Early and late results of coronary artery bypass after failed angioplasty. Actuarial analysis of late cardiac events and comparison with initially successful angioplasty

We reviewed the results of early (less than 24 hours) coronary artery bypass after unsuccessful percutaneous coronary artery angioplasty in 146 patients treated between October 1979 and July 1986. Overall operative mortality was 2.7%, and risk was significantly increased among patients with hemodynamic instability and new occlusion or further narrowing of the dilated vessel (3.8 versus 0%, p less than 0.05). Actuarial analysis was used to compute the rates of cardiac events during the follow-up interval, and event rates were also estimated in a comparison group of 776 patients who had successful first-time PTCA during the same time period. At a follow-up interval of 5 years, the cumulative risks of recurrence of angina and need for an additional procedure (bypass or angioplasty) were significantly (p less than 0.05) lower for patients who had undergone bypass than for those who had successful angioplasty (angina 21% versus 56%, PTCA 2% versus 21%, CAB 6% versus 16%). Cumulative risks of myocardial infarction and death were 4% versus 9% and 6% versus 9% in the two groups. The differences between late outcomes in the bypass and angioplasty groups persisted when patients were stratified into cohorts with single-vessel and multivessel disease, and the highest late event rate occurred in patients in the angioplasty group who had incomplete revascularization. The difference in late events after bypass or angioplasty was greatest during the first year. These late data should be considered when the mode of revascularization (bypass or angioplasty) is selected for symptomatic patients, especially those with multivessel disease.     

The outcome of surgical treatment of hypertrophic obstructive cardiomyopathy. Experience over 15 years

From 1972 through 1987, 115 patients between the ages of 1 and 83 years (mean, 44.5 years) underwent operation for hypertrophic obstructive cardiomyopathy. Methods of relief of left ventricular outflow obstruction were septal myectomy/myotomy (n = 109), mitral valve replacement (n = 4), and myectomy/myotomy plus mitral valve replacement (n = 2); concomitant procedures included coronary artery bypass (n = 19) and aortic valve replacement (n = 9). Systolic gradient (peak-to-peak) from the left ventricle to the aorta decreased from 70 +/- 38 mm Hg (mean +/- standard deviation) to 9 +/- 11 mm Hg. There were six hospital deaths, for an overall operative risk of 5.2%; one death occurred among 83 patients less than age 65 years (operative risk, 1.2%), and five deaths occurred in 32 older patients (operative risk, 15.6%; p = 0.008 for difference between age groups). Four (22.2%) of 18 patients with a residual gradient greater than 15 mm Hg died, compared with two (2.1%) of 97 patients with a lower gradient (p = 0.003). Follow-up ranged from 0.5 to 16 years (mean, 5.1 years), and 5-year actuarial survival rate, including hospital deaths, was 84% +/- 4%. The 5-year survival rate was decreased in patients who had operative procedures other than myectomy/myotomy (69% versus 91%, p less than 0.005) and in patients aged 65 years or older (54% versus 93%, p less than 0.005). No correlation was found between preoperative symptoms, functional class, left ventricle-aorta pressure gradient, or mitral valve insufficiency and operative or late mortality. Preoperative symptoms were relieved in 57 (76%) of 75 patients with dyspnea, 49 (83%) of 59 patients with angina, and 22 (96%) of 23 patients with syncope. This experience confirms the effectiveness of operation for relief of symptoms in patients with the obstructive form of hypertrophic cardiomyopathy. The current operative mortality rate is low, especially in patients less than 65 years of age (1.2%). Our experience suggests that incomplete relief of left ventricular outflow obstruction may increase the risk of early postoperative death.     

Early and five-year results for coronary artery bypass grafting. A benchmark for percutaneous transluminal coronary angioplasty

