Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease

Routine coronary angiography to determine the prevalence of severe coronary artery disease (CAD) has been recommended to all patients under consideration for elective peripheral vascular reconstruction at the Cleveland (Ohio) Clinic since April 1978. Those found to have severe, correctable CAD have been advised to undergo myocardial revascularization prior to performance of elective peripheral vascular operations. Forty-one of the 68 patients with abdominal aortic aneurysms (AAA) and 26 of the 71 patients with aortoiliac occlusive arterial disease (AI) had clinical evidence of CAD; coronary angiography demonstrated severe, correctable CAD in 23 patients with AAA and in 14 patients with AI. Twenty-seven patients with AAA and 45 patients with AI had no clinical evidence of CAD; severe, correctable CAD was found in six patients with AAA and in six patients with AI. Ninety-six patients, including 26 who had staged cardiac procedures performed, have had elective aortic reconstruction, with one operative death.

Curbing the nation's appetite: the case for controlling demand

For too long, controls have been placed on the costs of services, the construction of health care facilities, the numbers and kinds of providers, and the health insurance industry with no concomitant limits being set on the rising demand for capital-intensive and specialized services. If we are to avoid having a debilitated health care system that will be unable to respond to community needs, the author says, a more balanced approach in controlling supply and demand will have to be sought. He discusses some of the conceptual, technical, and operational problems that must be addressed immediately if these actions are to be successful.

The efficacy of CT: what the studies show

Is computed tomography (CT) a diagnostic miracle or an expensive and unproven procedure? In the multitude of published studies, critics of CT demand controlled clinical trials, but thus far the efficacy of CT has been judged from clinical experience alone, and few studies have been done on the effect of CT on disease management and patient outcome.

Ventricular tachyarrhythmias following surgery for myocardial revascularization. A follow-up study

Of 1,599 patients who underwent surgery for direct myocardial revascularization in 1973 at Cleveland Clinic Hospital, 19 patients (1.2 percent) developed primary ventricular fibrillation or ventricular tachycardia during the immediate postoperative period. Occurrence of postoperative ventricular tachyarrhythmias could not be predicted by assessment of preoperative symptoms or by evaluation of the extent of coronary artery disease and left ventricular function. There was no increase in early or late mortality or morbidity (including postoperative myocardial infarction) among patients who developed postoperative primary ventricular tachyarrhythmias.

Aortic valve replacement combined with myocardial revascularization. Late clinical results and survival of surgically-treated aortic valve patients with and without coronary artery disease

From 1967 through 1973, 80 consecutive patients underwent simultaneous aortic valve replacement (AVR) and coronary bypass grafting. Fourteen (18%) experienced no angina pectoris and had no history or electrocardiographic evidence of coronary atherosclerosis. Seven of these 14 had severe multiple vessel disease. All operations were performed under normothermic conditions without coronary perfusion. Seven patients (9%) died during operation. Intra-operative myocardial infarction was documented in eight (10%). After a mean follow-up of 35 months, overall mortality was highest in aortic regurgitation patients [seven of 13 (54%)] compared to aortic stenosis [17 of 54 (31%)] (P less than 0.07), and mixed pathology [1 of 13 (8%)]. Thirty-one of 34 (91%) grafts in 25 patients were patent an average of 12 months postoperatively. After 42 months a 65% actuarial survival was found in the combined AVR and graft(s) series versus a 76% survival in 300 AVR patients proven by angiography not to have severe coronary atherosclerosis.