Percutaneous transluminal coronary angioplasty after previous coronary artery bypass surgery

To improve symptomatic status and avoid repeat coronary artery bypass graft surgery (CABG), 115 lesions were approached for transluminal coronary angioplasty (PTCA) in 94 patients (82 men, 12 women) with angina pectoris and prior CABG at a mean of 60 months (range 4 to 192) after CABG. Fifteen patients were in Canadian Cardiovascular Society functional class I, 32 were in class II, 31 were in class III, and 16 were in class IV. Patients were 37 to 76 years old (mean 57). PTCA was successful (at least a 40% reduction in stenosis diameter and improvement in symptomatic status) in 83 patients (88%) and 103 (90%) lesions. Mean stenosis was reduced from 80 +/- 14% to 20 +/- 16% (mean +/- standard deviation) and mean pressure gradient from 41 +/- 7 mm Hg to 14 +/- 6 mm Hg. Seven patients had lesions that could not be crossed for technical reasons and these patients underwent non-emergency CABG. Four patients required emergency CABG after PTCA; 1 patient subsequently died and 2 survived acute myocardial infarction. One patient had a femoral artery laceration, which required surgical repair. At a mean follow-up of 8 +/- 4 months, 63 patients (76%) with initially successful results were free of angina or in improved condition. Of the remaining 20 patients, 18 consented to repeat coronary angiography. Four patients did not have restenosis. Of the 14 patients with documented restenosis, 5 underwent successful repeat PTCA, 5 had repeat CABG, and 4 were treated medically. Thus, when coronary anatomy is suitable, PTCA is an effective alternative to reoperation in symptomatic patients with prior CABG.     

Emergency coronary bypass surgery after coronary angioplasty: the national heart, lung, and blood institute''s percutaneous transluminal coronary angioplasty registry experience

The frequency and outcome of emergency CABG for complications of PTCA in the NHLBI PTCA Registry were analyzed. Emergency surgery was performed in 202 patients (6.6%). The most frequent indications for emergency operation were coronary dissection in 46%, coronary occlusion in 20%, prolonged angina in 14% and coronary spasm in 11%. Emergency surgery was most often necessary in patients in whom lesions could not be reached or traversed, but more than 25% of patients who required emergency surgery had initially successful dilatation followed by abrupt reclosure of the vessel. The mortality rate with emergency CABG was 6.4%, and nonfatal Ml occurred in 41% of patients, with Q waves developing in approximately 60% of patients with MI. However, 53% of patients managed with emergency CABG for severe ischemic events with PTCA did not have evidence of MI or die and had an uncomplicated postoperative course. No baseline clinical predictors of emergency surgery were identified. Lesion eccentricity was associated with a significant increase in frequency of emergency operation, and the incidence of emergency surgery declined with increasing experience with PTCA.     

Quality of life comparisons after coronary angioplasty and coronary artery bypass graft surgery

OBJECTIVE: To examine the differences in realization of expected benefits, complications, and quality of life (QOL) 3 months after percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery. DESIGN: Nonexperimental, prospective, and comparative. Before discharge, participants listed benefits expected from the procedure, as well as comorbid health problems (Charlson Comorbidity Index) and complications. At 3 months, they quantified their realization of expected benefits, reported postdischarge complications, and completed Ferrans and Powers' Quality of Life Index-Cardiac Version III. SAMPLE: 36 patients who had PTCA; 38 patients who had CABG. RESULTS: There were no differences between groups in realization of expected benefits or QOL. Patients who had CABG reported a greater number of complications after discharge, and a greater proportion of patients who had PTCA reported angina. Patients who had PTCA and then recurrent angina had significantly lower health QOL and psychologic and spiritual QOL. CONCLUSIONS: Patients who undergo CABG need guidance regarding what complications to expect, and patients who undergo PTCA need to know that recurrent angina is possible and how to manage it.     

Mortality in patients undergoing coronary artery bypass surgery after myocardial infarction

Data on 1,700 patients who underwent coronary artery bypass surgery without additional cardiovascular procedures at the Texas Heart Institute were analyzed, relating the interval between myocardial infarction and operation to early mortality (within 30 days after operation). Patients who underwent coronary artery bypass surgery after a recent infarction (within 2 months before operation) had a higher rate of early mortality (14.5 percent) than patients who had an old infarction (6.9 percent) or no previous infarction (4.1 percent). The interval between recent infarction and operation was most significant. Mortality in patients who underwent operation within the first 7 days after acute infarction (38.1 percent) was more than six times greater than in patients who were operated on 31 to 60 days after infarction (5.8 percent). Mortality of those operated on 8 to 30 days after infarction was 16.4 percent. Elective coronary artery bypass surgery after recent infarction is best accomplished after the first 30 days, when there is no increased risk to the patient. Emergency coronary artery bypass after complicated acute myocardial infarction may be a lifesaving procedure, but it is associated with increased early mortality and should be reserved for those whose condition has not responded to aggressive medical therapy.     

