Aortocoronary bypass grafting in patients without left main stenosis. Relation of risk factors to early and late survival.

Three-hundred and thirty-five patients without left main stenosis or recent acute myocardial infarction underwent isolated aortocoronary bypass grafting during 1974 and 1975. The hospital mortality was 2 per cent for the four-year predicted survival is 94 per cent. Neither the preoperative presence or absence of a progressive or unstable angina pattern, the extent of coronary artery disease, nor the left ventricular ejection fraction predicted postoperative survival. None of the 25 patients whose ejection fraction was 0.30 or less died in the perioperative period, and no late deaths occurred in this subgroup until after 36 months of follow-up, giving a predicted four-year survival rate of 82 per cent. With only one exception, patients in this subgroup were operated on because of angina, which was unstable in three-quarters of them. We believe that this study shows that patients with a severely reduced ejection fraction should not be refused aortocoronary bypass grafting if symptoms of angina are severe and predominate over symptoms of heart failure.     

Efficacy of coronary artery bypass grafting in elderly patients with coronary artery disease

A consecutive series of 121 patients 70 years of age and older who underwent aortocoronary artery saphenous vein bypass grafting without other cardiac procedures during a 5 year period was analyzed and follow-up status ascertained. This group was compared with a consecutive series of 2,850 patients under the age of 70 who underwent aortocoronary bypass during the same period. The patients aged 70 years or greater had a higher incidence of unstable angina pectoris, congestive heart fallure and cardlomegaly on roentgenography. They had more severe coronary obstruction with a 29 percent incidence rate of left main coronary disease versus a 15 percent incidence rate in the patients aged less than 70 years (P < 0.001). The hospital mortality rate for patients aged less than 70 years was 1.1 percent (31 of 2,850) and for those aged 70 years or greater was 1.6 percent (2 of 121). The 119 patients aged 70 years or greater who survived surgery had a significantly greater incidence of postoperative stroke (3 patients), supraventricular tachycardia (28 patients), transient postoperative psychosis (9 patients), heart block requiring permanent pacing (2 patients), intraaortic balloon pumping (5 patients) and pulmonary embolism (4 patients) than patients aged less than 70 years. Both groups had significant symptomatic improvement: More than 95 percent of the survivors in each group were angina-free or in improved condition at late follow-up. Survival at 36 months was 95 percent for the patients in both age groups. A subgroup of patients aged 75 years or greater had comparable symptomatic results and survival. Patients aged 70 years or greater need not be denied the benefits of coronary bypass surgery on the basis of advanced age alone, although these patients have complfcations of surgery more frequently. However, severe calcification of the ascending aorta is a relative contraindication to saphenous vein bypass surgery in this age group.     

Myocardial revascularization in patients with severe ventricular impairment. Short-term follow-up

To assess the influence of aorto-coronary bypass grafting on surgical risk and short-term survival of patients with marked impairment of left ventricular (LV) function, we evaluated--among 435 patients who underwent coronary bypass surgery between January 1981 and December 1982--22 cases with: LV ejection fraction (EF) less than or equal to 0.35 (mean 0.27 +/- 0.06), LV end-diastolic pressure greater than or equal to 15 mmHg (mean 19.9 +/- 6.9 mmHg.), presence of three or more dysfunctional (hypokinetic or akinetic) segments on biplane LV angiography, three vessels disease in 90.1%. All patients but two had angina refractory to medical therapy. Operative mortality rate was 4.5%. Perioperative non fatal infarction rate was 9.1%. There were three late deaths. Mean duration of follow-up was 10.5 +/- 8.3 months with a survival of 81.8%. In the survivors we observed: dramatic improvement in respect to angina (94.5% are asymptomatic) and quality of life; exercise performance improvement (75% of patients have a functional impairment less than or equal to 30% at treadmill test); significant improvement in global and segmental LV function (mean echocardiographic EF 0.37 +/- 0.10, p less than 0.001). Because of relative low surgical risk and encouraging short-term results, aortocoronary bypass grafting can be performed even in patients with important LV disfunction, when associated with severe angina.     

