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Matta A, Ohlmann P, Nader V, Levai L, Kang R, Carrié D, Roncalli J. A review of the conservative versus invasive management of ischemic heart failure with reduced ejection fraction. Curr Probl Cardiol 2024; 49:102347. [PMID: 38103822 DOI: 10.1016/j.cpcardiol.2023.102347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
Heart failure is increasing in terms of prevalence, morbidity, and mortality rates. Clinical trials and studies are focusing on heart failure as it is the destiny end-stage for several cardiovascular disorders. Recently, medical therapy has dramatically progressed with novel classes of medicines providing better quality of life and survival outcomes. However, heart failure remains a heavy impactful factor on societies and populations. Current guidelines from the American and European cardiac societies are not uniform with respect to the class and level of treatment recommendations for coronary artery disease patients with heart failure and reduced ejection fraction. The discrepancy among international recommendations, stemming from the lack of evidence from adequately powered randomized trials, challenges physicians in choosing the optimal strategy. Hybrid therapy including optimal medical therapy with revascularization strategies are commonly used for the management of ischemic heart failure. Coronary artery bypass graft (CABG) has proved its efficacy on improving long term outcome and prognosis while no large randomized clinical trials for percutaneous coronary intervention (PCI) are still available. Regardless of the lack of data and recommendations, the trends of performing PCI in ischemic heart failure prevailed over CABG whereas lesion complexity, chronic total occlusion and complete revascularization achievement are limiting factors. Lastly, regenerative medicine seems a promising approach for advanced heart failure enhancing cardiomyocytes proliferation, reverse remodeling, scar size reduction and cardiac function restoration.
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Affiliation(s)
- Anthony Matta
- Department of Cardiology, Civilian Hospital of Colmar, Colmar, France.
| | - Patrick Ohlmann
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Vanessa Nader
- Department of Cardiology, Civilian Hospital of Colmar, Colmar, France
| | - Laszlo Levai
- Department of Cardiology, Civilian Hospital of Colmar, Colmar, France
| | - Ryeonshi Kang
- Department of Cardiology, University Hospital of Toulouse, Toulouse, France
| | - Didier Carrié
- Department of Cardiology, University Hospital of Toulouse, Toulouse, France
| | - Jerome Roncalli
- Department of Cardiology, University Hospital of Toulouse, Toulouse, France
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Nader V, Matta A, Kang R, Deney A, Azar R, Rouzaud-Laborde C, Kunduzova O, Itier R, Fournier P, Galinier M, Carrié D, Roncalli J. Mortality rate after coronary revascularization in heart failure patients with coronary artery disease. ESC Heart Fail 2023. [PMID: 37376752 PMCID: PMC10375079 DOI: 10.1002/ehf2.14445] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/21/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
AIMS Coronary artery disease (CAD) is a common cause of heart failure (HF). It remains unclear who, when and why to direct towards coronary revascularization. The outcomes of coronary revascularization in HF patients are still a matter of debate nowadays. This study aims to evaluate the effect of revascularization strategy on all-cause of death in the context of ischaemic HF. METHODS AND RESULTS An observational cohort was conducted on 692 consecutive patients who underwent coronary angiography at the University Hospital of Toulouse between January 2018 and December 2021 for either a recent diagnosis of HF or a decompensated chronic HF, and in whom coronary angiograms showed at least 50% obstructive coronary lesion. The study population was divided into two groups according to the performance or not of a coronary revascularization procedure. The living status (alive or dead) of each of the study's participants was observed by April 2022. Seventy-three per cent of the study population underwent coronary revascularization either by percutaneous coronary intervention (66.6%) or coronary artery bypass grafting (6.2%). Baseline characteristics including age, sex and cardiovascular risk factors did not differ between the invasive and conservative groups, respectively. Death occurred in 162 study participants resulting in an all-cause mortality rate of 23.5%; 26.7% of observed deaths have occurred in the conservative group versus 22.2% in the invasive group (P = 0.208). No difference in survival outcomes has been observed over a mean follow-up period of 2.5 years (P = 0.140) even after stratification by HF categories (P = 0.132) or revascularization modalities (P = 0.366). CONCLUSIONS Findings from the present study showed comparable all-cause mortality rates between groups. Coronary revascularization does not modify short-term survival outcomes in HF patients compared with optimal medical therapy alone outside the setting of acute coronary syndrome.
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Affiliation(s)
- Vanessa Nader
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
- Faculty of Sciences, Paul-Sabatier Toulouse III University, Toulouse, France
- INSERM I2MC - UMR1297, Toulouse, France
| | - Anthony Matta
- Department of cardiology, Civilians Hospital of Colmar, Colmar, France
- Notre Dame des Secours University Hospital Center, Lebanon/School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
| | - Ryeonshi Kang
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
- Faculty of Sciences, Paul-Sabatier Toulouse III University, Toulouse, France
| | - Antoine Deney
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Rania Azar
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon
| | - Charlotte Rouzaud-Laborde
- INSERM I2MC - UMR1297, Toulouse, France
- Clinical Department of Pharmacy, Faculty of Pharmacy, UFR Toulouse III, Toulouse, France
| | | | - Romain Itier
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Pauline Fournier
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Michel Galinier
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
- Faculty of Sciences, Paul-Sabatier Toulouse III University, Toulouse, France
| | - Didier Carrié
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
- Faculty of Sciences, Paul-Sabatier Toulouse III University, Toulouse, France
| | - Jerome Roncalli
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
- Faculty of Sciences, Paul-Sabatier Toulouse III University, Toulouse, France
- INSERM I2MC - UMR1297, Toulouse, France
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Velagaleti RS, Vetter J, Parker R, Kurgansky KE, Sun YV, Djousse L, Gaziano JM, Gagnon D, Joseph J. Change in Left Ventricular Ejection Fraction With Coronary Artery Revascularization and Subsequent Risk for Adverse Cardiovascular Outcomes. Circ Cardiovasc Interv 2022; 15:e011284. [PMID: 35411780 PMCID: PMC10103079 DOI: 10.1161/circinterventions.121.011284] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Coronary revascularization is recommended to treat ischemic cardiomyopathy. However, the relations of revascularization-associated ejection fraction (EF) change to subsequent outcomes have not been elucidated. METHODS In 10 071 veterans (mean age 67 years; 1% women; 15% non-White) who underwent a first percutaneous coronary intervention (PCI) or coronary artery bypass grafting between January 1, 1995, and December 31, 2010, and had prerevascularization and postrevascularization EF measured, we calculated delta-EF (postprocedure EF-preprocedure EF). We related delta-EF as a continuous measure and as categories (≤-5, -5<delta-EF<0, delta-EF=0, 0<delta-EF<5, and delta-EF≥5) to death (using Cox regression) and heart failure hospitalization days (using negative binomial regression) in multivariable-adjusted models, for total sample, and PCI and coronary artery bypass grafting strata. RESULTS Over follow-up (mean/maximum 5/14 years) 56% died. Each 5% improvement in delta-EF was associated with statistically significant reductions in death and heart failure hospitalization days of 5% (95% CI, 3%-7%) and 10% (95% CI, 5%-15%), respectively, in the total sample and 6% (95% CI, 4%-8%) and 10% (95% CI, 5%-16%), respectively, in the PCI subgroup. Patients in the highest delta-EF category had 27% (95% CI, 19%-34%) lower mortality (30% [95% CI, 21%-37%] lower in PCI stratum) and ≈40% lower heart failure hospitalization days in total sample and PCI stratum, compared with those in the lowest category. Relations of delta-EF and outcomes in coronary artery bypass grafting subgroup did not reach statistical significance. CONCLUSIONS Revascularization-associated EF improvement was associated with significant reductions in mortality and heart failure hospitalization burden, particularly in the PCI subgroup.