Coronary angioplasty in patients with prior coronary artery bypass surgery: all prior coronary artery bypass surgery patients and patients more than 5 years after coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been used successfully in patients who have had prior bypass surgery (CABG) as a means of revascularizing the myocardium and avoiding repeat myocardial revascularization. However, angioplasty has been considered inappropriate as a means of dilating old saphenous vein grafts. The first section of this article details the authors' experience with PTCA of prior CABG patients, and the second section discusses the results of PTCA in the subset of patients 5 or more years after their last coronary bypass surgery. These data may make individuals rethink the appropriateness of PTCA in old saphenous vein grafts.     

Comparison of coronary artery bypass surgery and percutaneous transluminal coronary angioplasty including surgery for failed angioplasty

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease and has thus redefined candidates for coronary artery bypass surgery. During our first years of experience with percutaneous angioplasty, 339 patients underwent the procedure and were compared with 338 patients who underwent isolated coronary artery bypass surgery. Patients who underwent PTCA had a shorter duration of angina and a lower number of prior myocardial infarctions and were found to have better left ventricular function (p less than 0.01). PTCA was considered initially successful in 87% (295 of 339) of patients. The most common finding at operation in those with failed angioplasty who underwent urgent or emergency revascularization was dissection of atheromatous plaque. Although the cumulative frequency of new Q waves in the entire 18-month angioplasty series was low (2.7%), the incidence was high (18%) in those with angioplasty failure and subsequent operation (N = 20) and significantly greater than in patients who had elective coronary artery bypass surgery (3.6%). Use of inotropic agents and lidocaine for ventricular arrhythmias was significantly higher in patients with unsuccessful PTCA who required operation than in those who underwent elective bypass surgery (10% vs 3% and 10% vs 1.5%, respectively; p less than 0.01). In an analysis of our entire experience between October 1980 and June 1982, 777 patients who had PTCA and 2068 patients who underwent coronary artery bypass surgery were analyzed for differences in clinical complications and early outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Late outcome of multivessel coronary artery disease after angioplasty or bypass surgery

Background. Results from randomized trials to determine optimal treatment for patients with multivessel coronary disease are not yet available. Thus, the early and late outcomes of 191 PTCA and 221 CABG patients done in 1985-86 were evaluated. Methods and Results. CABG patients selected had more coronary risk factors and more severe coronary artery disease compared to PTCA patients. Comparison of the initial outcome showed that clinical success without major cardiovascular events was similar (93.7% for PTCA vs. 90.0% for CABG; p=n.s.). Five year followup was obtained in 99.0% of PTCA patients and 94.4% of CABG patients. In the PTCA group, 89.8% were alive, 4.8% had sustained an MI, and repeat revascularization was required in 46.8%. In the CABG group, 87.1% were alive, 3.2% had had a MI, and 3.5% required repeat revascularization. Statistical comparison demonstrated no difference between the groups in survival or late cardiac events, but rate of repeat revascularization was significantly higher for PTCA patients (p less than 0.0001). Incompleteness of revascularization (p<0.01) was independently associated with an increased need for repeat revascularization in the PTCA group. In the CABG group, depressed left ventricular function (p less than 0.001) and female sex (p<0.01) were associated with lower survival rates. An analysis of cost per patient showed that the strategies were comparable. Conclusions. PTCA and CABG in multivessel disease patients have similar early results and comparable rates of survival and late cardiac events. Significantly more repeat revascularization is required in PTCA patients to maintain these results.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary angioplasty in patients following coronary artery bypass surgery

