therapy. In patients without evidence of viability, survival and symptom improvement with bypass grafting are apparent only among those patients with severe angina.     

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.     

Management of patients with unstable angina in a general cardiology unit

AIMS: To review the clinical management of patients with unstable angina and to relate prospectively initial risk stratification, according to the Braunwald criteria, to subsequent cardiovascular events. METHODS: From February to April 1996 we performed a three month prospective review of all patients with a diagnosis of unstable angina admitted to the coronary care unit at Auckland Hospital. RESULTS: One hundred and four patients (61% male), with a mean age of 64 years, were classified as high (58%), intermediate (41%) or low risk (1%) for an adverse cardiac event. Twelve (12%) patients had a documented myocardial infarction, of whom 11 were in the high-risk group (p = 0.038). During hospitalisation there was one death. Twelve (12%) patients underwent inpatient exercise testing, five of whom proceeded to a coronary angiogram prior to hospital discharge. Twenty-two (21%) unstable patients underwent inpatient angiography without prior exercise testing. Twenty-one (20%) patients required revascularisation on the same admission: percutaneous coronary angioplasty (n = 14) or coronary artery bypass grafting (n = 7). Twelve of these 21 patients were in the high-risk group (p = 0.999, NS). CONCLUSION: Patients admitted with unstable angina had low inpatient mortality but a 12% rate of subsequent myocardial infarction. Braunwald low-risk unstable angina patients were not admitted to the coronary care unit. Braunwald high-risk patients were more likely to develop a subsequent myocardial infarction. Stratification of patients into intermediate or high-risk groups did not relate to initial medical management or subsequent revascularisation. Thus, while this method of risk stratification may predict cardiovascular events, it may be of limited clinical use in the New Zealand environment.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

Coronary artery reoperation

Coronary artery reoperation has been performed in 51 patients (4%) including 5 second reoperations among 1,245 CABGs during past 9 years. There were 40 males and 11 females with a mean age of 58 year old ranging from 19 to 75 year old. Extent of coronary artery disease were; single vessel disease in 2 patients, double vessel disease in 18 patients, triple vessel disease in 22 patients and left main disease in 9 patients. Preoperative ejection fraction ranged from 0.24 to 0.69 (mean 0.48) and 21 patients (41%) showed unstable angina. Interval between primary CABG and reoperation ranged from 1 month to 20 years with a mean of 6 years. There were two groups which had early reoperation at the mean of 6 months (14 patients) and late reoperation at the mean of 9 years (37 patients) after primary CABG. Causes of reoperation varied from graft failure (29 patients), progression of native CAD (2 patients), both of them (19 patients), and incomplete revascularization (1 patient). There were 32 patients who had patent old graft at the time of reoperation. Re-entry approaches used were midsternal in 41 patients and left thoracotomy in 10 patients. The ITA, GEA, IEA and SV grafts were used in 30, 38, 5 and 28 patients, respectively. There were 4 patients who underwent CABG without cardiopulmonary bypass. The mean number of bypass was 2.1 and the mean duration of aortic crossclamp and cardiopulmonary bypass were 63 minutes and 114 minutes, respectively. As a result, there were 4 early and 1 late death. Postoperative angiography revealed that patency rate of ITA, GEA, IEA and SV grafts were 100% (22/22), 97% (30/31), 75% (3/4) and 87% (20/23), respectively. In conclusion, risk of coronary artery reoperation is still high and use of arterial graft is important to obtain high patency rate and low reoperation rate.     

Revascularization of the circumflex artery with mechanical stabilization: initial experience