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Affiliation(s)
- Raghava S Velagaleti
- Cardiology Section, Department of Medicine (R.S.V., J.J.), VA Boston Healthcare System
| | - Joy Vetter
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Rachel Parker
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Katherine E Kurgansky
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Yan V Sun
- Emory School of Public Health, Atlanta, GA (Y.V.S.).,Atlanta VA Healthcare System, Decatur, GA (Y.V.S.)
| | - Luc Djousse
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System.,Division of Aging (L.D., J.M.G.), Brigham and Women's Hospital, Boston, MA
| | - J Michael Gaziano
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System.,Division of Aging (L.D., J.M.G.), Brigham and Women's Hospital, Boston, MA
| | - David Gagnon
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Jacob Joseph
- Cardiology Section, Department of Medicine (R.S.V., J.J.), VA Boston Healthcare System.,Division of Cardiovascular Medicine (J.J.), Brigham and Women's Hospital, Boston, MA
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Revascularization for Heart Failure: Can We Do Better? JACC-HEART FAILURE 2018; 6:527-529. [PMID: 29852934 DOI: 10.1016/j.jchf.2018.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 11/20/2022]
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Bruno P, Iafrancesco M, Massetti M. CABG for patients with heart dysfunction: when and why to refuse surgery. Minerva Cardioangiol 2018; 66:551-561. [PMID: 29687703 DOI: 10.23736/s0026-4725.18.04711-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Surgical myocardial revascularization in patients with reduced left ventricular function has been a matter of debate for decades. A recently-published 10-year extension follow-up of the STICH trial has conclusively demonstrated the benefit of surgical myocardial revascularization in patients with significant coronary artery disease and low left ventricular ejection fraction. However, patient selection for surgery remains challenging, and so does the decision to perform percutaneous rather than surgical revascularization in this class of patients. New evidence helped to clarify the role of preoperative patients' characteristics as risk factors for surgery and to identify those patients who may benefit the most from surgery. Focus of this review is to review epidemiology and results of observational and investigational studies on revascularization in patients with reduced left ventricular function with a particular emphasis on relative indication of coronary artery bypass grafting and percutaneous coronary intervention.
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Affiliation(s)
- Piergiorgio Bruno
- Unit of Cardiac Surgery, Department of Cardiovascular Surgery, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Mauro Iafrancesco
- Unit of Cardiac Surgery, Department of Cardiovascular Surgery, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy -
| | - Massimo Massetti
- Unit of Cardiac Surgery, Department of Cardiovascular Surgery, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy
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Abstract
Perioperative vision loss (POVL) may cause devastating visual morbidity. A prompt anatomical and etiologic diagnosis is paramount to guide management and assess prognosis. Where possible, steps should be undertaken to minimize risk of POVL for vulnerable patients undergoing high-risk procedures. We review the specific risk factors, pathophysiology, and management and prevention strategies for various etiologies of POVL.
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Affiliation(s)
- Bart Chwalisz
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
| | - Aubrey L Gilbert
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
| | - John W Gittinger
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
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Comparison of Outcomes of Coronary Artery Bypass Grafting Versus Drug-Eluting Stent Implantation in Patients With Severe Left Ventricular Dysfunction. Am J Cardiol 2017; 120:69-74. [PMID: 28483202 DOI: 10.1016/j.amjcard.2017.03.261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/24/2017] [Accepted: 03/24/2017] [Indexed: 11/20/2022]
Abstract
The optimal revascularization strategy for patients with significant coronary artery disease (CAD) and severe left ventricular (LV) dysfunction (ejection fraction ≤35%) remains unclear. We compared the effects of coronary artery bypass surgery (CABG, n = 442) versus percutaneous coronary intervention (PCI) with drug-eluting stents (n = 469) on long-term mortality in 911 patients with significant CAD and severe LV dysfunction using large real-world registry data. Databases of 3 real-world registries were merged for a patient-level meta-analysis. Primary outcome was death from any cause; secondary outcomes were death from cardiac causes, myocardial infarction, stroke, or repeat revascularization. At a median follow-up of 37.3 months, the risk of all-cause death (adjusted hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.31 to 0.61; p <0.001) was significantly lower in the CABG group than in the PCI group after adjustment. Similar findings were observed with regard to the risks of death from cardiac cause (adjusted HR 0.49; 95% CI 0.33 to 0.73; p <0.001) and repeat revascularization (adjusted HR 0.08; 95% CI 0.03 to 0.20; p <0.001). However, there were no significant differences in the risks of myocardial infarction and stroke between the 2 groups. The superiority of CABG over PCI was particularly pronounced in patients receiving β blockers and angiotensin-converting enzyme inhibitor or angiotensin receptor blockers than those who are not. In conclusion, among patients with significant CAD and severe LV dysfunction, CABG showed a lower risk of all-cause death, cardiac-cause death, and repeat revascularization compared with PCI with drug-eluting stents.