Objectives : We aimed to study the trends in management and outcome of post CABG patients presenting with acute MI. Background: Primary angioplasty is the treatment of choice in patients with acute myocardial infarction. Saphenous vein grafts used for CABG are large‐diameter conduits that tend to accumulate a large mass of thrombus when they are the culprit artery for acute myocardial infarction (MI). We hypothesized that performing PCI in these patients is more complex and possibly results in worse outcome compared to non‐CABG patients. Methods : Data for patients with STEMI was obtained from five acute coronary syndromes Israeli biennial Surveys (ACSIS) during 2000–2008. Baseline characteristics, management and outcome of post‐CABG patients were compared to non‐post CABG patients during 2006–2008 surveys. Results : A total of 9,781 patients were included. About 1,002 (10.2%) were post‐CABG. Reperfusion therapy for post‐CABG patients (34–48%) was consistently lower compared to non‐CABG patients (57–65%). Angiographic outcome in patients with STEMI who underwent primary PCI (17 post‐CABG, mean age 66.6 ± 9.1 and 821 non‐CABG, age 60.1 ± 12.9) was successful (TIMI flow 3) in 86 and 88%, respectively. Thirty‐day mortality was 5.9 and 5.1% (P = 0.89) and MACE rates were 17.6 and 12.5%, respectively (P = 0.54). Conclusions : Use of primary PCI in post‐CABG patients was lower than in non‐CABG patients but increased steadily and to a similar extent in both groups. Angiographic and clinical outcome was similar despite assumingly larger thrombus burden in post CABG patients. Therefore, primary angioplasty is appropriate also in post‐CABG patients presenting with STEMI. © 2011 Wiley‐Liss, Inc.     

冠状动脉旁路手术后康复

目的 :探讨冠状动脉搭桥术后早期康复运动的疗效。方法 :对 90例冠状动脉旁路手术患者于术后早期进行康复治疗。于胸部物理治疗的同时协助病人肢体各大关节、肌群先被动、后主动活动。待拔除引流管 2小时后 ,督促指导患者先平地行走后下台阶 ,逐渐至上、下 5层楼梯 (5METs) ,每日 2～3次。结果 :所有病人术后第 3日可下床活动。结论 :冠脉旁路手术的术前、后康复对病人早日回归社会有一定意义     

A comparison of three-year survival after coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty

Objectives. The purpose of this study was to compare 3-year risk-adjusted survival in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty.Background. Coronary artery bypass graft surgery and angioplasty are two common treatments for coronary artery disease. For referral purposes, it is important to know the relative pattern of survival after hospital discharge for these procedures and to identify patient characteristics that are related to survival.Methods. New York’s CABG surgery and angioplasty registries were used to identify New York patients undergoing CABG surgery and angioplasty from January 1, 1993 to December 31, 1995. Mortality within 3 years of undergoing the procedure (adjusted for patient severity of illness) and subsequent revascularization within 3 years were captured. Three-year mortality rates were adjusted using proportional hazards methods to account for baseline differences in patients’ severity of illness.Results. Patients with one-vessel disease with the one vessel not involving the left anterior descending artery (LAD) or with less than 70% LAD stenosis had a statistically significantly longer adjusted 3-year survival with angioplasty (95.3%) than with CABG surgery (92.4%). Patients with proximal LAD stenosis of at least 70% had a statistically significantly longer adjusted 3-year survival with CABG surgery than with angioplasty regardless of the number of coronary vessels diseased. Also, patients with three-vessel disease had a statistically significantly longer adjusted 3-year survival with CABG surgery regardless of proximal LAD disease. Patients with other one-vessel or two-vessel disease had no treatment-related differences in survival.Conclusions. Treatment-related survival benefit at 3-years in patients with ischemic heart disease is predicted by the anatomic extent and specific site of the disease, as well as by the treatment chosen.     

Left main coronary artery stenosis and progression of coronary artery atherosclerosis after angioplasty and stenting in patients directed to coronary artery bypass surgery

Recent investigations demonstrated appearance of left main coronary artery stenosis after PTCA. We performed a retrospective study of specific characteristics of development of coronary lesions after percutaneous coronary interventions (PCI) in patients subjected to coronary artery bypass grafting (CABG) because of angina recurrence after PCI. Data of 150 patients operated because of angina recurrence after PCI were analyzed. The recurrence of angina in 93% of cases was associated with development of significant stenoses in previously intact segments of coronary arteries, but not with restenosis or occlusion of the stented segment. The recurrence of symptoms occurred in 1 year after coronary stenting in 54% of patients. In 19 patients rapid development of a novel left main coronary artery stenosis was observed. Some characteristics of this group (the use of Back-up, XB, AL-catheters, repetitive PCI, manipulations in more than 2 coronary segments, stenting of bifurcations with 2 stents, use of kissing-balloons, small diameter of left coronary artery, and concomitant diabetes) significantly differed from those of the main group. In all patients CABG was successful.     