OBJECTIVES: To evaluate the short-term result of the coronary artery revascularization without cardiopulmonary bypass for triple vessel disease, including the circumflex territory performed on the stabilized beating heart. METHODS: Prospective study conducted on the first 35 consecutive patients with triple vessel disease operated upon without cardiopulmonary bypass by a single surgeon (RC) at the Montreal Heart Institute between October 1996 and March 1997. RESULTS: Mean age of patients was 64 +/-1.6 years and the majority were men (30). Most common risk factors were hypercholesterolemia (65%) and familial history (55%) of ischemic heart disease. Main surgical indication was unstable angina (74%) and mean preoperative left ventricular ejection fraction was 53 +/- 3%. Hundred and twelve bypass were constructed averaging 3.2 +/- 0.1 grafts/patients of which 39 were made on branches of the circumflex artery. Average ischemic time was 34.17 +/- 2.17 minutes. The internal thoracic artery, saphenous vein, and radial artery were used as a vascular conduit in 44, 67, and 1 occasions respectively. There was one operative mortality, and one non Q perioperative myocardial infarction (CK-MB: 89 U/L). No patient required aortic counterpulsation balloon assistance. The average postoperative CK-MB (U/L) were 12.2 +/- 1.9, 15.2 +/- 3.2, and 10.3 +/- 1.7 at 1, 24 and 48 hours respectively. During the post-operative period 26% (9) of the patients presented atrial fibrillation, 6.5% (2) early reexploration for bleeding, and 63% (22) did not require transfusion. Average stay in hospital was 6.1 +/- 45 days. Coronary grafts were angiographically assessed in the first 10 patients and at the postmortem exam in one and displayed a 100% patency with 93.5% (29/31) adequate runoff. Conclusion: Triple vessel coronary artery disease revascularization is feasible on the beating heart without cardiopulmonary bypass with excellent short-term clinical and angiographic results.     

Validation of an LC-MS assay for the quantification of the enantiomers of Org 4428 in human plasma

OBJECTIVE: The aim of this study was to assess the long-term results of use of the radial artery as a conduit for coronary artery bypass grafting. METHODS: After revival of the technique in 1989, the radial artery was used as a conduit in 910 patients undergoing coronary artery bypass grafting. A complete follow-up was obtained for the first 102 consecutive patients from 4 to 7 years after the operation (mean 5.27 +/- 1.30 years). Fifty-nine percent of the patients were receiving calcium-channel inhibitors. An electrocardiographic stress test was obtained for 51 patients, with no contraindications found. Routine follow-up angiography was performed in 50 cases, including those of all patients with symptoms. Thus 64 radial artery and 48 left internal thoracic artery grafts were followed up from 4 to 7 years after the operation (mean 5.6 +/- 1.40 years). RESULTS: The actuarial survival was 91.6% at 5 years, and the actuarial rate of freedom from angina was 88.7% at 5 years. Four patients underwent percutaneous transluminal angioplasty during the period of follow-up, and there were no reoperations for revision of the bypass. The electrocardiographic stress test showed negative results in 73% of cases, electrocardiographic changes alone in 21%, and clinically positive results in 6%. Angiography showed that the patency rate of the radial artery grafts was 83%. The patency rate of the left internal thoracic artery grafts (n = 47) was 91%. The difference in patency could be related to the implantation sites of the grafts, mainly the circumflex artery (51%) for the radial artery grafts and almost exclusively the left anterior descending artery (94%) for the left internal thoracic artery. CONCLUSION: The use of the radial artery for coronary bypass grafting provides excellent clinical and angiographic results at 5 years. Routine use of the radial artery in combination with the left internal thoracic artery can be recommended.     

A case of de novo translocation 16;21: trisomy 16q phenotype and origin of the aberration

We reviewed our experience over a 12 month period with using minimally invasive direct coronary artery bypass (MIDCAB) for the management of high-risk patients with three-vessel coronary artery disease. Twenty patients (4 females, mean age 67 years) received left internal mammary artery (LIMA) grafts to the left anterior descending (LAD) coronary artery. Associated co-morbidity included: severe chronic renal failure, severe extensive arteriopathy, chronic obstructive airway disease, poor general condition and severely impaired left ventricular function. There was one early postoperative mortality and no other cardiac-related morbidity. Graft patency investigated, using angiography was 90%, and 5 patients underwent follow-up angioplasty to other coronary arteries. All patients remain entirely angina free at a follow-up period between 3 and 12 months. We conclude that MIDCAB is a safe and effective approach for managing high-risk patients with three-vessel coronary artery disease.     