Patients currently undergoing coronary artery bypass grafting will likely have worse early and late results because of the selection of patients with fewer risk factors for percutaneous transluminal coronary angioplasty. Therefore, until the results of randomized prospective studies are available, angioplasty should also be compared to bypass grafting before the era of angioplasty to facilitate current comparison with bypass grafting. To obtain these data, I analyzed 500 consecutive patients (aged 33 to 79 years [58 +/- 10 SD], 20% [100/500] female, and 60% [300/500] with three vessel disease) undergoing first-time coronary bypass without associated procedures between late 1976 and mid-1980. Intermittent aortic cross-clamping (for each distal graft) was used for revascularization of all arteries 1.0 mm in internal diameter or larger with stenoses of 50% or greater. This strategy resulted in complete revascularization in 99.8% of patients, averaging 3.2 +/- 1.2 distal grafts per patient. The hospital mortality rate was 0.2% (1/500). The incidence of low output syndrome necessitating pressors (0.8%) or intraaortic balloon pump support (0.2%) was 1% (5/500). Perioperative myocardial infarction rate based on new Q waves was 2.2% (11/500). All but three patients (99.4%) were contacted at 5 years or later with respect to repeat coronary bypass or angioplasty and survival. The survival rate at 5 years, including hospital deaths, was 92.7% +/- 1.2% (70% confidence limits) for cardiac deaths, 89.8% +/- 1.4% for all deaths, and 89.8% +/- 1.4% for all deaths plus three patients lost to follow-up. Approximately 40 factors were screened univariately to determine their effect on survival and survival free from repeat intervention. Multivariate analysis revealed, as in other series, that decreased left ventricular function (ejection fraction less than 50%) was the predominant determinant of decreased 5-year survival for both cardiac death and total mortality. At 5 years, the freedom from reintervention was 97.7% +/- 0.7%. Factors associated with repeat intervention were younger age (52 +/- 11 years versus 58 +/- 10, p less than 0.05) and fewer grafts (2.3 +/- 1.0 versus 3.3 +/- 1.2, p less than 0.01) because of less severe disease (three vessel disease 31% versus 60%, p less than 0.05). These results provide a benchmark for angioplasty which should attain a hospital mortality rate of under 1%, a periprocedure myocardial infarction rate under 3%, and a 5-year survival rate of approximately 90% with more than 95% of survivors free of repeat intervention in unselected patients, not cohorts with primarily single vessel disease.     

Performance of glutaraldehyde-preserved porcine bioprosthesis as a mitral valve substitute in a young population group

Porcine bioprostheses were implanted in the mitral position in 289 patients. The mean age was 25.8 +/- 13.7 years. One hundred thirty-five patients (47%) were 20 years old or younger. Most patients had chronic rheumatic valvulitis (74%). Mitral regurgitation and mixed mitral valve disease were the dominant lesions. Hancock, Angell-Shiley, and Carpentier-Edwards prostheses were implanted in 84, 14, and 191 patients, respectively. There were 19 early and 64 late deaths. Mean follow-up was 5.04 +/- 1.03 patient-years. Fifty-eight patients (6.71% per patient-year) were reoperated on for degenerated prostheses, with 13 deaths. Twelve patients died without reoperation, and 17 await reoperation for degenerated valves. The rate of structural failure (total, 87 patients) was 21.07% and 3.04% per patient-year for patients less than and older than 20 years, respectively (p less than 0.001). The 6-year actuarial survival for these two groups was 50% and 68%, respectively. However, for patients 20 years old or younger, survival free from degeneration was only 20% at 6 years (p less than 0.001). Bioprostheses have a high failure rate and should not be implanted in young patients or in patients with a life expectancy exceeding 10 years.     

Late cerebrovascular accidents after repair of abdominal aortic aneurysms

In this follow-up of 1,112 patients operated on for abdominal aortic aneurysm (AAA) it was noted that cerebrovascular accidents (CVAs) caused significant (8.2%) late mortality. Seventy-one patients developed non-fatal or fatal CVAs at 5.9 +/- 2.9 (mean +/- SD) years after the initial aneurysm repair. The incidence of CVA was 4.2% and 9.5% within five and ten years, respectively. In patients with preoperative evidence of both hypertension and heart disease, the incidence of CVA within five years was 9.1% compared to an incidence less than 4% in patients with either or neither of these risk factors (p less than 0.01). Multivariate analysis of individual risk factors revealed that only age (p less than 0.001), hypertension (p less than 0.001), angina pectoris (p less than 0.02) and other heart disease (p less than 0.001) were independently associated with a reduced survival free of CVA. Thus, cerebrovascular accidents are responsible for significant late morbidity after AAA repair. Patients at high age or with evidence of hypertension and heart disease carry a greater risk for this complication.     

