Invasive treatment for coronary artery disease in the elderly

The widespread availability of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty presents important treatment options for the older patient. The findings from a number of surgical series of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty are summarized. Certain trends are evident. Perioperative mortality, cardiovascular morbidity, and other complications, while declining, remain somewhat higher in elderly patients. However, the impact of age alone is slight. In both coronary artery bypass grafting and percutaneous transluminal coronary angioplasty, complications are more closely correlated with the presence of serious concomitant disease. Long-term survival and pain relief after coronary artery bypass grafting are excellent in older patients, and percutaneous transluminal coronary angioplasty may be the treatment of choice in some elderly patients with coronary artery disease. As in younger patients, prolongation of survival should not be the exclusive goal. Rather, a focus on quality of life and freedom from dependency should be seriously considered.     

Impact of coronary artery disease on valvular heart surgery

Patients who undergo coronary bypass grafting in association with aortic valve replacement currently have a low in-hospital mortality, but their late survival is inferior to that of patients without coronary disease who undergo isolated aortic valve replacement. Patients who receive porcine heterografts to replace the aortic valve have better late survival and event-free survival after aortic valve replacement combined with bypass grafting than those who received mechanical valves. The analyses of patients who combine coronary artery and mitral valve disease is difficult because of changing surgical practices and diagnostic techniques. Patients undergoing surgery for mitral valve replacement combined with bypass grafting have had higher in-hospital mortality and worse late survival than patients undergoing aortic valve replacement combined with bypass grafting. The increased use of techniques for reconstructing rather than replacing the mitral valve may help improve the long-term results for patients undergoing surgery for mitral valve dysfunction combined with coronary disease.     

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.     

Long-term outcome of unsuccessful percutaneous transluminal coronary angioplasty

We analyzed the long-term outcome of 198 patients after unsuccessful percutaneous transluminal coronary angioplasty. Forty-nine percent underwent emergency coronary artery bypass grafting surgery, 17% had elective bypass surgery, and 34% were treated medically. The in-hospital mortality rate was 4%, and myocardial infarction occurred in 36% of patients. Follow-up was completed in 100% of patients with a mean follow-up period of 35 +/- 22 months. Actuarial cardiac survival at 4 years was 97% in the emergency bypass surgery group, 100% in the elective bypass surgery group, and 86% in the medically treated group. Actuarial event-free survival (freedom from myocardial infarction, bypass surgery, coronary angioplasty, and cardiac death) at 4-year follow-up was 81% in 198 patients, 90% in the emergency bypass surgery group, 85% in the elective bypass surgery group, and 65% in the medically treated group. Results of multivariate analysis showed that emergency or elective bypass surgery after failed coronary angioplasty, normal or mildly impaired left ventricular function, and male sex were predictors of better outcome at 4 years.     

Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% (19/20 patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.     

Clinical outcome for coronary artery bypass grafting in patients with severe carotid occlusive disease]

OBJECTIVES: To evaluate the management of coexisting severe carotid stenosis in candidates for coronary artery bypass grafting. METHODS: Twenty-six candidates for coronary artery bypass complicated with severe carotid stenosis > or = 70% were analyzed retrospectively. The prevalence of significant carotid stenosis was 6.4%. There were 21 males and 5 females with a mean age of 65.3 +/- 9.3 years. The hemodynamics of cerebral circulation, intervention for carotid stenosis, surgical mortality, morbidity, and long-term survival were analyzed retrospectively. RESULTS: The prevalence of bilateral carotid stenosis was 30.8% (8/26). Nine patients had total occlusion of the internal carotid artery, 10 had carotid stenosis of 90-99%, and 7 had carotid stenosis of 70-89%. Seven patients required mechanical support for cardiopulmonary insufficiency, including six patients requiring simultaneous artificial ventilation and intraaortic balloon pumping, and one requiring intraaortic balloon pumping. Concomitant carotid endarterectomy and coronary bypass grafting was performed in 10 patients, preceding carotid endarterectomy in 1, and preceding coronary bypass grafting with subsequent carotid endarterectomy in 7. Cardiopulmonary bypass was used in 22 patients. There was no surgical death. Although one patient undergoing concomitant carotid endarterectomy and coronary artery bypass grafting had perioperative stroke, the remaining patients recovered without any neurological complication (morbidity of stroke: 3.8%). The five-year survival rate was 71.9 +/- 11.7%. CONCLUSIONS: Coronary artery bypass grafting in candidates with carotid stenosis can be treated safely when appropriate preoperative evaluation and surgical strategies are utilized.     