Aortocoronary bypass in the diabetic patient

One hundred twelve patients undergoing aortocoronary bypass—35 with diabetes of adult onset and 77 without diabetes—were studied to determine whether diabetic patients have additional operative risks and greater operative mortality and whether their coronary disease differs from that of nondiabetic patients. Among the diabetic patients there was a greater prevalence of preoperative unstable angina, prior myocardial infarction and class IV functional disability (New York Heart Association criteria). The major coronary arteries angiographically and at operation appeared similar in both groups. The blood flow rates measured in aortocoronary bypass vein grafts were similar in both groups, raising doubt about the presence of microvascular disease in the myocardium of the diabetic patient. Preliminary follow-up results demonstrated relief of anginal symptoms in 76 percent of diabetic and 78 percent of nondiabetic patients. The operative mortality rate of 9 percent in diabetic and 4 percent in nondiabetic patients occurred among the first 40 patients in the series; no patient in either group has died in the immediate postoperative period during the last 18 months of the study.

Aortocoronary bypass should be recommended to diabetic patients with symptomatic coronary arteriosclerosis using the same criteria for operability applied to the nondiabetic population.     

Aorto-coronary bypass surgery in 62 patients with severe left ventricular dysfunction--a follow-up study

Long-term follow-up of 62 consecutive patients with severe left ventricular dysfunction (ejection fraction = less than 0.30) and disabling angina pectoris following aorto-coronary bypass surgery was investigated. Prior to surgery all patients had angina pectoris and a history of remote myocardial infarction, 35% were in congestive heart failure (CHF). Significant stenoses in 3 major coronary vessels were present in 51 patients (82%). An average of 3.5 grafts per patient were employed. Operative mortality (30 days) rate was 4.8% (3 patients) and 13 patients died during the following period. The average follow-up was 37 months (range: 6 to 116 months). At follow-up, the 5-year survival probability for these patients was 70% (SD = 9%). Thirty-one patients (67%) of the 46 survivors had complete relief of angina, but signs of CHF were still evident in 17 patients (36%). Compared to patients with ejection fractions above 0.30% (surgical mortality 1.4% and 5-year survival rate 94% (SD = 3%] the outcome of coronary artery bypass grafting in patients with poor left ventricular function showed a significantly higher surgical mortality (P = 0.03) and impaired long-term survival (P = 0.02). However, aorto-coronary bypass grafting can be performed in patients with severe left ventricular dysfunction with reasonable relief of angina and with an acceptable surgical mortality.     

Clinical outcome 5 years after attempted percutaneous transluminal coronary angioplasty in 427 patients

This study was performed to define the 5 year clinical status of 427 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in 1981. Their mean age was 54 +/- 10 years (+/- 1 SD). Sixty-one percent had unstable angina, 23% had prior myocardial infarction, 86% had one-vessel disease, and 92% had normal left ventricular function. Sixty-seven percent of patients had left anterior descending artery stenosis. Angiographic success was achieved in 84% of patients. Coronary bypass surgery was required in 9.6% of patients, in 5.9% as an emergency procedure. There were no in-hospital deaths. Follow-up at 5 years was 100% complete. There were 15 late deaths (96.3 +/- 1.0% survival), including seven of cardiac cause (98.1 +/- 0.7% cardiac survival). Myocardial infarction occurred in 24 patients (94% freedom from myocardial infarction), coronary bypass surgery was required in 63 (84% freedom from bypass surgery), and 365 patients (85%) were asymptomatic at follow-up. At 5 years, 83 patients (20%) had required an additional PTCA. Unstable angina pectoris and proximal left anterior descending coronary artery stenoses were present in 162 patients. The overall survival and cardiac survival in this subset was 94.4 +/- 1.8% and 98.1 +/- 1.1%, respectively. The excellent survival and low event rates over 5 years in this population support the concept that PTCA is safe and effective for patients with symptomatic angina pectoris, single-vessel disease, and normal left ventricular function.     