Mitral valve replacement combined with coronary artery operation: determinants of early and late results

Mitral valve replacement combined with coronary artery bypass grafting has been reported as being associated with a higher mortality than either mitral valve replacement or coronary artery bypass grafting alone. Cause of mitral valve disease and severity of mitral regurgitation have been reported as related to mortality. To study the correlation of the cause of mitral valve disease and severity of mitral regurgitation to hospital mortality and long-term survival, we analyzed the results of 135 patients undergoing mitral valve replacement and coronary artery bypass grafting between June 1974 and August 1989. The hospital mortality was 11.8% (16/135). Fifteen preoperative and operative variables were tested for correlation with hospital or late mortality using univariate tests and multivariate regression. Advanced age (greater than 60 years), New York Heart Association functional class, and wall motion score were independently associated with hospital mortality (p less than 0.05). The cause of mitral valve disease and severity of mitral regurgitation were not related to hospital mortality or long-term survival (p greater than 0.05). The follow-up rate was 96.6% for the hospital survivors (115/119). Mean follow-up was 52.6 +/- 4.1 months. There were 35 late deaths. Survival was 91.9%, 89.9%, 78%, and 49.9% at 1, 2, 5, and 10 postoperative years, respectively. Preoperative New York Heart Association functional class and use of catecholamines during the postoperative intensive care period were independently related to late survival (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial revascularization with combined aortic and mitral valve replacements

Although the results of coronary artery bypass grafting plus single aortic or mitral valve replacement have been documented, the risk of myocardial revascularization with combined aortic and mitral valve replacement is not well defined. We present a series of 33 consecutive patients undergoing myocardial revascularization with combined aortic and mitral valve replacement during a period of almost seven years. There were 21 men and 12 women with a mean age of 67 years. All patients had congestive heart failure, and 21 (64%) had angina pectoris. Mean New York Heart Association functional classification was 3.4; eight patients (24%) had ejection fractions less than 0.40, and 13 patients (41%) had cardiac indices less than 2.0 L/min/m2. All operations were performed with hypothermic crystalloid potassium cardioplegia. The number of coronary arteries grafted varied from one to four (mean, 1.7 grafts per patient). Four patients died while in the hospital (12.1%). There were no perioperative myocardial infarctions. At a follow-up of 2 to 80 months (mean 40.7 months), death had occurred in eight (27.6%) of the 29 hospital survivors. Actuarial survival rate at 72 months was 60.7%. Although no preoperative factors predicted late death, early deaths were related significantly to severe mitral regurgitation, low ejection fraction, high New York Heart Association classification and extensive coronary artery disease (p less than 0.05). Myocardial revascularization with combined aortic and mitral valve replacement can be performed with an acceptable early mortality rate but with an appreciable late mortality rate.     

The influence of gender on the outcome of coronary artery bypass surgery

BACKGROUND: To assess the impact of gender as an independent risk factor for early and late morbidity and mortality following coronary artery bypass surgery. METHODS: Perioperative and long-term data on all 4,823 patients undergoing isolated coronary bypass operations from November 1989 to July 1998 were analyzed. Of these patients, 932 (19.3%) were females. RESULTS: During the years 1989 to 1998 there was a progressive increase in the percentage of women undergoing coronary artery bypass surgery. The following preoperative risk factors were more prevalent among women than men: age above 70, angina class 3 or 4, urgent operation, preoperative intraaortic balloon pump usage, congestive heart failure, previous percutaneous transluminal coronary angioplasty, diabetes, hypertension, and peripheral vascular disease (all p < 0.05). Men were more likely to have an ejection fraction less than 35%, three-vessel disease, repeat operations, and a recent history of smoking. Women had a statistically significant smaller mean body surface area than men (1.72+/-0.18 versus 1.96%+/-0.26% m2). On average, women had fewer bypass grafts constructed than men (2.9%+/-0.8% versus 3.2%+/-0.9%) and were less likely to have internal mammary artery grafting (76.2% versus 86.1%), multiple arterial conduits (10.1% versus 19.8%), or coronary endarterectomy performed (4.9% versus 8.6%). The early mortality rate in women was 2.7% versus 1.8% in men (p = 0.09). Women were more prone to perioperative myocardial infarction (4.5% versus 3.1% p < 0.05). After adjustment for other risk variables, female gender was not an independent predictor of early mortality but was a weak independent predictor for the prespecified composite endpoint of death, perioperative myocardial infarction, intraaortic balloon counterpulsation pump insertion, or stroke (8.55 versus 5.9%; odds ratio, 1.30; 95% confidence interval, 0.99 to 1.68; p = 0.05) Recurrent angina class 3 or 4 was more frequent in female patients (15.2%+/-4.0% versus 8.5%+/-2.0% at 60 months, p = 0.001) but not repeat revascularization procedures (percutaneous transluminal coronary angioplasty, redo) (0.6%+/-0.3% versus 4.1%+/-0.8% at 60 months). Actuarial survival at 60 months was greater in women then men (93.1%+/-1.7% versus 90.0%+/-1.0%), and after adjustment for other risk variables, female gender was protective for late survival (risk ratio, 0.40; 95% confidence interval, 0.16-0.74; p < 0.005). CONCLUSIONS: Perioperative complications were increased and recurrent angina more frequent in women. Despite this, late survival was increased in women compared with men after adjustment for other risk variables     