Comparison of angioplasty and bypass surgery in multivessel coronary artery disease

The role of coronary angioplasty in the treatment of patient with multivessel coronary artery disease has not been fully established. We compared immediate and 1-year follow-up results in 60 patients undergoing coronary angioplasty for multivessel coronary disease in 1982 with 41 patients anatomically suitable for angioplasty but who underwent elective coronary bypass surgery during the same time period. Baseline variables were similar in both groups except for number of vessels diseased which was higher in the surgical group. Angioplasty was initially successful in 70% of cases. There were no deaths. Mean initial hospital days were lower in the angioplasty group. At follow-up there were no significant differences in survival, functional class, occurrence of subsequent myocardial infarction or use of cardiac medications. However, 33% of the successfully dilated patients required either repeat dilatation or subsequent bypass surgery because of restenosis or inadequate initial revascularization. The statistical power of the study was limited due to the small sample sizes. While demonstrating that angioplasty can be successfully performed in patients with multivessel disease, definitive conclusions about the comparability of the two treatments are hampered by possible selection bias and small patient numbers. This issue could be better addressed by a multicenter prospective randomized trial.     

Life adaptation after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Life adaptation of 32 patients who had undergone percutaneous transluminal coronary angioplasty (PTCA) for coronary stenosis was compared with that of 15 patients who had coronary artery bypass grafting (CABG). Patients were matched for psychosocial, anatomic and cardiac functions. Life adaptation was measured at 6 and 15 months after PTCA or CABG by the Psychosocial Adjustment to Illness Scale (PAIS), a multidimensional instrument that evaluates change in 7 primary life domains. The overall PAIS scores for patients who had undergone PTCA were significantly better (p less than 0.04) than the scores for those who had undergone CABG after 6 months, and this superior functioning continued after 15 months (p less than 0.05). After 6 months patients who had undergone PTCA functioned better at work (p less than 0.005), in sexual performance (p less than 0.0001) and with their families (p less than 0.002). The improvement in work functioning continued at 15 months (p less than 0.04), but the differences in sexual and family domains became nonsignificant.     

Functional status after coronary artery bypass grafting and percutaneous transluminal coronary angioplasty

Two cohorts of consecutive patients of comparable age with similar preprocedure cardiac function who underwent either coronary artery bypass grafting (CABG; n = 106) or percutaneous transluminal coronary angioplasty (PTCA; n = 64) were entered into a prospective comparison study examining functional status and return to work during the first year of recovery. Patients were evaluated using standardized functional status instruments for activities of daily living, work performance, social activity, mental health and quality of social interaction at 1, 6 and 12 months after the procedure. Within the CABG group, statistically significant improvements of functional status on every subscale were noted over the 1-year follow-up. Patients undergoing PTCA demonstrated significant improvement in all dimensions except for the quality of interaction at 1 year as compared with baseline. When the 2 groups were compared, the PTCA group demonstrated greater participation than the CABG group in routine daily physical and social activities at 1 and 6 months, but this apparent advantage disappeared by 1 year. Measures of psychological functioning were better after CABG than after PTCA. A reduction in the number of those with employment occurred in both the CABG and PTCA groups, independent of physical functional status measures, which improved in both groups after the procedures. For those with employment, the CABG group reported the greatest improvement in work performance.     

Pulmonary function after coronary artery bypass surgery

Coronary artery bypass graft surgery (CABG) adversely affects pulmonary function tests (PFTs). Although several previous studies have addressed these changes, none has measured the forced vital capacity (FVC) on a daily basis. The purpose of the present study was to assess serial changes in the FVC following CABG and to identify factors that may influence these changes. The FVC was obtained pre-and daily postoperatively (1–10 days) in 120 patients. Fifty-one patients received saphenous vein grafts (SVG group) while 69 received at least one internal mammary artery graft in addition to SVG (IMA group). On the first postoperative day, the FVC decreased to 33% of the pre-operative value in the SVG group and to 29% in the IMA group. The spirometry gradually improved, but after 10 days, the FVC remained reduced (SVG, 70%; IMA, 60%). Although the decreases in FVC tended to be greater in the IMA group, there was no significant difference in the two groups (P=0·27). The changes in FVC were not significantly related to age (P=0·48), smoking history (P=0·65), anesthesia (P=0·38) or pump time (0·09). From this study, it is concluded that after CABG, there is a significant worsening of the pulmonary function. The nadir of FVC occurs immediately after surgery and improves gradually thereafter. However, on the tenth postoperative day, the FVC still remains more than 30% below pre-operative values. Since there is only a slight tendency for patients undergoing IMA grafting to have larger decreases in their pulmonary function, patients with ventilatory impairment should not be excluded from IMA grafting.