The long-term results of aortocoronary bypass surgery in patients with a severe preoperative left ventricular dysfunction]

We analyze retrospectively the short- and long-term results of coronary artery bypass surgery in 50 patients with severe left ventricular dysfunction operated in a period of 11 years. Sixty-six percent of patients had unstable angina and 12% of total presented angina post-acute postmyocardial infarction. Thirty-eight percent of patients were in preoperative functional class III-IV of NYHA. Three-vessel disease was present in 70% of the patients, two-vessel in 30%, and the main trunk was affected in 12% of the global. Hospital mortality was 4% (2/50) due to low cardiac output syndrome. Follow-up was available in all the survivors and ranged 6 months-11 years (mean: 4.8 +/- 3.1). During follow-up, 13 patients died, but in only six was due to cardiac cause. The 35 patients followed were in functional class I-II of NYHA. Eighty-eight percent of the patients were angina free at follow-up. Actuarial analysis, after exclusion of 3 patients who died of causes no directly related to the heart, showed an intrahospital survival rates of 96%; at first year was 92, at 3rd was 78%, and 5th year survival rates were 75%. In conclusion, patients with symptomatic angina and preoperative severe left ventricular dysfunction, coronary artery bypass graft has a low hospital mortality, is effective in improving angina and heart failure, and the long-term survival is acceptable.     

Surgical versus medical treatment of occlusive disease confined to the left anterior descending coronary artery

The results of saphenous vein bypass grafting and medical treatment were compared in 53 patients with stable angina pectoris, high grade occlusive disease confined to the left anterior descending coronary artery and normal or minimally impaired left ventricular function. Survival, incidence of myocardial infarction, relief of angina and response to exercise testing were evaluated. In the 29 surgically treated patients, followed up a mean of 24 months, there were two late deaths (7 percent) and five myocardial infarctions (17 percent). Twelve patients (41 percent) were free of angina and the majority had increased exercise performance when tested up to 18 months postoperatively. In the 24 medically treated patients, there were no deaths and one myocardial infarction (4 percent) in a mean follow-up period of 37 months. Six patients (25 percent) were free of angina. Less improvement in exercise performance was observed than in the surgically treated group.

This subset of patients with isolated left anterior descending coronary artery disease has a favorable prognosis that is not enhanced by bypass grafting. Surgical treatment is more effective than medical treatment in relieving angina and improving exercise performance in the early years after coronary arteriography.     

Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function

Late survival and freedom from myocardial infarction were determined for 192 patients with coronary artery disease and depressed left ventricular ejection fraction at rest (less than or equal to 35%) determined by biplane angiography who were evaluated between 1970 and 1977. Seventy-seven patients had coronary artery bypass grafting and 115 patients were treated medically and were considered surgical candidates. The medical and surgical groups were comparable in all baseline characteristics examined except frequency of three vessel disease and angina pectoris, which occurred in a significantly greater percent of the surgically treated patients (p less than 0.01). Only three medically treated patients (2.6%) underwent coronary bypass grafting in the follow-up period. Seven year actuarial survival was 63% in the surgical and 34% in the medical group (p less than 0.001). Ninety-three percent of patients in the surgical group and 81% of those in the medical group were free of nonfatal myocardial infarction (p = 0.01), and 62 and 33%, respectively, were alive and free of myocardial infarction (p less than 0.001) at 7 years. Significant differences in survival favoring surgical treatment were observed for the subsets of patients with an ejection fraction of 25% or less (p = 0.0002) and 26 to 35% (p = 0.01), and for the subsets with three vessel coronary disease (p less than 0.001), normal left ventricular end-diastolic volume (less than or equal to 100 ml/m2) (p = 0.005) and elevated end-diastolic volume (greater than 100 ml/m2)(p = 0.001). After adjustment for other important prognostic variables, the type of treatment remained significant in predicting the relative risk (medical to surgical) of mortality at 5 and 7 years (2.58 and 2.12, respectively). These data corroborate the trends observed in several randomized trials of medical and surgical therapy in patients with abnormal left ventricular function. If hospital mortality for coronary artery bypass grafting is less than 5%, substantial benefit can be anticipated for the majority of patients with depressed ventricular function.     