Symptomatic improvement after transmyocardial laser revascularization: how long does it last?

BACKGROUND: The aim of this study was to determine whether short-term clinical improvement after isolated transmyocardial holmium laser revascularization (TMLR) in patients with coronary artery disease not amenable to traditional treatment is maintained through a longer follow-up. METHODS: Between November 1995 and June 1999 34 patients underwent TMLR (mean age, 67+/-7 years); previous revascularization procedures had been performed in 76%. Preoperatively, mean angina class was 3.6+/-0.5 in 12 patients with unstable angina; mean left ventricular ejection fraction was 47%+/-9%. RESULTS: There was 1 early death due to low cardiac output. Mean duration of TMLR and of the entire operation was 25+/-12 minutes and 125+/-43 minutes, respectively. There were no major postoperative complications; mean hospital stay was 8+/-4 days. There were 8 late deaths caused by stroke (2 patients), cardiac failure (1 patient), and myocardial infarction (5 patients). Follow-up of current survivors ranges from 4 to 48 months (mean, 32+/-12 months). At 1-year follow-up mean angina class was 1.8+/-0.8; but at a later follow-up (mean, 35+/-10 months) it significantly increased to 2.2+/-0.7 (p = 0.005). Three-year actuarial survival was 76%+/-8% and freedom from cardiac events 44%+/-10%. CONCLUSIONS: Our results show that after initial clinical improvement many patients experience return of angina or cardiac events; this questions the long-term symptomatic benefit of TMLR.     

Replacement of the ascending aorta. Early and late results

From 1978 through 1987, 225 patients underwent operations that included replacement of the ascending aorta. One hundred twenty-three patients underwent composite aortic valve and ascending aortic replacement, 30 had aortic valve replacement with separate graft replacement of the ascending aorta, and 72 underwent replacement of the ascending aorta without aortic valve replacement. Thirty-one (13.8%) in-hospital deaths occurred. Univariate testing of preoperative and operative variables followed by logistic regression analyses identified miscellaneous aortic disease, coronary artery bypass grafting, aortic arch replacement, emergency operation, surgical date (1978 to 1983), and age (all p less than 0.05) as factors having independent association with in-hospital mortality. Follow-up of in-hospital survivors (mean interval 46 months, range 8 to 123 months) documented an overall 5-year survival rate of 76%, 83% after primary operation and 37% after reoperation. Univariate analyses followed by multivariate testing indicated that previous operation (p less than 0.0001) and a history of preoperative neurologic symptoms (p = 0.021) were associated with decreased late survival. At follow-up 88% of late survivors were free of symptoms. Seven patients have undergone reoperation 1 day to 69 months postoperatively. Although the in-hospital mortality for operations that include ascending aortic replacement exceeds that for isolated aortic valve replacement, the late death rate and rate of reoperation are low.     

Cumulative stroke and survival ten years after carotid endarterectomy

With the life-table method, late stroke and survival data were calculated for 329 patients (mean age 59 years) followed a minimum of 10 years after carotid endarterectomy. The cumulative incidence of stroke was 24% at 10 years after operation, but only 10% of patients sustained strokes that clearly involved the ipsilateral cerebral hemisphere. Late strokes were most common (p less than or equal to 0.05) among hypertensive patients (31%), those with preoperative strokes (31%), and patients with recognized contralateral carotid stenosis (42%). Contralateral hemispheric strokes occurred in 36% of patients with uncorrected contralateral stenosis compared with 8% of those who had elective bilateral reconstruction (p = 0.09). Myocardial infarctions caused more late deaths (37%) than did strokes (15%), and 10-year survival after incidental myocardial revascularization (55%) was superior (p = 0.0001) to survival for patients with suspected but undocumented coronary disease (32%).     