介入治疗在无保护左主干病变中的应用——对不能耐受旁路移植术或手术高危患者的疗效

目的　探讨经皮冠状动脉介入治疗 (PCI)在不能耐受冠状动脉旁路移植术 (CABG)或手术高危的无保护左主干病变 (UPL MT)患者中的应用及近、远期疗效。方法　自 1993年 2月至 2 0 0 2年 8月期间 ,对 85例被列为不能耐受 CABG或手术高危的 UPL MT进行了 PCI治疗 ,其中定向斑块旋切术 (DCA) 4 8例 ,支架术 37例。术后半年内每月至少门诊复查一次 ,以后定期随诊、电话随访。术后 3、6、12月行冠状动脉造影复查。结果　 PCI术均获技术成功(术后残余直径狭窄 <5 0 % ,且获得 TIMI3级血流 )。住院期间主要不良心脏事件 (MACE)共 12例 (14 .1% ) :死亡9例 (10 .6 % ) ,其中心源性死亡 3例 (3.5 % ) ;再次 PCI术 3例 (3.5 % ) ;无 Q波心肌梗死、急诊 CABG。术后半年随访发现死亡共 15例 (17.6 % ) ,其中心源性死亡 8例 (9.4 % ) ;半年内共有 71例患者接受冠状动脉造影复查 ,其中对19例 (2 6 .8% )进行了靶血管重建 ;对资料完整的 6 4例患者作左心室射血分数 (L VEF)对比分析 ,结果显示 :PCI术后 (3或 /和 6个月 ) L VEF较术前显著改善 (5 .5± 8.7% ,P<0 .0 5 )。Kaplan- Meier生存分析显示 :PCI术后 1年、3年 (免于死亡 )的生存率为 81.2 %、76 .5 % ,免于心源性死亡的生存率为 90 .6 %、89.4 % ,免于心脏事件的生     

Ten-year outcome after coronary angioplasty in patients with single-vessel coronary artery disease and comparison with the results of the Coronary Artery Surgery Study (CASS)

The 10-year results of randomized trials comparing percutaneous transluminal coronary angioplasty (PTCA) in patients with single-vessel coronary artery disease (CAD) with coronary artery bypass grafting (CABG) and medical treatment are not available yet. The aim of this evaluation was to compare our 10-year follow-up results after PTCA in patients with single-vessel CAD with the 10-year follow-up results after CABG and medical treatment in the Coronary Artery Surgery Study (CASS) trial. We evaluated the clinical outcome of 509 patients with single-vessel CAD 10 years after coronary angioplasty. The data were compared with the results of 214 patients with single-vessel CAD after CABG or medical treatment from the CASS trial. End points were defined as death and myocardial infarction. Statistical evaluation was performed by life-table analysis and 2-sided Fisher's exact test. The rate of survival was 86% 10 years after PTCA compared with 85% after CABG and 82% after medical treatment in patients from the CASS trial (p = NS). Survival free from myocardial infarction was 77% after coronary angioplasty, 70% after CABG, and 72% after medical treatment (p = NS). Thus, in patients with single-vessel CAD, infarct-free survival 10 years after coronary angioplasty compared favorably with the results after bypass surgery or medical treatment from the CASS trial.     

Long-term clinical outcome following coronary artery bypass grafting for isolated stenosis of the left anterior descending coronary artery

Aims To detail the clinical and angiographic profile, and long-termoutcome in consecutive patients with isolated stenosis of theleft anterior descending coronary artery undergoing bypass surgery. Methods A retrospective study of all patients (n=301) (January 1984–December1990) and undergoing coronary artery bypass grafting for isolatedleft anterior descending disease, in the Irish Republic, wasperformed. Survival was compared with that of an exact age-and gender-matched cohort. Results Mean age was 53 (±9·3) years. There were 238 (79%)males. In 241 (80%) patients an internal thoracic arterial bypassgraft was used. Operative mortality was 1·3%. Of the280 (93%) patients alive (16 cardiac deaths) at 7·1 (±1·9)years, 105 (35%) had angina, 26 (9%) suffered an interval myocardialinfarction, and repeat revascularization was required on 29(10%). Female gender (P=0·002), pre-operative myocardialinfarction (P=0·02), significant diagonal disease (P=0·04)and postoperative myocardial infarction (P=0·0001) wereindependently associated with survival. Females were more likelyto develop congestive cardiac failure (P=0·01) or postoperativeangina (P=0·03) than their male counterparts. Conclusions Survivorship (97%) and event-free survival (96%) at 5 yearsfollowing coronary artery bypass grafting for isolated leftanterior descending coronary artery disease is excellent andequivalent to an age-matched and gender-matched cohort.     

Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.     

Usefulness of angioplasty during acute myocardial infarction in patients with prior coronary artery bypass grafting

The efficacy and risk of reperfusion strategies for myocardial infarction in patients with prior coronary artery bypass surgery are uncertain. In this study 72 patients with prior bypass grafting underwent direct percutaneous transluminal coronary angioplasty without antecedent thrombolytic therapy. There were 26 anterior and 46 inferior infarctions, including 11 patients (15%) in cardiogenic shock. The baseline ejection fraction was less than 40% in 47 (65%) patients. Angioplasty was successful in 41 of 48 (85%) vein grafts and 24 of 24 (100%) arteries (difference not significant) at 5.1 +/- 4.0 hours from the onset of symptoms (79% treated less than 6 hours). There were no urgent bypass operations, strokes or transfusions. In-hospital survival was 90% (nonshock 95% vs shock 64%, p less than 0.01). Symptomatic acute reclosure occurred in 1 patient. Predischarge coronary arteriography in 34 patients demonstrated continued vessel patency in 32 infarct vessels (94%), although 5 of these vessels were redilated for restenoses. Predischarge paired ventriculography in 26 patients showed an increase in ejection fraction from 44 +/- 16% to 51 +/- 18% (p less than 0.01). One- and 3-year actuarial survival was 89 and 87%. Thus, prior coronary surgery should not preclude reperfusion therapy by direct angioplasty, which can be accomplished with low procedural risk, improvements in ventricular function and excellent in-hospital and late survival.     

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less.

OBJECTIVE--To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians. SETTING--A tertiary referral cardiac centre. PATIENTS--57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient. RESULTS--The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival. CONCLUSIONS--In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.     

Long-term follow-up results after plain balloon coronary angioplasty.

Between September 1987 and June 1992, 571 patients of coronary artery disease underwent percutaneous transluminal coronary angioplasty in our institute. Their ages ranged from 31-82 years (mean 51 +/- 9) and majority (88.3%) were males. At baseline, 318 (55.7%) patients had chronic stable angina, 184 (32.2%) unstable angina, and 57 (10%) underwent PTCA for recurrence of angina in the post-infarction period. Single vessel angioplasty was performed in 406 (71.1%), two-vessel angioplasty in 121 (21.2%) and three or more vessels were dilated in 44 (7.7%). The procedure was successful in 524 (91.8%) patients. Follow-up was available in 438 (83.6%) patients, and ranged from 78 to 135 months (mean 89 +/- 29) with all the patients completing at least 60 months of follow-up. Using Kaplan-Meier statistical analysis, event-free survival (freedom from repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, or death) was 72.5 percent at three, 68.0 percent at five, 61.8 percent at seven and 55.6 percent at 10 years of follow-up. Freedom from major adverse cardiac events (myocardial infarction, coronary artery bypass surgery or death) was 88.3, 85.8, 82.0 and 75.4 percent at 3, 5, 7 and 10 years, respectively. Overall survival was 97.4 and 95.2 percent, respectively at 5 and 10 years. Subgroup analysis for all major events was done between males and females, diabetics and non-diabetics, previous history or absence of myocardial infarction, stable versus unstable angina and single versus multivessel disease. Event-free survival rates were compared between the groups using log rank test. On follow-up, the need for surgical revascularisation was more in males compared to females although statistically insignificant, and in patients with unstable angina compared to stable angina (p < 0.02). Similarly, freedom from major adverse cardiac events was significantly better in females compared to males (p < 0.05) and in stable versus unstable angina (p < 0.01). Event-free survival (repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, death) was also significantly better in patients with stable angina (p < 0.02). The other outcomes were comparable in all the subgroups. In conclusion, plain balloon angioplasty provides excellent long-term results in patients with coronary artery disease in terms of reduction in major adverse cardiovascular events and need for subsequent revascularisation.     

Emergency coronary artery surgery after refractory cardiac arrest: a single centre experience.

OBJECTIVE--To determine the incidence and outcome of refractory cardiac arrest necessitating emergency coronary artery bypass grafting. DESIGN--Retrospective survey of cardiac catheterisation and surgical records. SETTING--The London Chest Hospital. PATIENTS--All patients requiring emergency coronary artery bypass grafting after cardiovascular collapse in the catheterisation suite between January 1984 and December 1989. MAIN OUTCOME MEASURES--Incidence of refractory cardiac arrest in the study group and perioperative mortality. RESULTS--Thirteen of 8675 patients undergoing coronary arteriography or angioplasty had refractory cardiac arrests. Five patients died, but the remainder survived to be discharged from hospital without serious morbidity. CONCLUSION--Without immediate surgical intervention the mortality for these 13 patients would have been 100%.     