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Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in Patients With Multivessel Coronary Artery Disease and Severe Left Ventricular Systolic Dysfunction: Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery. Circulation 2016; 133:2132-40. [PMID: 27151532 DOI: 10.1161/circulationaha.115.021168] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/28/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular systolic dysfunction. However, CABG has not been compared with PCI in such patients in randomized trials. METHODS AND RESULTS Patients with multivessel disease and severe left ventricular systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of myocardial infarction, stroke, and repeat revascularization. Among the 4616 patients who fulfilled our inclusion criteria (1351 everolimus-eluting stent and 3265 CABG), propensity score matching identified 2126 patients with similar propensity scores. In the short term, PCI was associated with a lower risk of stroke (hazard ratio [HR], 0.05; 95% confidence interval [CI], 0.01-0.39; P=0.004) in comparison with CABG. At long-term follow-up (median, 2.9 years), PCI was associated with a similar risk of death (HR, 1.01; 95% CI, 0.81-1.28; P=0.91), a higher risk of myocardial infarction (HR, 2.16; 95% CI, 1.42-3.28; P=0.0003), a lower risk of stroke (HR, 0.57; 95% CI, 0.33-0.97; P=0.04), and a higher risk of repeat revascularization (HR, 2.54; 95% CI, 1.88-3.44; P<0.0001). The test for interaction was significant (P=0.002) for completeness of revascularization, such that, in patients in whom complete revascularization was achieved with PCI, there was no difference in myocardial infarction between PCI and CABG. CONCLUSIONS Among patients with multivessel disease and severe left ventricular systolic dysfunction, PCI with everolimus-eluting stent had comparable long-term survival in comparison with CABG. PCI was associated with higher risk of myocardial infarction (in those with incomplete revascularization) and repeat revascularization, and CABG was associated with higher risk of stroke.
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Affiliation(s)
- Sripal Bangalore
- From New York University School of Medicine (S. Bangalore, Y.G., S. Blecker); and School of Public Health, University at Albany, State University of New York at Albany (Z.S., E.L.H.).
| | - Yu Guo
- From New York University School of Medicine (S. Bangalore, Y.G., S. Blecker); and School of Public Health, University at Albany, State University of New York at Albany (Z.S., E.L.H.)
| | - Zaza Samadashvili
- From New York University School of Medicine (S. Bangalore, Y.G., S. Blecker); and School of Public Health, University at Albany, State University of New York at Albany (Z.S., E.L.H.)
| | - Saul Blecker
- From New York University School of Medicine (S. Bangalore, Y.G., S. Blecker); and School of Public Health, University at Albany, State University of New York at Albany (Z.S., E.L.H.)
| | - Edward L Hannan
- From New York University School of Medicine (S. Bangalore, Y.G., S. Blecker); and School of Public Health, University at Albany, State University of New York at Albany (Z.S., E.L.H.)
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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Facilitation of left ventricular function recovery post percutaneous coronary intervention by levosimendan. Int J Cardiol 2013; 168:237-42. [DOI: 10.1016/j.ijcard.2012.09.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 05/25/2012] [Accepted: 09/15/2012] [Indexed: 11/20/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1227] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1719] [Impact Index Per Article: 132.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 894] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 575] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Svedjeholm R, Vidlund M, Vanhanen I, Håkanson E. A metabolic protective strategy could improve long-term survival in patients with LV-dysfunction undergoing CABG. SCAND CARDIOVASC J 2010; 44:45-58. [DOI: 10.3109/14017430903531008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gorki H, Patel NC, Panagopoulos G, Jennings J, Balacumaraswami L, Plestis K, Subramanian VA. Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hagen Gorki
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY USA
- Department of Cardiac Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Nirav C. Patel
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY USA
| | | | - Joan Jennings
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, NY USA
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Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:33-41. [PMID: 22437274 DOI: 10.1097/imi.0b013e3181cf8228] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Long-term survival after off-pump surgery in patients with low ejection fraction was investigated. Methods Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery. Results The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients. Conclusions OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.
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Briguori C, Aranzulla TC, Airoldi F, Cosgrave J, Tavano D, Michev I, Montorfano M, Carlino M, Castelli A, Sangiorgi MG, Colombo A. Stent implantation in patients with severe left ventricular systolic dysfunction. Int J Cardiol 2009; 135:376-84. [DOI: 10.1016/j.ijcard.2008.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 04/01/2008] [Accepted: 04/04/2008] [Indexed: 11/26/2022]
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Biondi Zoccai G, Moretti C, Abbate A, Lipinski MJ, De Luca G, Agostoni P, Meliga E, Goudreau E, Vetrovec GW, Trevi GP, Sheiban I. Percutaneous coronary stenting in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis. EUROINTERVENTION 2007; 3:409-415. [PMID: 19737725 DOI: 10.4244/eijv3i3a72] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
AIMS There is uncertainty on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with left ventricular dysfunction (LVD). We thus performed a systematic review of studies reporting on PCI in LVD. METHODS AND RESULTS Pertinent studies were searched in PubMed, and included if reporting on >/=30 patients, with ejection fraction < 50%, and prevalently (>60%) treated with stents. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) at the longest follow-up. Outcomes were pooled with random-effect methods (95% confidence intervals). We retrieved 11 studies including 1,284 patients with ejection fraction <50% (specifically <40% in 1,033 and <30% in 211). All studies but one reported on bare-metal stenting only. In-hospital MACE occurred in 5% (3-6), with death in 2% (1-3), myocardial infarction in 3% (2-4), and repeat revascularisation in 1% (0-2). After a median of 18 months, MACE occurred in 33% (30-36), with death in 11% (9-13), myocardial infarction in 7% (6-9), and repeat revascularisation in 15% (13-18). Meta-regression suggested the beneficial impact of drug-eluting stents on MACE (p=0.030). CONCLUSIONS Currently available data support the adoption of percutaneous revascularisation in carefully selected patients with LVD. While event attrition remains substantial at long-term follow-up, drug-eluting stents hold the promise of significantly improving event-free and overall survival.