Retrospective study of 412 aortic valve replacements by Bjork-Shiley prosthesis implanted between January 1972 and October 1984. Actuarial survival, mortality, complications

Between January 1972 and October 1984, 412 aortic valve replacements by Bjork-Shiley disk prosthesis were performed. 183 patients suffered from aortic incompetence, 132 from an aortic disease and 97 from aortic stenosis. 116 associated procedures (28%) were performed = 36 myocardial revascularizations, 61 Bentall operations, 12 patch grafts to the ascending aorta and 7 Wheat operations. The mean age was 53.6 years and 25% of the patients were over the age of 65 years. Fifty percent of the patients had stage III or IV disease according to the NYHA classification. The cardiac index was less than 2.3 l/min/m2 in 44.26% of cases. The early postoperative mortality was 4.85% and 20% of these deaths were related to the prosthesis. The late mortality was 17.25%, with 20% of deaths related to the valve. The mean follow-up 59.75 +/- 2 months (range: 1 to 166 months) with a cumulative survival of 2.092 patients-years. It was significantly influence by the existence of preoperative angina, another operation associated with AVR and a cardiac index less than 2.3 l/min/m2. Seventy-one complications were related to the prosthesis including dysfunction (0.05% patient-year), 3 valve thromboses (0.15% patient-year), 6 infected valves (0.31% patient-year), 12 cases of peri-prosthetic dehiscence (0.61% patient-year), 10 embolic complications (0.61% patient-year) and 37 complications related to anticoagulants, including 26 major complications (1.48% patient-year). The valve failure rate was 1.19% patient-year. The results of our series are comparable to those reported in the literature, which confirm the reliability of the Bjork-Shiley Valve.     

Prospective randomized study of St Jude Medical versus Bj?rk-Shiley or Starr-Edwards 6120 valve prostheses in the mitral position. Three hundred and fifty-seven patients operated on from 1979 to December 1983

During a 5 year period (January 1979-December 1983) 357 patients were submitted to mitral valve replacement. These were performed by the same surgeon and were randomized in 2 groups: Group A consisted of 179 patients who received a St Jude Medical (SJM) prosthesis in the mitral position. Group B comprised 178 patients with a Bj?rk-Shiley valve (BSM) initially (113 patients from 1979 to December 1981 matched with 111 SJM) and later a Starr-Edwards 6120 valve prosthesis (65 patients matched with 63 SJM). Analysis of 21 preoperative clinical, hemodynamic data and operative variables showed the groups to be well randomized. All patients were anticoagulated postoperatively. A follow-up study was performed each year postop: at the end of 1986 there was a 35 to 95 months follow-up with a mean of 64.7 months (1596 patient years follow-up). Fifteen patients were lost to follow-up. There were 8.4% deaths related to the prosthesis in group A and 20.2% in group B (p less than 0.001). The difference was due mainly to deaths from thromboembolic complications and sudden deaths. The rate of peripheral arterial embolic complications was 2.3% in group A and 4.3% in group B per patient year (NS). The difference between the 2 groups is significant for all thromboembolic events including sudden deaths: 3.1% in group A and 7.9% per patient year in group B (p less than 0.001). There were no statistical differences in the rates of endocarditis per patient year (0.3% in group A, 0.9% in group B), reoperation (0.75% in group A, 0.89% in group B), or anticoagulant related hemorrhage (1.6% in group A, 2.4% in group B). Actuarial survival rate, including all postoperative deaths, is significantly different (p less than 0.05) at 5 years, 87.6% +/- 4.5 (group A) versus 77.4% +/- 6 (group B) and at 7 years follow-up, 83.4% +/- 6.5 (group A) versus 73.2% +/- 7.2 (group B). The probability of freedom from death and complications related to the prosthesis is significantly different (p less than 0.001) at 5 years postoperatively: 79% +/- 6.5 for group A versus 54% +/- 7.5 for group B and at 7 years: 72% +/- 7.5 (group A) versus 46% +/- 8.5 (group B). Comparison of subgroups, 113 BSM versus 111 SJM (1979-81) and 65 SE 6120 versus 63 SJM (1982-83) showed similar significant differences in the results: however there were more early deaths, valve thrombosis, valve dysfunctions and sudden late deaths in the BSM group and more peripheral arterial emboli in the SE 6120 group.(ABSTRACT TRUNCATED AT 400 WORDS)     

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up.