The optimal mode of coronary revascularization for diabetics: A risk-adjusted long-term study comparing coronary angioplasty and coronary bypass surgery

Aims Some recent studies have reported superior outcomes for diabeticpatients following coronary bypass surgery compared with coronaryangioplasty. However, the available data are conflicting, arebased on relatively small numbers of diabetic patients, andhave limited duration of follow-up. The aims of this study wereto compare risk adjusted long- term survival in diabetic patientsfollowing first-time revascularization via either coronary bypasssurgery or coronary angioplasty; and, to identify variablesindependently associated with mortality. Methods and Results This was a two centre database project involving 15809 patientsundergoing either coronary angioplasty or coronary bypass surgeryas their initial revascularization procedure. Diabetes was presentin 1938 (12%). Mean follow-up was 4·6±2·7years for angioplasty and 6·6±4·3 yearssurgery diabetic patients. Multivariable time-related analysesin the hazard function domain for death were performed. Overallten-year survival for pharmacologically treated diabetics wasbetter after coronary bypass surgery (60%) than angioplasty(46%, <0·0001). However, the risk-adjusted survivaladvantage conferred by bypass surgery over angioplasty was strongestfor patients receiving oral agents for diabetic control (75%vs 62%) and less impressive for diet (84% vs 81%) and insulin-treateddiabetics (63% vs 64%). The major factors independently associatedwith worse outcome after angioplasty were incomplete revascularization,and the use of a sulfonylurea agent. The use of the left internalmammary graft improved survival in surgical patients. Conclusions In general, diabetic patients had better long-term survivalafter bypass surgery than angioplasty. Incomplete revascularizationand sulfonylurea therapy worsened outcome after angioplasty,and use of the left internal mammary improved outcome afterbypass surgery.The European Society of Cardiology     

Emergency coronary artery surgery after refractory cardiac arrest: a single centre experience.

OBJECTIVE--To determine the incidence and outcome of refractory cardiac arrest necessitating emergency coronary artery bypass grafting. DESIGN--Retrospective survey of cardiac catheterisation and surgical records. SETTING--The London Chest Hospital. PATIENTS--All patients requiring emergency coronary artery bypass grafting after cardiovascular collapse in the catheterisation suite between January 1984 and December 1989. MAIN OUTCOME MEASURES--Incidence of refractory cardiac arrest in the study group and perioperative mortality. RESULTS--Thirteen of 8675 patients undergoing coronary arteriography or angioplasty had refractory cardiac arrests. Five patients died, but the remainder survived to be discharged from hospital without serious morbidity. CONCLUSION--Without immediate surgical intervention the mortality for these 13 patients would have been 100%.     

The Dutch experience in percutaneous transluminal angioplasty of narrowed saphenous veins used for aortocoronary arterial bypass

Of 19,994 percutaneous transluminal coronary angioplasty procedures performed in The Netherlands between April 1980 and January 1989, the long-term follow-up of 454 patients who underwent angioplasty of greater than or equal to 1 saphenous vein bypass graft was reviewed. In 46% of patients single graft angioplasty was attempted, and in 54% of patients sequential graft angioplasty was attempted. The clinical primary success rate was 90%. In-hospital mortality was 0.7%, 2.8% of patients sustained a procedural myocardial infarction, and 1.3% of patients underwent emergency bypass surgery. After a follow-up period of 5 years, 74% of patients were alive, and 26% were alive and event-free (no myocardial infarction, no repeat bypass surgery or repeat angioplasty). In patients in whom the initial angioplasty attempt was unsuccessful, only 3% were event-free at 5 years, versus 27% of successfully dilated patients. The time interval between the angioplasty attempt and previous surgery was a significant predictor for 5-year event-free survival. The event-free survival rates for patients who had bypass surgery 1 year before, between 1 and 5 years, and 5 years before angioplasty, were 45, 25 and 19%, respectively. Less than one-third of patients with previous bypass surgery who had angioplasty of the graft remained event-free after 5 years. In patients needing angioplasty within 1 year after bypass surgery, better long-term results were achieved.     