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Pusca SV, Puskas JD. Revascularization in Heart Failure: Coronary Bypass or Percutaneous Coronary Intervention? Heart Fail Clin 2007; 3:211-28. [PMID: 17643922 DOI: 10.1016/j.hfc.2007.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Coronary artery disease (CAD) is the most common cause of heart failure in Western countries. Selected patients who have low left ventricular ejection fraction (LVEF) and CAD clearly benefit from coronary revascularization with coronary artery bypass grafting (CABG). CABG results seem to be superior to percutaneous coronary intervention (PCI) in the few comparative studies of the two approaches in patients who have CAD and low LVEF completed to date. Clinical improvement should be expected in most patients who undergo CABG. This is important for patients who have a limited life span that they could spend with a good functional status rather than being hospitalized for multiple repeat PCIs or symptomatic deterioration.
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Affiliation(s)
- Sorin V Pusca
- Emory University School of Medicine, Atlanta, GA 30308, USA
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Affiliation(s)
- Magdy Selim
- Department of Neurology, Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Gioia G, Matthai W, Gillin K, Dralle J, Benassi A, Gioia MF, White J. Revascularization in severe left ventricular dysfunction: Outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting. Catheter Cardiovasc Interv 2007; 70:26-33. [PMID: 17585381 DOI: 10.1002/ccd.21072] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We compared the outcome of drug eluting stent (DES) implantation (Sirolimus or Paclitaxel) in patients with ischemic cardiomyopathy and severe left ventricular (LV) dysfunction with the outcome of a similar group of patients undergoing coronary artery by-pass grafting (CABG). BACKGROUND Revascularization provides long-term benefits in patients with severe LV dysfunction. However the modality to achieve it is still unsettled in this high risk group of patients. METHODS Two-hundred-twenty patients (20% women) with severe LV dysfunction (LV Ejection Fraction <or=35%) underwent revascularization with either coronary stent implantation or CABG between May 2002 and May 2005. One-hundred-twenty-eight patients received DES (Sirolimus in 72 and Paclitaxel in 54) and 92 patients underwent surgery. Patients with acute STEMI were excluded. The primary endpoint was all cause mortality. A composite endpoint of major cardiac adverse events (MACCE), including all cause mortality, stroke, myocardial infarction (STEMI), and TVR was the secondary endpoint. RESULTS Mean follow-up was 15 +/- 9 months. No differences were noted in age (69 +/- 10 years vs. 68 +/- 10 years, P = NS), LVEF (28 +/- 6 vs. 27 +/- 8, P = NS) history of diabetes (48% vs. 45%, P = NS), congestive heart failure (47% vs. 37%, P = NS) or MI (60% vs. 50%, P = NS) between the DES and CABG groups. The NYHA class was also similar between the two groups (2.6 +/- 0.9 vs. 2.7 +/- 0.8). More patients in DES group had previous CABG (24% vs. 7%. P = 0.001). Patients undergoing CABG had a greater number of vessel disease (2.8 +/- 0.5 vs. 2.3 +/- 0.7, P = 0.001) and received a mean of 3.0 +/- 0.8 graft per patient. Most of the CABG patients had a left internal mammary artery (83%) graft and 24% had off-pump surgery. The DES group had 1.3 artery/patient treated and 1.3 stents were implanted per artery. During the follow-up there were a total of 20 deaths of which three were cancer related (two in DES group and one in the CABG group). Ten deaths (8%) occurred in the DES group and 10 (11%) in the CABG group (P = NS by log-rank test). The 30-day mortality was significantly greater in patients undergoing CABG than DES (five patients in the CABG vs. only one patient in DES group, P = 0.04). At 6 months there was only a trend toward better survival in DES group (97% vs. 93%, P = 0.2). At 2 years follow-up however both groups had the same survival probability from death (83% in both groups). The 2 years MACCE free survival rate was 76% in DES group and 79% in the CABG cohort (P = NS by log rank test). Eight (6%) DES patients needed additional PCI in nontarget vessel during follow-up. The magnitude of NYHA class improvement was greater for the CABG than DES patients (0.9 vs. 1.5, P = 0.01). CONCLUSION In selected high risk patients with severe LV dysfunction revascularization with DES implantation offers comparable long term mortality and MACCE rate to CABG patients.
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. Revascularization in Severe Left Ventricular Dysfunction. J Am Coll Cardiol 2005; 46:567-74. [PMID: 16098417 DOI: 10.1016/j.jacc.2005.03.072] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Revised: 03/09/2005] [Accepted: 03/15/2005] [Indexed: 11/29/2022]
Abstract
Revascularization is a treatment option for moderate-to-severe ischemic cardiomyopathy. Limitations of the current literature, lack of completed randomized trials, and higher periprocedural risks create significant uncertainty about the optimal treatment strategy. This review focuses on the available literature describing the effect of revascularization on outcome and the role of noninvasive viability testing. It attempts to identify a subset of patients likely to benefit from therapy.
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Roncalli J, Richez F, Galinier M, Fourcade J, Cérène A, Fournial G, Marco J, Bounhoure JP, Puel J, Fauvel JM. [Prognosis scores to help revascularization for ischemic heart failure]. Ann Cardiol Angeiol (Paris) 2004; 53:177-87. [PMID: 15369313 DOI: 10.1016/j.ancard.2004.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
AIMS Patients suffering from coronary heart disease with ventricular systolic dysfunction present a bad prognosis and should be potentially revascularized. Up to now, surgery appeared to be the most feasible revascularization technique for such patients. Aims of this study were to assess the influence of different treatments (surgery, angioplasty or exclusively medical treatment) on clinical outcome and to establish a prognostic score practitioners to select the most appropriate therapy adapted to their patient profiles. METHOD From 1995 to 2000, 492 patients were included in this cohort: 365 in the angioplasty group, 96 in the surgical group and 31 in the medical group. Kaplan Meier curves were made with a multivariate analysis to determine the significant predictive factors of mortality and major adverse cardiac events. RESULTS After a mean follow-up of 32 +/- 19 months, there was no statistical difference in mortality rate between the groups. However, the survival rate without MACE is higher in the surgical group, intermediate in the angioplasty group and lower in the medical group. Using the significant predictive factors of MACE in multivariate analysis, a prognostic score has been established in order to discriminate three categories of severity. For each category, angioplasty was compared with surgery in terms of the event-free-survival rate. For the two extreme categories (severe and non-severe), both treatments were equal. For the intermediate category, surgery obtained greater results. CONCLUSION This prognostic score could help physicians in choosing the appropriate revascularization technique to treat patients with severe ischemic heart failure.
