Current results of coronary bypass surgery after failed angioplasty
Pragliola, C.; Kootstra, G.J.; Lanzillo, G.; Rose, P.A.; Quafford, M.; Uitdenhaag, G.
Journal of Cardiovascular Surgery 35(5): 365-369
1994
ISSN/ISBN: 0021-9509 PMID: 7995825 Document Number: 437806
Percutaneous Transluminal Coronary Angioplasty (PTCA) is a technique in continuous development. Since its introduction indications, number, quality of stenosis amenable to treatment and device employed have evolved leading to a change in the population undergoing treatment. Therefore surgical results obtained in the early 80's may not apply to the beginning of the 90's. This reason prompted us to review our recent experience. In the last 4 years (1989-1992) among 2563 PTCA procedures performed in our Institution, 114 patients (4.3%, CL 3.5%-5%) underwent urgent surgical revascularization because of failed angioplasty. Thirty-four patients (30%, CL 21%-38%) were older than 65 years; 68 patients (60%, CL 50%-68%) had multiple vessel disease; 63 patients (55%, CL 46%-64%) had previous Myocardial Infarction (M.I.); 20 patients (17%, CL 10%-24%) had already undergone a PTCA and 3 patients (2%, CL 0%-6%) had had coronary surgery. In 21 patients (18%, CL 11%-25%) the left ventricular Ejection Fraction (EF%) was below lt 50%. Complete revascularization was always performed with an average of 2.2+-1 graft/patient. A Left Internal Mammary Artery (LIMA) was implanted in 20 patients (17%, CL 10%-25%) of the patients and in 52% of cases requiring LAD grafts in the last two years. There were 2 deaths (1.7%, CL 0%-4%), both patients were in cardiac arrest before surgery (p lt 0.001), 2 patients required a LVAD to be weaned from ECC and 7 patients (6%, CL 1%-10%) had an IABP inserted at the moment of surgery. Twenty-five patients (21%, CL 14%-29%) showed evidence of a new myocardial infarction. Only ongoing ischemia (31 patients: 27%, CL 19%-35%) at the moment of surgery was predictive of postoperative MI (48%, CL 30%-65%; p lt 0.001). A perfusion catheter was inserted before surgery in 23 patients. In this group of patients the incidence of postoperative MI (17%, CL 2%-32%) was lower than the group with ongoing ischemia (p=0.01). We conclude that the current population undergoing surgery for failed PTCA has a high incidence of previous major cardiac events and multiple vessel disease. The incidence of postoperative MI remains higher than elective surgical cases and is one of the major pitfalls of the PTCA procedures, although the use of perfusion catheters contributes to reduce this complication. The in-hospital mortality is low, while the increasing use of LIMA may improve long term results.