Outcome of off-pump coronary artery bypass in renal dialysis patients

BACKGROUND: Renal dialysis patients are a subgroup at major operative risk when undergoing coronary artery bypass grafting (CABG). Even though CABG without cardiopulmonary bypass (CPB) has decreased the surgical risk and provided good short-term results, the long-term survival seems uncertain. We report here on the long-term outcome of CABG without CPB in renal dialysis patients. METHODS: From 1998 to 2002, 44 renal dialysis patients underwent elective CABG without CPB, including 17 minimally invasive direct coronary artery bypass (MIDCAB) and 27 off-pump CABG (OPCAB) procedures. There were 5 one-vessel, 12 two-vessel and 27 multi-vessel coronary artery disease patients, who mainly had left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) grafting with an additional saphenous vein graft to non-LAD coronaries. RESULTS: All 44 patients were followed up for 44.4 +/- 31.2 months. Three (6.8 %) surgical deaths within 30 days occurred and 25 late mortalities happened over a period of 2 - 79 months. The 5-year cumulative rate of total survival is 38.2 % and the freedom from cardiac death is 70.9 %. Using hazard analysis, old age (> 60 years) and incomplete coronary revascularization was found to significantly affect the total survival. CONCLUSIONS: CABG without CPB provided an acceptable surgical mortality and morbidity. The high incidence of non-cardiac death associated with dialysis complications had an adverse impact on the overall outcome. The LITA bypass operation method combined with intensive care for dialysis complications would hopefully fulfill the goal to improve the short- and long-term results in this subgroup.     

Outcome following emergency coronary artery bypass grafting for failed elective balloon coronary angioplasty in patients with prior coronary bypass

To assess frequency and outcome of emergency coronary artery bypass grafting (CABG) for failed coronary angioplasty in patients with prior CABG, 2,136 elective angioplasty procedures in prior CABG patients were reviewed over a 10-year period. Emergency surgical revascularization was required in 19 patients (0.9%) with prior CABG, compared with 130 of 6,974 patients (1.9%) without prior CABG (p = 0.001). The interval from the most recent CABG to the failed coronary angioplasty was 6.8 years (range 1 to 16). Referral for emergency CABG was made on the basis of an acute closure not responding to repeat dilatation in 12 native coronary arteries and in 7 saphenous vein grafts. Severe hemodynamic instability after acute closure required the placement of an intraaortic balloon pump in 3 patients, including 2 who required cardiopulmonary resuscitation. A total of 34 saphenous vein grafts and 1 internal mammary artery graft were placed emergently. Three patients with high-risk features (3 prior CABG operations in 1 patient, single remaining vessel to heart in 2 patients) could not be weaned from cardiopulmonary bypass. The remaining 16 patients were discharged after a mean hospital stay of 16 days. Four patients developed new Q waves after CABG. At follow-up (mean 52 months, range 3 to 99), 1 patient died late from an acute myocardial infarction. The 15 survivors had no or mild angina and were free of further CABG. Thus, emergency CABG after failed angioplasty in patients with prior CABG is required infrequently. In patients without extreme high-risk features, emergency repeat CABG can be accomplished with good hospital and long-term results.     

Coronary artery surgery: conventional coronary artery bypass grafting versus off-pump coronary artery bypass grafting

PURPOSE OF REVIEW: Coronary revascularization has become the principal treatment modality in patients with severe coronary artery disease. The broader application of percutaneous coronary interventions in patients with multivessel disease and the recent introduction of drug-eluting stents have both lead to a decline in the number of patients referred for surgical revascularization. Conventional coronary artery bypass grafting using cardiopulmonary bypass is an excellent treatment, however less invasive surgical approaches such as off-pump coronary artery bypass grafting have appeared in the past few years. The exact role of off-pump coronary artery bypass grafting is still vaguely defined and being critically evaluated. Our aim is to provide an objective review of the recent literature in regard to surgical outcomes. RECENT FINDINGS: A critical review of all relevant clinical series from May 2003 to May 2005 was conducted. Current prospective data suggests that both techniques have similar rates of mortality, in regard to morbidity, multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. The incidence of postoperative myocardial infarction does not appear to differ between techniques. When analyzed carefully, the results presented herein seem to indicate that both techniques provide similar rates for long-term patency and freedom from surgical reintervention. SUMMARY: Coronary artery bypass grafting and off-pump coronary artery bypass grafting are both safe and beneficial in patients with multivessel coronary artery disease. It appears that elderly patients with additional co-morbid risk factors may benefit most from off-pump coronary artery bypass grafting. It has become increasingly apparent that off-pump coronary artery bypass grafting can be performed safely in reference centers.