Hepatolithiasis, a clinical study

To examine the value of transient regional asynergy on dobutamine stress echocardiography as a noninvasive predictor of future cardiac events, 51 symptomatic patients (aged 54 +/- 9 years) with suspected coronary artery disease (CAD) were studied using an incremental regimen of 5, 10, 15 and 20 micrograms/kg/min. Pretest likelihood of CAD was (mean +/- standard error of the percentage) 79.7 +/- 5.6% before and 83.4 +/- 5.2% after exercise electrocardiography using probability analysis based on age, sex and symptoms. Two-dimensional images were analyzed with reference to an 11-segment model and gave good interrater agreement. During 24 +/- 4 months (range 19 to 32) of follow-up, 23 patients had events (1 myocardial infarction, 9 unstable angina, 10 coronary bypass surgery, 3 coronary angioplasty) and 28 were event free. Age, proportion with baseline asynergy and both pretest echocardiographic ejection fraction and its response to dobutamine were similar in these 2 groups (all p = not significant). Transient asynergy was seen in 17 of 23 patients (74%) with and 8 of 28 patients (29%) without events (p < 0.01); 5 of 6 patients (83%) with involvement of 3 segments had events. Myocardial infarction or unstable angina occurred in 8 of 25 (32%) with a positive and 2 of 26 (8%) with a negative stress echocardiogram (p < 0.05). Both exercise duration (389 +/- 195 vs 517 +/- 237 seconds, p < 0.05) and time to diagnostic ST-segment shift (291 +/- 192 vs 447 +/- 212 seconds, p = 0.05) were shorter in those with inducible asynergy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary artery bypass grafting in cases with poor left ventricular function

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.     

Late survival after valve operation in patients with left ventricular dysfunction

BACKGROUND: Left ventricular dysfunction is a predictor of hospital mortality after cardiac valve operation. We evaluated late survival in a large cohort of these patients. METHODS: From 1980 to 1993, 257 patients with a preoperative ejection fraction of 0.40 or less underwent aortic (n = 177), mitral (n = 72), or combined (n = 8) valve operation, with or without concomitant coronary artery bypass grafting. RESULTS: Hospital mortality was 12.5%. Follow-up was 98% complete. Logistic regression analysis showed that an ejection fraction of less than 0.30, mitral regurgitation, concomitant coronary artery bypass grafting, emergency operation, and reoperation were independent correlates of hospital mortality (all at p < 0.05). Kaplan-Meier survival curves of the 220 hospital survivors showed a 65% 5-year survival. Multivariate analysis revealed preoperative use of diuretics, male sex, reoperation, age exceeding 60 years, and aortic regurgitation to be independent predictors of poor late outcome (all at p < 0.05). CONCLUSIONS: The liability of left ventricular dysfunction with regard to diminished long-term survival is not completely reversed by valve operation. If operation is not performed before left ventricular dysfunction develops, postoperative medical treatment of these dilated, remodeled ventricles should be considered.     

Long-term follow-up of a high risk cohort after stent implantation in saphenous vein grafts

OBJECTIVES: We sought to provide short- and long-term clinical outcomes of a high risk cohort treated with stents in saphenous vein grafts (SVGs). BACKGROUND: Data on the long-term outcome of SVG stenting in high risk patients are limited. METHODS: Johnson & Johnson stents were implanted in the SVGs of 186 patients (302 stents, 244 lesions). Ninety percent of patients presented with myocardial infarction (MI) or unstable angina (mean +/- SD ejection fraction [EF] 44 +/- 11%, patient age 71 +/- 9 years, graft age 9.4 +/- 5 years). Using a risk score classification, 155 patients (83%) were defined as high risk for repeat surgical repair or angioplasty. RESULTS: The procedural success rate was 97.3%, with 2.7% major complications (death, Q wave MI, coronary artery bypass graft surgery [CABG]). Clinical follow-up was obtained in 177 patients (mean 19.1 +/- 13.5 months, range 7 to 59). Event rates were 10% for death; 9% for MI; 11% for repeat CABG; and 15% for repeat angioplasty (total events 45%). Kaplan-Meier estimated survival and event-free survival at 4 years were 0.79 +/- 0.06 and 0.29 +/- 0.07, respectively. Predictors of death were congestive heart failure (p < 0.01) and EF <44% (p < 0.05). Predictors of combined events of death, MI and CABG were low EF (p < 0.01) and high SVG age (>10 years, p < 0.01). There were 66 revascularization procedures (35% of patients), 24% of which were in nontarget lesions. Fifty-three percent of the cardiac events occurred during the first year of follow-up. Of the 160 survivors, 36% were free of angina, 49% were in Canadian Cardiovascular Society functional class I or II, and 15% were in class III or IV. Sixty-nine percent of patients were in class I or II according to the Specific Activity Scale, and 31% of patients were in class III or IV. CONCLUSIONS: Balloon-expandable stent implantation in the SVGs of high risk patients is associated with a low early complication rate. Expected survival rates are good, as are the anginal and functional classifications, but there is a high rate of recurrent events and need for repeat revascularization. Vein graft stenting is an acceptable palliative option in many high risk patients.