BACKGROUND: Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience. METHODS: Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included. RESULTS: There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively. CONCLUSIONS: Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.     

Does the clinical evaluation of the cardiac status predict outcome in patients with abdominal aortic aneurysms?

A cost-effective method to reduce mortality rates after abdominal aortic aneurysm repair centers on selecting and investigating only those patients at risk for cardiac-related death. All 146 patients undergoing asymptomatic abdominal aortic aneurysm repair over a 5-year period (1986 to 1990) were retrospectively placed into one of the three following groups on the basis of a clinical evaluation. Group I: no history of myocardial infarction or angina, no congestive heart failure, and no ischemic changes on electrocardiogram (ECG). Group II: history of myocardial infarction or class I-II angina or ischemic changes on ECG. Group III: presence of congestive heart failure or class III-IV angina. Patients in group I had no further cardiac work-up; patients in group II with angina had left ventricular ejection fraction assessment by multiple gated acquisition (all greater than 37%) and were cleared for operation by a cardiologist; patients in group II without angina had no further cardiac work-up; patients in group III had coronary angiography and then coronary revascularization. The overall mortality rate was 4.8%, with a cardiac mortality rate of 3.4%. The mortality rate in group I (n = 64) was 1.8%, with no cardiac-related deaths; the mortality rate in group II (n = 63) was 9.5% (8% cardiac-related deaths). No deaths occurred in group III (n = 19). The difference between the cardiac mortality rates in groups I and II was significant (p = 0.02) as was the postoperative cardiac morbidity: total myocardial infarctions (p less than 0.001); congestive heart failure (p = 0.02); tachyarrhythmias (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of internal thoracic artery grafting over 15 years: single versus double grafts

One hundred consecutive patients who had coronary artery bypass grafting using both internal thoracic arteries (ITAs) and saphenous veins, operated on during a 3-year period between 1972 and 1975, have been compared retrospectively with a series of 100 patients operated on during the same period who had one ITA graft along with saphenous vein grafts. The two groups were similar with respect to age, sex, risk factors for coronary artery disease, angina class, extent of coronary artery disease, left ventricular function, number of coronary bypass grafts performed, and completeness of revascularization. Single ITA operative mortality was 2% and double ITA, 9% (p = NS). The mean follow-up of hospital survivors was 14.4 +/- 2.7 years; all but 7 patients had follow-up for at least 10 years. At 13 years, the actuarial patency of the right ITA was 85% and the left ITA, 82%. These data strongly suggest a survival benefit for patients with double ITA grafts among hospital survivors (74% versus 59%; p = 0.05). Patients receiving two ITA grafts had a significant freedom from subsequent myocardial infarction (75% versus 59%, p less than 0.025), recurrent angina pectoris (36% versus 27%, p less than 0.025), and subsequent total ischemic events (32% versus 18%, p less than 0.01). These data also suggest improved freedom from coronary artery interventional therapy (percutaneous transluminal coronary angioplasty and reoperation) when two ITA grafts were used. These results support the use of bilateral internal thoracic artery grafting in selected patients.     

Fatal myocardial infarction following carotid endarterectomy: three hundred thirty-five patients followed 6-11 years after operation.

