Percutaneous transluminal coronary angioplasty as palliation for patients considered poor surgical candidates

Percutaneous cardiopulmonary bypass-supported coronary angioplasty in patients with unstable angina pectoris or myocardial infarction and a left ventricular ejection fraction < or = 25%

The objective of this study was to determine the acute and long-term results of percutaneous cardiopulmonary bypass-supported angioplasty in treating high-risk patients with unstable presentations and severely depressed left ventricular (LV) function (ejection fraction [EF] < or = 25%). One hundred seven consecutive patients with a mean LVEF of 19 +/- 3% were studied. Seventy-four patients (69%) had unstable angina, 60 (56%) had New York Heart Association class III or IV symptoms, 74 (69%) had recent (< 15 days) documented acute myocardial infarction, 103 (96%) had 3-vessel disease, and 58 (54%) had only 1 remaining patent artery. A total of 50 patients (47%) were deemed unsuitable for bypass surgery. Of 196 severe narrowings attempted in 166 coronary arteries, 193 (98%) were successfully dilated in 105 patients (98%), and there was no procedure-related mortality, Q-wave myocardial infarction, or urgent requirement for coronary bypass surgery. There were 5 in-hospital deaths (4.7%) and the remaining 102 patients have been followed for 24.5 +/- 1.3 (mean +/- SE) months. Twenty-three patients (21%) died between 1 and 23 months after the procedure. One- and 2-year survival free of cardiac death was 83% and 77%, respectively. Of the 79 surviving patients, 65 have survived event free of myocardial infarction and revascularization; event-free survival for 1 and 2 years was 76% and 69.5%, respectively. In the 64 patients in whom LV function was measured before and after the procedure, global EF increased from 20.6% to 29.3% (p < 0.001). Patients who remained event free had a greater improvement in LVEF than those who had a cardiac event during follow-up (p < 0.05). Thus, this study demonstrates the safety and efficacy of percutaneous cardiopulmonary bypass-supported angioplasty in the immediate treatment of high-risk unstable patients with multivessel coronary artery disease and severely depressed LV function.

Late results of coronary angioplasty in patients with left ventricular ejection fractions < or = 40%

Left ventricular (LV) function is the most important independent predictor of long-term survival in patients with coronary artery disease, and results of bypass surgery improving survival in the setting of depressed LV function are well documented. Data regarding long-term outcome in patients undergoing coronary angioplasty are limited. From 1983 through 1989, 343 consecutive patients with an ejection fraction (EF) < or = 40% (mean 34% +/- 5%) undergoing elective coronary angioplasty were evaluated, retrospectively. The mean age was 61 +/- 10 years and 80% were men. Angiographic success (469 of 496 narrowings) was 95%. Major complications occurred in 26 patients (7.6%): emergency bypass surgery (n = 11), nonfatal myocardial infarction (n = 8), and death (n = 9). Follow-up was available for 99% of patients with clinical success (mean = 36 +/- 22 months). Fourteen patients (4.5%) developed nonfatal myocardial infarction and 72 patients (23%) had symptomatic restenosis, 32 patients requiring repeat angioplasty or atherectomy and 29 bypass surgery. Fifty-six patients (18.2%) died. Three-year survival was 84%. EF was a significant predictor of death: 3-year survival was 69%, 83% and 92%, respectively, in patients with EF < or = 30%, 31% to 35%, and 36% to 40% (p = 0.0001). A high angiographic success rate and an acceptable procedural risk were encountered in patients with depressed LV function undergoing angioplasty. The 3-year mortality rate, however, is substantial and directly related to the degree of LV dysfunction.

Coronary angioplasty in the elderly: immediate and long-term results

Coronary angioplasty was performed in 37 elderly patients (> sixty-eight years) with unstable or stable angina, refractory to medical treatment. History of myocardial infarction was present in 38% and of previous bypass surgery in 5% of patients. Coronary angiography revealed single-vessel disease in 22 (59%) and multivessel disease in 15 (41%) of patients. The mean left ventricular ejection fraction was 53 +/- 17%. Percutaneous transluminal coronary angioplasty (PTCA) was successful in 92% of patients; there were two angioplasty failures and 1 acute occlusion leading to Q wave myocardial infarction. In patients with multivessel disease complete revascularization was achieved in 33%. Follow-up data (21.29 +/- 9.23 months) are available in all patients with primary angiographic success. There was 1 death. Seventy-nine percent of patients had an improved anginal status, and repeat PTCA was performed in 2 patients because of clinical recurrence. Thus, coronary angioplasty is a safe and efficacious method of revascularization in symptomatic patients over the age of sixty-eight years.