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Affiliation(s)
- J Roncalli
- Fédération des services de cardiologie, CHU de Rangueil, 1, avenue Jean-Poulhes, 31403 Toulouse cedex, France.
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Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features. Circulation 2004; 109:2290-5. [PMID: 15117846 DOI: 10.1161/01.cir.0000126826.58526.14] [Citation(s) in RCA: 208] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Although most randomized clinical trials have suggested that long-term survival rates after percutaneous coronary intervention (PCI) or surgical multivessel coronary revascularization (CABG) are equivalent, some post hoc analyses in high-risk groups and adjustment for severity of coronary disease have suggested higher mortality after PCI.
Methods and Results—
We studied 6033 consecutive patients who underwent revascularization in the late 1990s. PCI was performed in 872 patients; 5161 underwent CABG. Half the patients had significant left ventricular dysfunction or diabetes. Propensity analysis to predict the probability of undergoing PCI according to 22 variables and their interactions was used. The C-statistic for this model was 0.90, indicating excellent discrimination between treatments. There were 931 deaths during 5 years of follow-up. The 1- and 5-year unadjusted mortality rates were 5% and 16% for PCI and 4% and 14% for CABG (unadjusted hazard ratio, 1.13; 95% CI, 1.0 to 1.4;
P
=0.07). PCI was associated with an increased risk of death (propensity-adjusted hazard ratio, 2.3; 95% CI, 1.9 to 2.9;
P
<0.0001). This difference was observed across all categories of propensity for PCI and in patients with diabetes or left ventricular dysfunction. Other independent predictors of mortality (
P
≤0.01 for all) were renal dysfunction, age, diabetes mellitus, chronic lung disease, peripheral vascular disease, left main trunk stenosis, and extent of coronary disease (Duke angiographic score).
Conclusions—
In patients with multivessel coronary artery disease and many high-risk characteristics, CABG was associated with better survival than PCI after adjustment for risk profile.
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Affiliation(s)
- Sorin J Brener
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-25, Cleveland, Ohio 44195, USA.
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Toda K, Mackenzie K, Mehra MR, DiCorte CJ, Davis JE, McFadden PM, Ochsner JL, White C, Van Meter CH. Revascularization in severe ventricular dysfunction (15% < OR = LVEF < OR = 30%): a comparison of bypass grafting and percutaneous intervention. Ann Thorac Surg 2002; 74:2082-7; discussion 2087. [PMID: 12643399 DOI: 10.1016/s0003-4975(02)04120-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND We sought to determine the optimal approach to revascularization of patients with severe left ventricular (LV) dysfunction. METHODS We conducted a single-center observational study of 117 consecutive patients who had severe LV dysfunction (15% < OR = LV ejection fraction < OR = 30%) and underwent either coronary artery bypass grafting (CABG, n = 69) or percutaneous revascularization (n = 48) between 1992 and 1997. RESULTS The CABG group was younger (62 versus 67 years, p = 0.026), and fewer previous bypasses (7% versus 40%, p < 0.0001) and fewer prior percutaneous revascularizations (16% versus 42%, p = 0.0019) were noted. More vessels were revascularized (3 +/- 0.8 versus 1.5 +/- 0.7, p < 0.0001), and revascularization was more complete by CABG (84% versus 48%, p < 0.0001). Morbidity and mortality at 30 days were similar, and there was no significant difference in 3-year survival (73% versus 67%), although 3-year cardiac event-free survival (52% versus 25%, p = 0.0011) and 3-year target vessel revascularization-free survival (71% versus 41%, p < 0.0001) were significantly better in the CABG group, and LV ejection fraction was significantly improved after CABG. In the subgroup of patients 65 years of age or older and those without proximal left anterior descending coronary artery lesions, significant benefit of CABG in cardiac event-free and target vessel revascularization-free survival disappeared. CONCLUSIONS We found that in clinically selected patients with severe ventricular dysfunction, CABG compared with percutaneous revascularization achieves more complete revascularization, improved LV function, fewer cardiac events, and fewer target vessel revascularizations, but does not affect mid-term survival. A prospective controlled trial with defined criteria for treatment assignment is warranted to confirm our results regarding the two revascularization strategies in patients with severe LV dysfunction.
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Affiliation(s)
- Koichi Toda
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana 07121, USA
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Scott R, Blackstone EH, McCarthy PM, Lytle BW, Loop FD, White JA, Cosgrove DM. Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization. J Thorac Cardiovasc Surg 2000; 120:173-84. [PMID: 10884671 DOI: 10.1067/mtc.2000.107280] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Multiple strategies to achieve some degree of myocardial revascularization are available. In some, less complete revascularization is accepted to limit invasiveness. To examine the issues of incomplete revascularization, we assessed the long-term impact of additional non-left anterior descending coronary artery stenoses in patients undergoing only grafting of the left internal thoracic artery to the left anterior descending coronary artery. METHODS A total of 2067 patients underwent primary isolated grafting of the left internal thoracic artery to the left anterior descending coronary artery from 1971 to 1997. Of these, 26% and 13% had 2- and 3-system disease, respectively. Multivariable analyses of survival and reintervention were performed in the hazard function domain for 27,683 patient-years of follow-up (mean 14 +/- 6.7). RESULTS Survival was 99%, 88%, and 62% at 1, 10, and 20 years. Right coronary artery or left circumflex system disease of 50% or more (P =.02) and particularly high-grade (>/=70%) left circumflex (P =.01) and proximal right coronary artery disease (P =.01), as well as any degree of left main trunk stenosis (P <.0001), were associated with reduced long-term survival. Compared with 75% 20-year survival in patients with no non-left anterior descending disease, those with either left circumflex or left main trunk disease experienced a 44% survival, and those with proximal right coronary artery disease, 42%. The most common stated reason for incomplete revascularization was small vessel size. Freedom from reintervention was 89% and 65% at 10 and 20 years, respectively. High-grade left main trunk disease, but, in contrast, mid or distal disease of the right coronary artery, and not left circumflex disease, were risk factors for reintervention. CONCLUSIONS These findings call into question the long-term appropriateness of interventions whose strategy includes leaving unrevascularized segments in territories not in the distribution of the left anterior descending coronary artery.