Long-term clinical results after intervention using aorto-coronary bypass

The survival and symptoms of 294 consecutive patients discharged from the hospital after isolated coronary artery bypass grafting from 1970 to 1975 were evaluated 6 to 10 years after surgery. The actuarial 10 years expectancy of cardiac death as 10.0 +/- 2.4% the non fatal myocardial infarction one was 11.2 +/- 2.8; the yearly probability of severe ischemic event therefore was 2.1%. One year after surgery, 56% patients were free from angina, 31% improved and only 7% symptomatically unchanged. These percentages became 45%, 26% and 13% respectively at the end of the follow-up, thus showing a definite though slight deterioration. Clinical status one year after operation was predictive of further evolution: only 6.2% of the symptom-free patients developed severe ischemic events, as opposed to 20% of the highly symptomatic ones. The actuarially determined curve of recurrence of angina in the patients asymptomatic at the first control shows, after 2 years of steady state, a progressive upslope which reaches 40% by the 7th year and 90% at the 10th year of follow-up. Subgroup analysis indicated that long term prognosis is influenced by the presence of left main stenosis and by perioperative myocardial damage. Clinical results at one year are influenced by completeness of revascularization, graft patency and perioperative myocardial infarction. The tendency of symptoms to recur in patients who are free from angina one year after intervention, is similar in the various subgroups and is adversely influenced only by perioperative myocardial damage. These results show that coronary artery bypass grafting has a true clinical impact, although symptomatic improvement is somewhat temporary.     

Long-term results of myocardial revascularization

During 1970 to 1977, among 1,733 patients who underwent isolated coronary bypass grafting, the operative mortality was 2.5 percent. Actuarial 5 year survival is 88.1 percent. At an average follow-up of 46 months (range 13 to 108), 90 percent of patients remain angina-free or with symptomatic improvement. The 5 year survival rate of patients with single vessel coronary artery disease is 97.9 percent. In patients with multivessel disease, operative survival appears to be favorably influenced by the presence of normal preoperative ventricular function. Late survival is significantly better in patients with multivessel disease with normal preoperative ventricular function or with complete revascularization. Risk of perioperative myocardial infarction has been appreciably reduced by the introduction of cold potassium chloride cardioplegia. Late myocardial infarction has occurred at an average annual risk of 1.46 percent. These data show that long-term survival and a small incidence of late myocardial infarction after myocardial revascularization are more likely in patients who undergo complete revascularization before significant left ventricular myocardial damage has occurred.     

Ischemic cardiomyopathy: the myopathy of coronary artery disease. Natural history and results of medical versus surgical treatment

Clinical, hemodynamic and angiographic data were analyzed in 66 patients with coronary artery disease and severe generalized left ventricular dysfunction (ischemic cardiomyopathy) in order to determine their prognosis and examine the results of medical and surgical management. Seventy-six percent of patients had angina, 85 percent a history of one or more myocardial infarctions, 73 percent cardiomegaly, 38 percent mitral regurgitation, 98 percent severe stenosis of two or three major coronary arteries, and 100 percent a left ventricular ejection fraction of 25 percent or less.Forty-two patients were managed medically, and 24 surgically with aortocoronary bypass grafts or ventricular plication, or both. The clinical and hemodynamic findings in both groups were nearly identical. In a follow-up period of 12 months, the mortality rate was 31 percent in the medical group and 50 percent in the surgical group, with 83 percent of the surgical deaths occurring within 1 month of operation. There was no significant difference in the functional status of medical and surgical survivors. Regardless of therapy, patients with mitral regurgitation or a left ventricular end-diastolic pressure of 24 mm Hg or greater had a significantly higher mortality rate than patients without these findings. This study indicates that patients with ischemic cardiomyopathy have a poor prognosis, and surgical intervention with current available techniques has a high operative mortality rate without significantly altering the symptoms in the survivors.     