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Safety and efficacy of percutaneous transluminal coronary angioplasty in patients with left ventricular dysfunction

The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.

Clinical factors affecting the immediate outcome of PTCA in patients with unstable angina and poor candidates for surgery

Percutaneous Transluminal Coronary Angioplasty (PTCA) has been successfully applied in unstable angina to carefully selected patients. In this study, PTCA was performed in 277 consecutive patients suffering from unstable angina and for whom bypass surgery was not a valid alternative because either of inoperable conditions or of emergency, or because surgery was not the best option. All patients were admitted first to the intensive care unit where an attempt was made to control unstable angina under conventional medical therapy using at least iv nitroderivative, heparin, and calcium blockers. After a standardized preparation PTCA was performed either as an emergency procedure in medically refractory unstable angina (107 cases) or as an elective procedure in controlled situations after a 7 to 10 days symptom-free period. Three hundred fifty-three coronary vessels were attempted. Results of this group are compared with those of a control group made of 670 consecutive stable patients recruited during the same period, and clinical characteristics are envisaged as potential predictive factors. Unstable angina is undoubtedly associated with a higher overall complication rate, but the immediate outcome is strongly affected by the clinical context. As an example, respective success and mortality rates are: 93% and 0% when a full revascularization is attempted; 91% and 0% in elective procedures in patients under 60; 87% and 1.2% in elective PTCA for multiple vessel disease; 80% and 6.5% in emergency PTCA; 80% and 11% in the overall triple vessel disease; 84% and 16% in patients with deeply altered ejection fraction; and 58% and 26% in triple vessel disease with 2 previously occluded coronary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty in patients with severe left ventricular dysfunction

The applications for coronary angioplasty have greatly expanded and the procedure is now increasingly used in complex and potentially high risk conditions. This report describes the short- and long-term effects of coronary angioplasty in 61 patients with severely depressed left ventricular function (ejection fraction less than or equal to 35%) with unstable or refractory anginal symptoms, or both, in whom revascularization was necessary despite increased risk. In a retrospective analysis of 1,260 patients undergoing angioplasty between January 1985 through December 1987, 61 had an ejection fraction less than or equal to 35%. The common clinical presentation was unstable angina (70%) with or without recent myocardial infarction. Mean left ventricular ejection fraction was 27 +/- 6%. Forty-five patients (74%) had multivessel disease. Clinical success after angioplasty was achieved in 55 patients (90%). Major complications (death, infarction and emergency bypass surgery) occurred in five patients (8.2%), with death in two (3.2%). During long-term (mean 21 +/- 11 months) follow-up study of the 55 patients with successful angioplasty, 13 (23%) died, including 3 of noncardiac causes, and 11 (20%) had clinically symptomatic recurrence. Continued clinical success was present in 39 patients (71%), of whom 28 (51%) were event-free patients and 11 (20%) had clinical recurrence; a successful second angioplasty procedure was performed in 9 because of restenosis. Thus, in patients with depressed left ventricular function, coronary angioplasty can be performed with a short-term success rate comparable to that of routine angioplasty or surgical procedures. However, acute complications are more frequent and the late mortality rate is higher than in patients with less depressed function.