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Affiliation(s)
- R Scott
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Mayordomo J, Batalla A. Therapeutic strategy with total coronary artery occlusions. Int J Cardiol 2000; 72:289-90. [PMID: 10716141 DOI: 10.1016/s0167-5273(99)00185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- J Mayordomo
- Department of Cardiology, Central Hospital of Asturias, Oviedo, Spain
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Spiecker M, Windeler J, Vermeer F, Michels R, Seabra-Gomes R, vom Dahl J, Kerber S, Verheugt FW, Westerhof PW, Bär FW, Nixdorff U, Barth H, Hopkins GR, von Fisenne MJ, Meyer J. Thrombolysis with saruplase versus streptokinase in acute myocardial infarction: five-year results of the PRIMI trial. Am Heart J 1999; 138:518-24. [PMID: 10467203 DOI: 10.1016/s0002-8703(99)70155-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Short-term safety and efficacy of thrombolysis with saruplase in acute myocardial infarction have been shown in several trials. To assess long-term outcome of patients treated with saruplase or streptokinase for myocardial infarction, a 5-year follow-up of patients included in the Pro-Urokinase in Myocardial Infarction Trial was performed. METHODS AND RESULTS Follow-up data are available from 8 centers on 255 (92.4%) of 276 included patients. The 5-year mortality rate was comparable with 20.8% of patients in the saruplase group and 16.9% in the streptokinase group (odds ratio 1.29, 95% confidence interval 0.69 to 2.42). In both groups, a considerable number of fatal cardiovascular events occurred more than 1 year after study inclusion. Rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting were comparable in both groups. Reinfarction within 5 years occurred in 19.0% of patients in the saruplase group and tended to be less frequent at 10.8% after streptokinase treatment (odds ratio 1.94, 95% confidence interval 0.98 to 3.84). In both groups, the majority of reinfarctions took place more than 3 months after study inclusion. The 5-year stroke rate was 3.6% and 7.2% in the saruplase and streptokinase groups, respectively (odds ratio 0.49, 95% confidence interval 0.16 to 1.47). Subjective symptoms of heart failure and angina pectoris were comparable in both groups. CONCLUSIONS Our data are consistent with a similar long-term outcome for patients treated with saruplase or streptokinase. Despite the low-risk profile of the patient cohort, there were considerable adverse event rates over a 5-year period.
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Affiliation(s)
- M Spiecker
- Department of Cardiology, University of Mainz, Germany.
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Affiliation(s)
- S B King
- Andreas Gruentzig Cardiovascular Center, Emory University Hospital, Atlanta, Georgia, USA.
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Laham RJ, Ho KK, Baim DS, Kuntz RE, Cohen DJ, Carrozza JP. Multivessel Palmaz-Schatz stenting: early results and one-year outcome. J Am Coll Cardiol 1997; 30:180-5. [PMID: 9207640 DOI: 10.1016/s0735-1097(97)00146-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine whether the benefits outlined in Background might extend to patients with multivessel disease, we examined the short- and long-term outcome of multivessel Palmaz-Schatz stenting. BACKGROUND Percutaneous transluminal coronary angioplasty (PTCA) has become the dominant treatment for most patients with single-vessel coronary artery disease and has emerged as an alternative treatment for selected patients with multivessel coronary artery disease. Although multivessel angioplasty has excellent early results and low procedural complication rates, long-term outcome is tempered by the frequent need for repeat revascularization. In patients with single-vessel coronary artery disease, Palmaz-Schatz stenting has been shown to have a higher success rate and a lower restenosis rate than conventional PTCA. METHODS A total of 103 patients (mean age 64 +/- 11 years, 78 men and 25 women) underwent stenting of 212 vessels (saphenous vein graft [53%], left anterior descending coronary artery [20%], left circumflex artery [12%] and right coronary artery [15%]). In 88 patients (85%), multivessel stenting was performed during the same procedure, whereas the remaining 15 patients (15%) had staged multivessel stenting within 1 week of the index stent. Stenting involved only native coronary arteries in 33 patients and only vein grafts in 51 patients. RESULTS Angiographic success was achieved in 102 patients (99%). Major complications developed in three patients: one patient died, and two patients had Q wave myocardial infarction, with no emergency coronary artery bypass graft surgery or stent thrombosis. Eleven additional patients (11%) developed non-Q wave myocardial infarction, and nine patients (9%) had local vascular complications requiring surgical repair. Clinical follow-up was available in all patients at a mean of 13 +/- 8 months. At 1 year, survival was 98%, with an event-free survival rate of 80%, reflecting predominantly repeat revascularization (17% overall, with 9% target site revascularization). Multivessel native coronary stenting resulted in a higher event-free survival rate and a lower probability of repeat revascularization than did multivessel saphenous vein graft stenting. CONCLUSIONS In selected patients, multivessel Palmaz-Schatz stenting is technically feasible and carries both excellent early results and favorable 1-year clinical outcome.
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Affiliation(s)
- R J Laham
- Department of Medicine, Harvard Medical School, Beth Israel Hospital, Boston, Massachusetts 02215, USA
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Cishek MB, Gershony G. Roles of percutaneous transluminal coronary angioplasty and bypass graft surgery for the treatment of coronary artery disease. Am Heart J 1996; 131:1012-7. [PMID: 8615289 DOI: 10.1016/s0002-8703(96)90188-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- M B Cishek
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento
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Yamaguchi A, Ino T, Adachi H, Mizuhara A, Murata S, Kamio H. Left ventricular end-systolic volume index in patients with ischemic cardiomyopathy predicts postoperative ventricular function. Ann Thorac Surg 1995; 60:1059-62. [PMID: 7574948 DOI: 10.1016/0003-4975(95)00488-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We investigated the usefulness of the preoperative left ventricular end-systolic volume index (LVESVI) as a predictor of postoperative ventricular function. METHODS We retrospectively reviewed the records of 310 patients who underwent coronary artery bypass grafting and identified 20 patients with ischemic cardiomyopathy with a preoperative ejection fraction less than 0.30. We determined the preoperative and postoperative ejection fraction, LVESVI, and left ventricular enddiastolic volume index using biplane left cineventriculography. Patients were divided into groups depending on whether their preoperative LVESVI was less than 100 mL/m2 (group A, n = 10) or greater than 100 mL/m2 (group B, n = 10). RESULTS The mean ejection fraction increased significantly after coronary artery bypass grafting in group A from 0.25 +/- 0.05 to 0.40 +/- 0.09 (p < 0.01), but did not change significantly in group B (0.26 +/- 0.05 versus 0.23 +/- 0.06). The mean LVESVI decreased significantly in group A from 83.2 +/- 13.7 to 61.7 +/- 20.4 mL/m2 after operation (p < 0.05), but did not change significantly in group B (124.7 +/- 21.0 versus 121.5 +/- 37.6 mL/m2). In group B, 4 patients had signs of congestive heart failure during the follow-up period and had to be rehospitalized. CONCLUSIONS The mean ejection fraction improved significantly after coronary artery bypass grafting in patients with a preoperative LVESVI less than 100 mL/m2, despite the presence of a global left ventricular ejection fraction less than 0.30. Our results suggest that the preoperative LVESVI predicts the postoperative status and left ventricular function in patients with ischemic cardiomyopathy.