Asymptomatic myocardial ischemia as a predictor of cardiac events after coronary artery bypass grafting for stable angina pectoris

Thirty-six patients with chronic stable angina were studied before and after coronary artery bypass grafting (CABG) to assess the prevalence and prognostic implications of asymptomatic myocardial ischemia obtained by ambulatory monitoring. Ambulatory monitoring performed during medical therapy before CABG detected 66 episodes of transient ischemia, 54 (82%) being asymptomatic. All patients were asymptomatic or with minimal symptoms 3 months after CABG. Additional ambulatory monitoring was performed for 36 hours. There were 39 episodes of silent ischemia detected in the 12 patients of group 1, whereas no episodes of ST-segment shift occurred in the 24 patients of group 2. Coronary artery bypass grafting reduced the frequency of transient ischemia by 41% (p less than 0.05) compared with medical therapy, whereas the number of ischemic episodes in group 1 increased from 23 during medical therapy to 39 episodes after CABG (41%, p less than 0.05). During a follow-up of 9 months, 8 cardiac events occurred: 6 in group 1 comprising sudden death (1), revascularization (2), and angina (3) and 2 in group 2, including revascularization (1) and angina (1) (p = 0.005). Kaplan-Meier analysis demonstrated that asymptomatic myocardial ischemia was correlated with a significant cumulative probability of cardiac events (p less than 0.025) and multivariate analysis of 11 variables showed that silent ischemia was the most powerful predictor of cardiac events (p less than 0.005). Silent ischemia was a forerunner for angina pectoris in some patients, whereas angina did not occur during the follow-up period in others. This study does not reveal whether or not these patients are at higher risk for cardiac events during long-term follow-up.     

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting: ten years' experience

We evaluated the acute and long-term results of percutaneous transluminal coronary angioplasty in 140 patients with prior coronary artery bypass grafting treated over a 10-year period (1981–1991). Angioplasty was technically successful in 85% of 122 nonoccluded native vessels and in 86% of 50 saphenous vein grafts. Two patients (1.4%) had a myocardial infarction and there were three procedure-related deaths (2.1%). The cumulative probability of survival was 91.5% and 74.5% at 1 and 5 years, respectively. Survival free from myocardial infarction and repeat bypass grafting at 1 and 5 years was 77.3% and 53.9%, respectively. At census, 31% of the 117 survivors were asymptomatic, and 47% were improved by at least two angina grades. Coronary angioplasty provides an apparently safe and effective alternative method of revascularization in selected patients with prior coronary artery bypass grafting. This treatment strategy potentially avoids reoperation with its attendant risks. © 1994 Wiley-Liss, Inc.     

Complete surgical revascularization: the treatment of choice in young patients with multivessel coronary disease

Since the advent of coronary angioplasty, nonoperative techniques to manage coronary artery disease have become attractive alternatives to coronary artery bypass grafting (CABG). To provide a standard against which new procedures could be judged, 123 consecutive patients less than 45 years of age who have had CABG since 1978 were systematically followed. The indications for operation were unstable angina or postinfarction angina (60%), life-threatening coronary anatomy with stable angine (36%), and sudden death or uncontrolled ventricular tachycardia (4%). Seventy-five patients had documented preoperative myocardial infarction, 55% within 30 days of CABG. An average of 3.2 vessels were grafted per patient; only 10 had single CABG. Complete revascularization was accomplished in 91% of patients. Five patients (4%) had myocardial infarction within 30 days of operation. No operative deaths or strokes occurred. The 6-year follow-up was 94.4% (the 5-year actuarial survival rate, 87.4%). There were four late deaths; two were due to myocardial infarction, one to prosthetic valve failure, and one to sudden death. At 2.7 years, 88.1% of the patients were NYHA Functional Class I; 85.4% continued full-time employment, and 98% considered their quality of life the same or better than before CABG. Five patients suffered myocardial infarctions during the follow-up period. Nine patients required reoperation: eight for graft occlusion (three less than 1 year, five greater than 3 years), and one for disease progression. These data confirm that complete operative revascularization remains the standard of therapy for young patients with multivessel coronary artery disease as evidenced by the absence of early mortality, the low incidence of morbidity, the excellent functional recovery, and the high return to gainful employment.     

Reoperation after aortocoronary bypass procedure. Results in 53 patients in a group of 1041 with consecutive first operations.

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.     