Failed elective percutaneous transluminal coronary angioplasty requiring coronary artery bypass surgery. In-hospital and late clinical outcome at 5 years

This study was performed to define the in-hospital and late clinical outcome at 5 years in 430 patients who had a failed elective percutaneous transluminal coronary angioplasty (PTCA) and underwent coronary artery bypass graft (CABG) surgery during their hospitalization. This group comprised 5.9% of 7,246 patients undergoing elective PTCA. CABG surgery was performed in 346 patients with ongoing myocardial ischemia (80.5%) and in 84 patients without ischemia (19.5%). Their mean age was 56 +/- 9 years, and 76.3% were male. One-vessel disease was present in 72.3%, and the mean left ventricular ejection fraction was 59 +/- 11%. Overall, 1.9 +/- 0.9 bypass grafts were placed. There was increased use of the internal thoracic artery in the nonischemic group. A new nonfatal postprocedural Q wave myocardial infarction occurred in 21.2% and occurred more frequently in the ischemic (25.4%) than in the nonischemic (3.6%) group (p less than 0.0001). There were six in-hospital deaths (1.4%), an incidence that did not differ between the two groups. Follow-up was 99.8% complete. There were 25 deaths (93.2 +/- 1.5%, 5-year survival), including 16 of cardiac cause (95.3 +/- 1.3%, 5-year cardiac survival). Q wave myocardial infarction occurred in 111 patients (91 in-hospital), and freedom from cardiac death or nonfatal myocardial infarction at 5 years was 71 +/- 3%. In the group going to CABG surgery with ongoing ischemia, the 5-year cardiac survival was 94.9 +/- 1.6%, and in the group without ischemia, the corresponding survival was 96.2 +/- 2.2%. By multivariate analysis, the presence of preoperative myocardial ischemia, pre-PTCA diameter stenosis less than 90%, and the presence of multiple-vessel disease correlated with the occurrence of cardiac death or nonfatal myocardial infarction at 5 years. At this large-volume center with extensive PTCA operator and surgical experience, the excellent survival and low event rates over 5 years support the concept that despite the failed elective PTCA procedure, there was little effect on long-term survival provided the patient underwent prompt successful surgical revascularization.

"High-risk" percutaneous transluminal coronary angioplasty with preventive intra-aortic balloon counterpulsation

Between January 1987 and February 1988, 1,385 patients underwent percutaneous transluminal coronary angioplasty; 27 procedures were performed using prophylactic intraaortic balloon counterpulsation. Twenty-four patients had poor left ventricular function (EF less than 40%), and coronary dilatation was performed in arteries opposite to an occluded myocardial necrosis related vessel. In three patients of advanced age with distal stenoses and normal left ventricular function a multivessel dilatation was performed. Primary success rate was achieved in all patients. There were no deaths, myocardial infarctions or emergency bypass operations in the hospitalization period. During the follow-up (9 to 21 months) there were 2 deaths, 1 cardiac transplantation, and 6 restenosis with repeated dilatation. If revascularization is warranted, in high-risk patients, coronary angioplasty can be performed safely and successfully with protection by intraaortic balloon counterpulsation. However the long-term prognosis of these patients is complicated by the presence of other high-risk variables, such as advanced age or poor left ventricular function.

Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy

Patients with very poor ventricular function have been thought to be highly vulnerable to elective myocardial revascularization. Ischemic cardiomyopathy is now the major indication for cardiac transplantation. The 2-year survival of medically treated patients with ejection fractions less than 20%, but who are not sufficiently symptomatic for cardiac transplantation, is less than 25%. At our institution we have taken an aggressive approach by using myocardial revascularization for chronic ischemic cardiomyopathy. Between 1983 and 1988, 39 patients with preoperative ejection fractions less than 20% underwent coronary artery bypass. Patients were excluded if they had valvular heart disease other than mild to moderate mitral regurgitation, required resection of a left ventricular aneurysm, or required emergency operation for acute coronary occlusion. Mean age was 63.3 years (range, 43 to 80 years) and 31 were men. Mean preoperative ejection fraction was 18.3% (range, 10% to 20%) and the mean preoperative left ventricular end diastolic pressure was 22 mm Hg (range, 8 mm Hg to 38 mm Hg). There was one operative death (2.6%). Mean follow-up was 21 months (range, 3 to 60 months) with eight late deaths (a total mortality rate of 21%). Seven deaths were due to arrhythmias. Three patients continued to have severe heart failure, one of whom underwent successful cardiac transplantation. By life table analysis, there was a 3-year survival rate of 83%. With the present shortage of cardiac transplant donors, myocardial revascularization for ischemic cardiomyopathy is a reasonably effective means for preserving residual ventricular function.