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Affiliation(s)
- A Yamaguchi
- Department of Cardiovascular Surgery, Jichi Medical School, Omiya Medical Center, Saitama, Japan
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Gunnell D, Harvey I, Smith L. The invasive management of angina: issues for consumers and commissioners. J Epidemiol Community Health 1995; 49:335-43. [PMID: 7650455 PMCID: PMC1060119 DOI: 10.1136/jech.49.4.335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To review, from the purchaser's perspective, the current state of knowledge of techniques for investigation and treating coronary artery disease. The study was based on evidence from past and continuing randomised controlled trials (RCTs). CRITERIA FOR INCLUSION OF REPORTS: Articles listed on Medline (1990-3) with the keywords coronary disease, angina, and unstable angina (combined with surgery, economics, therapy, or drug therapy) and percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were included. Articles published before 1990 were obtained from two comprehensive literature reviews published by the Rand organisation in 1991 and from the papers obtained using the Medline search. A hand search of relevant journals published between July 1993 and June 1994 was also undertaken. Results from more recently published RCTs are included. RESULTS CABG provides improved angina relief compared with drug treatment and may prolong life in patients with more severe illness. PTCA is also better than drug treatment, but less so than CABG, and its cost advantages over CABG decrease with time. Repeat intervention for return of symptoms is more frequently required after PTCA, but increasing numbers of patients are also undergoing second and third repeat CABG for graft occlusion in the years after the original operation. Newer PTCA techniques are not, as yet, fully evaluated. One technique, atherectomy, has been shown to be no more effective, and more expensive, than conventional balloon angioplasty. In the short term intracoronary stents reduce the problems associated with vessel occlusion after PTCA and therefore reduce the need for further intervention. PTCA should not be performed without ready access to cardiothoracic support. There is an increasing trend towards the development of coronary catheterisation units at peripheral sites. This may lead to increasing, inappropriate use of this investigation in suboptimal circumstances. CONCLUSIONS Ischaemic heart disease is an important cause of morbidity and mortality and invasive management techniques are developing rapidly; some service expansion is occurring without trial evidence. More research is required to determine the optimum balance of PTCA, CABG, and angiography and population requirements for these procedures. In the meantime, in the absence of firm long term evidence of the superior cost effectiveness of PTCA compared with CABG, the rapid expansion of this procedure should be limited. Patients should be fully informed of the benefits and disadvantages of CABG and PTCA, where either procedure is indicated, to enable them to make fully informed choices.
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Affiliation(s)
- D Gunnell
- Department of Social Medicine, University of Bristol
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Wang N, Gundry SR, Van Arsdell G, Razzouk AJ, Hill AC, Sjolander M, Cavazos KA, Brewer JM, Vyhmeister EE, Bailey LL. Percutaneous transluminal coronary angioplasty failures in patients with multivessel disease. Is there an increased risk? J Thorac Cardiovasc Surg 1995; 110:214-21; discussion 221-3. [PMID: 7609545 DOI: 10.1016/s0022-5223(05)80028-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In recent years, there has been a nationwide trend toward performing percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease. The clinical course of 57 consecutive patients who required emergency first-time coronary artery bypass grafting operations were reviewed to assess for difference in outcome between the 28 patients (49%) with single-vessel disease and the 29 patients (51%) with multivessel disease. The two groups were similar in preoperative characteristics except for a higher proportion of chronic obstructive pulmonary disease in the patients with multivessel disease (p = 0.03). Twice as many patients with multivessel disease were in shock (single-vessel disease = 4 [14%], multivessel disease = 8 [28%], p = not significant) en route to the operating room and significantly more patients with multivessel disease required on-going cardiopulmonary resuscitation (single-vessel disease = 0 [0%], multivessel disease = 5 [17%], p = 0.03). Significantly more coronary artery bypass grafts were placed in the patients with multivessel disease (single-vessel disease = 1.5 +/- 0.6, multivessel disease = 2.9 +/- 0.7, p < 0.01), which required longer aortic clamping time (p = 0.02) and cardiopulmonary bypass time (p < 0.01). There were seven postoperative deaths; all but one occurred in patients with multivessel disease (single-vessel disease = 1 [4%], multivessel disease = 6 [21%], p = 0.05). According to multivariate analysis, incremental risk factors of mortality were preoperative shock (p < 0.01), urgent or emergency percutaneous transluminal coronary angioplasty (p = 0.06), and multivessel disease (p = 0.12). Despite a similar incidence of myocardial infarction (single-vessel disease = 8 [29%], multivessel disease = 12 [41%], p = not significant), patients with multivessel disease had a higher incidence of cardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 11 [38%], p = 0.04) and noncardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 12 [41%], p = 0.02). By multivariate analysis, incremental risk factors of morbidity were preoperative shock (p < 0.01), multivessel disease (p = 0.02), and ejection fraction < 50% (p = 0.07). In the subset of patients with multivessel disease, preoperative shock, ejection fraction < 50, and an age of 60 years or greater were associated with higher morbidity and mortality. In conclusion, the risk of percutaneous transluminal coronary angioplasty failure is considerably higher in patients with multivessel disease. In certain subsets of patients with multivessel disease, coronary artery bypass grafting would be a safer procedure when compared with percutaneous transluminal coronary angioplasty for initial myocardial revascularization.