Incidence, risk, and outcome of reintervention after aortocoronary bypass surgery.

Reintervention was required in 123 (12%) individuals during a follow up (mean 7.5 years, range 5-14.5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5.6%) than at the primary operation (1.2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1.82) and with extent of vascular disease (rate ratio 1.80) but not with reintervention (rate ratio 1.45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention. Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.     

Left main coronary artery disease Clinical, arteriographic and hemodynamic appraisal

Thirty patients with 70 percent or greater obstruction in the left main coronary artery were evaluated during hemodynamic and angiographic studies. There were 25 male and 5 female patients; the average age was 54 years. Twenty-seven patients had moderate to severe angina pectoris, with 14 noting an increase in severity of chest pain within 6 months before arteriography. Six patients also had hemodynamic evaluation by atrial pacing. In each, angina pectoris was easily induced, and all 6 had abnormal pacing ventricular function curves with marked increase in left ventricular end-diastolic pressure associated with a reduction in left ventricular stroke work.

Image intensification fluoroscopy revealed calcification in the left main coronary artery in 7 patients. A striking finding was the severity of obstructive disease in the other coronary arteries. Eight patients had total occlusion of the right coronary artery, and 29 of the 30 patients had 2- or 3-vessel disease. Significant coronary arterial collateral vessels were noted in 21 patients. Contraction abnormalities were present in 24 left ventriculograms.

Three deaths were associated with cardiac catheterization (mortality rate 10 percent). Only 2 of 18 patients who underwent aortocoronary bypass surgery died. The 16 surgical survivors are in clinically improved condition after a follow-up period of 10 months. Three of 9 patients not operated on have died, all within 1 month of arteriography.

Because of the high risk of sudden death, coronary arteriography should be performed with caution in a patient with severe angina pectoris, very positive findings on exercise testing, easily induced angina and heart failure with stress and calcification in the left main coronary artery. After cardiac catheterization all patients should undergo routine monitoring and, when technically feasible, saphenous vein aortocoronary bypass surgery should be performed.     

Risk analysis of urgent coronary artery bypass grafting

We analyzed the risk factors of morbidity and mortality associated with urgent coronary artery bypass grafting (CABG) for impending myocardial infarcton. Among 1,428 consecutive patients who underwent isolated on-pump CABG between 1992 and 1998, a total of 126 were urgent cases. Their inhospital and long-term data were analyzed by the Kaplan-Meier method or logistic model. The mean number of grafts performed during urgent CABG was 3.2, and arterial reconstruction was performed in 117 (93.9%) cases. Major postoperative complicatons occurred in 64 cases (50.8%), and there were 9 inhospital deaths (7.1%). Significant predictor of inhospital death, identified by multivariate analysis, was a history of cerebral vascular accident. During a mean follow-up period of 3.1 years, there was a total of 7 remote deaths giving an actuarial 5-year survival rate of 93.5% (excluding inhospital deaths). Remote cardiac events occurred in 23 patients, giving an actuarial 5-year event-free rate of 74.8%. Multivariate logistic regression analysis found that risk factors influencing cardiac events were poor left ventricular function, preoperative renal dysfunction, postoperative use of intra-aortic balloon pumping, and postoperative induction of dialysis, while those influencing survival were previous myocardial infarction. Comparing elective CABG performed in the same period, the inhospital mortality of urgent cases was 33.8 times higher. Among hospital-survivors, patients after urgent CABG demonstrated fair long-term survival and future development of cardiac events. All efforts to achieve complete revascularization and frequent use of the internal mammary artery may contribute to improving the long-term results; however, careful management is necessary for patients with poor cardiac function.The paper was presented in part at the 41st Annual World Congress, International College of Angiology, Sapporo, Japan, July 3–10, 1999.     

Incidence, risk, and outcome of reintervention after aortocoronary bypass surgery

Reintervention was required in 123 (12%) individuals during a follow up (mean 7.5 years, range 5-14.5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5.6%) than at the primary operation (1.2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1.82) and with extent of vascular disease (rate ratio 1.80) but not with reintervention (rate ratio 1.45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention. Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.