Routine coronary angiography has been recommended to all patients undergoing carotid endarterectomy at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization as a staged or combined procedure in conjunction with carotid endarterectomy in an attempt to reduce the incidence of fatal myocardial infarction during the postoperative period, and during the late follow-up interval. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 95% of 335 consecutive patients who underwent carotid endarterectomy between 1969 and 1973. Fatal myocardial infarction accounted for 60% of early deaths within 30 days of operation and occurred in 1.8% of the entire series. Among the patients who survived operation, the five-year mortality rate was 27%, and the 11-year mortality rate was 48%. Myocardial infarction caused 37% of the deaths that occurred within five years after operation and 38% of the deaths that have occurred within 11 years. Differences in the incidence of fatal myocardial infarction within five years after operation between a group of 116 patients who had no clinical evidence of CAD and a group of 209 patients suspected to have CAD attained statistical significance (p less than 0.1) despite the fact that 67 patients suspected to have CAD eventually underwent myocardial revascularization. Improvement in actuarial survival (p less than 0.05) and reduction in the late mortality rate (p less than 0.01) were statistically significant for the subset of patients with suspected CAD who had aortocoronary bypass graft procedures.     

Coronary artery bypass grafting in 105 patients with hemodialysis-dependent renal failure

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.     

Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris. A report from the Coronary Artery Surgery Study (CASS) registry

We examined survival rates during a 6-year follow-up of patients in the registry of the Coronary Artery Surgery Study who had three vessel coronary artery disease and Canadian Cardiovascular Society class III-IV angina pectoris. All patients had a stenosis of 70% or greater in either the mid or proximal segment of all three coronary arteries. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, the estimated probability of being alive at 6 years was 82% for surgically treated patients and 59% for medically treated patients (p less than 0.0001). Among patients with the most severe left ventricular dysfunction (left ventricular wall motion score of 16 to 30), the 6-year survival rate was 63% for surgically treated patients and 30% for medically treated patients (p less than 0.0001). Those with three proximal lesions (all gradations of left ventricular score) had an 81% 6-year survival rate with surgical treatment and 40% with medical treatment (p less than 0.0001). Ninety percent of surgically treated patients with normal ventricular function were living at 6 years and 78% of medically treated patients (p less than 0.0001). Among these patients, the survival rate was significantly better after surgical treatment than after only medical treatment if two or three proximal stenoses were present. If no proximal lesions were present (all categories of left ventricular function), 84% of surgically treated patients and 67% of medically treated patients were alive at 6 years (p less than 0.0001). In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was a strong predictor of survival (estimated relative risk 0.38).     

Schistosomal versus nonschistosomal variceal bleeders. Do they respond differently to selective shunt (DSRS)?

The distal splenorenal shunt (DSRS) was performed in 125 consecutive variceal bleeders. To date, no patients have been lost to follow-up (mean of 79 +/- 20 months). Liver pathology was documented in 85 patients: 45 patients had schistosomal hepatic fibrosis, 17 had nonalcoholic cirrhosis, and 23 had mixed pattern (hepatic fibrosis and cirrhosis). The preoperative data base for these three groups was matched (p greater than 0.05), with a mean follow-up of 79 +/- 20, 70 +/- 14, and 77 +/- 22 months for each population, respectively. The results showed low operative mortality (4.8%), high cumulative patency rate (94.8%) and low recurrent variceal hemorrhage (5.6%). The biochemical data showed significant increase in serum bilirubin (p less than 0.001) and aspartate transaminase (AST) (p less than 0.05) in the nonschistosomal patients. Chronic hyperbilirubinemia was found in 33% of the schistosomal group. Prograde portal perfusion was detected in 94% of the patients, with development of collaterals in 91%. The angiographic pattern of these collaterals was 50% pancreatic, 45% gastric, and 26% colosplenic. Patients with mixed liver disease had a high incidence of Grade III portal perfusion (57%) and more common pancreatic and gastric collaterals (71%). The cumulative survival for all patients was 74.1%, with hepatic cell failure being the leading cause of death (13 patients, 50% of all deaths). The schistosomal patients had a 91.6% incidence, whereas the cirrhotic and mixed groups had survival rates of 75.6% and 65.2%, respectively. Also, of a 15% total incidence of encephalopathy, 4.4% was related to the schistosomal patients, 23.5% to the cirrhotics, and 21.7% to the mixed population. Statistically, the survival rate was significantly better (p less than 0.05) and encephalopathy was significantly lower (p less than 0.05) in the schistosomal population. In conclusion, this data shows that: 1) DSRS has a high patency rate and a low variceal hemorrhage recurrence rate; 2) it maintains some degree of portal perfusion in patients with different nonalcoholic liver diseases, despite development of collaterals; and 3) the schistosomal patients have a better survival rate, with a low incidence of encephalopathy after DSRS, compared with the cirrhotic and mixed populations.