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Affiliation(s)
- N Wang
- Department of Surgery, Loma Linda University Medical Center, Calif. 92354, USA
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Armstrong B, Zidar JP, Ohman EM. The use of intraaortic balloon counterpulsation in acute myocardial infarction and high risk coronary angioplasty. J Interv Cardiol 1995; 8:185-91. [PMID: 10155228 DOI: 10.1111/j.1540-8183.1995.tb00530.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Patients with complex coronary arterial stenoses, decreased ejection fraction, or acute myocardial infarction are at increased risk during percutaneous coronary interventions. Intraaortic balloon counterpulsation (IABP) can provide benefit in such cases by several mechanisms. Myocardial perfusion is improved and left ventricular afterload is reduced by balloon counterpulsation. Patients with cardiogenic shock clearly benefit from balloon counterpulsation until revascularization can be performed. Recent studies have documented the utility of balloon counterpulsation in patients undergoing angioplasty as treatment for an acute myocardial infarction. Balloon counterpulsation is also an effective means to reduce ischemia and provide hemodynamic support during complex percutaneous coronary interventions. This review will summarize the benefits, indications, and complications of balloon counterpulsation during acute myocardial infarction and high-risk coronary angioplasty.
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Affiliation(s)
- B Armstrong
- Duke University Medical Center, Durham, North Carolina 27710, USA
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Morrison DA, Sacks J, Grover F, Hammermeister KE. Effectiveness of percutaneous transluminal coronary angioplasty for patients with medically refractory rest angina pectoris and high risk of adverse outcomes with coronary artery bypass grafting. Am J Cardiol 1995; 75:237-40. [PMID: 7832130 DOI: 10.1016/0002-9149(95)80027-p] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This study was undertaken to test the hypothesis that percutaneous transluminal coronary angioplasty (PTCA) is a reasonable alternative to coronary artery bypass grafting (CABG) for some high-risk patients with medically refractory rest angina. Over a 5-year period, 1 operator at a tertiary Veterans Affairs Medical Center performed angioplasty on 624 patients, of whom 441 had unstable angina. Of these 441 patients, 288 had rest angina and 225 had medically refractory rest angina. Medically refractory unstable angina was defined as reversible myocardial ischemia occurring at rest in an intensive care unit setting with low flow oxygen despite the following medications: (1) oral aspirin, intravenous heparin, or both; (2) some combination of beta blocker, calcium blocker, and/or nitrate so that resting heart rate is < 70 beats/min or resting blood pressure < 140 mm Hg, or both. There were 207 patients with medically refractory rest angina who had > or = 1 of the following characteristics predictive of a more than twofold increased risk of operative death at CABG: age > 70 years, prior CABG, recent myocardial infarct, need for intravenous nitroglycerin, need for intraaortic balloon pump, and left ventricular ejection fraction < 0.35. Of these 207 patients, 11 died (5%) during index hospitalization, 196 (95%) were discharged, and 186 (90%) went home angina free. There were 2 emergency CABGs and 9 acute myocardial infarctions. At follow-up (3 to 60 months, average 24), there were 27 late deaths (for a total of 38 [18%]), 8 (4%) late CABGs, and 44 (21%) late PTCAs (with 17 [8%] late myocardial infarctions). The 2-year mortality of 18% for this cohort is comparable to a 21% 2-year mortality observed in a group of 1,073 "high-risk" patients who underwent CABG in the Veterans Affairs Medical Center from 1987 to 1988. These data support the hypothesis that PTCA provides an alternative to CABG in some high-risk patients with medically refractory rest angina.
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Affiliation(s)
- D A Morrison
- Cardiac Catheterization Laboratory, Department of Veterans Affairs Medical Center, Denver, Colorado 80220
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O'Keefe JH, Sutton MB, McCallister BD, Vacek JL, Piehler JM, Ligon RW, Hartzler GO. Coronary angioplasty versus bypass surgery in patients > 70 years old matched for ventricular function. J Am Coll Cardiol 1994; 24:425-30. [PMID: 8034879 DOI: 10.1016/0735-1097(94)90299-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study compared the relative risks and benefits of coronary angioplasty and coronary artery bypass graft surgery in patients > 70 years old. BACKGROUND Few objective, comparative data exist to guide the clinician in the decision to use bypass surgery or angioplasty in elderly patients. METHODS The study was a case-control, retrospective analysis of 195 consecutive patients who underwent bypass surgery in 1987 and 1988 and were compared with a concurrent cohort of 195 coronary angioplasty-treated patients. The groups were matched for left ventricular function, age and gender mix. RESULTS The in-hospital morbidity and mortality rates were significantly lower in the coronary angioplasty-treated patients. Mean postprocedural hospital stay was 4.8 and 14.3 days for angioplasty and surgical group patients, respectively (p < 0.001). In-hospital death occurred in 2% of angioplasty-treated patients compared with 9% of surgically treated patients (p = 0.007). Serious in-hospital stroke occurred in no patient in the angioplasty group and in 5% of patients in the surgical group (p < 0.0001). Q wave infarction occurred in 1% of angioplasty-treated patients and 6% of bypass-treated patients (p = 0.01). The 5-year actuarial survival rate was similar in the two groups: 63% in the angioplasty group, 65% in the bypass group (p = NS). However, surgical group patients experienced less recurrent angina, required fewer repeat revascularization procedures and had fewer Q wave infarctions during follow-up compared with angioplasty group patients. CONCLUSIONS When performed in patients > 70 years old, angioplasty and coronary bypass surgery result in similar long-term survival rates but otherwise distinctly different clinical courses.
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Affiliation(s)
- J H O'Keefe
- Mid America Heart Institute, St. Luke's Hospital, Kansas City, Missouri
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Abstract
Prognostic variables such as the ejection fraction and peak oxygen consumption can be used to place patients with heart failure in risk strata. Some vasodilators have been shown to improve survival at all stages of heart failure with the probability of benefit increasing as the prognosis worsens. Quantitative estimates of survival among groups defined by prognostic variables and treatments should be used to make more informed benefit-to-risk assessments.
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Affiliation(s)
- T S Rector
- Department of Medicine, University of Minnesota Medical School, Minneapolis 55455
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Ryan TJ, Bauman WB, Kennedy JW, Kereiakes DJ, King SB, McCallister BD, Smith SC, Ullyot DJ. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American Heart Association/American College of Cardiology Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1993; 88:2987-3007. [PMID: 8252713 DOI: 10.1161/01.cir.88.6.2987] [Citation(s) in RCA: 257] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- T J Ryan
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596
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