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Coronary angioplasty in patients who were considered poor bypass surgery candidates
R L Feldman1, M Carmichael, M Domingo
1Munroe Regional Medical Center, Ocala Heart Institute, FL 32671.
Insights
Percutaneous coronary angioplasty (PTCA) is a viable option for patients unsuitable for coronary artery bypass grafting (CABG). However, these "salvage PTCA" patients face increased risks of complications and in-hospital death compared to standard PTCA candidates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary artery disease (CAD) management often involves percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG).
- A subset of patients with severe CAD symptoms are candidates for PTCA but are poor candidates for CABG.
- These patients, termed "salvage PTCA" candidates, represent a unique clinical challenge.
Purpose of the Study:
- To compare outcomes of PTCA in patients who were candidates for CABG versus those who were not (salvage PTCA patients).
Main Methods:
- Retrospective analysis of 704 patients undergoing PTCA between April 1988 and December 1989.
- Exclusion of 47 patients with evolving myocardial infarction.
- Comparison of 99 "salvage PTCA" patients with 605 patients considered CABG candidates.
Main Results:
- Salvage PTCA patients were older, had higher rates of heart failure, prior CABG, elevated left ventricular end-diastolic pressure, and lower ejection fraction (p < 0.01).
- PTCA success rates per lesion were similar (96% vs. 95%), but lesion non-dilation was higher in salvage patients (14% vs. 7%, p < 0.02).
- Severe complications, including Q-wave infarction (2% vs. 0.3%) and in-hospital death (7% vs. 0.2%), were significantly more common in salvage PTCA patients.
Conclusions:
- PTCA can be successfully performed in patients unsuitable for CABG, but carries increased risks.
- These findings highlight the importance of careful patient selection and risk assessment in interventional cardiology.
- Approximately 13% of the PTCA experience involved patients who were not surgical candidates, underscoring the clinical relevance of this subgroup.
Abstract:
In most patients who undergo coronary angioplasty (PTCA), coronary bypass surgery (CABG) is an alternative. Patients with severe symptoms secondary to coronary disease, amenable to PTCA, but who are poor CABG candidates are commonly seen. From April 1988 to December 1989 PTCA was performed in 751 patients. Patients with evolving infarction (47) were excluded. Of the remaining 704, 605 were considered candidates for CABG and they were compared to the 99 patients not felt to be candidates for CABG. The objective of this report was to compare these 2 patient groups. These salvage PTCA patients were older, had a higher incidence of heart failure, more prior CABG, higher left ventricular end-diastolic pressure and lower ejection fraction (all p less than 0.01). PTCA had a high success rate per lesion in both groups (96% CABG candidates vs. 95% salvage patients), but there were more patients whose culprit lesion could not be dilated in the salvage group (14% vs. 7%, p less than 0.02). Severe complications including Q wave infarction (2% vs. .3%) and in-hospital death (7% vs. 0.2%) were more common in salvage patients. As planned, emergency CABG was not performed on any salvage PTCA patient but on 2.6% of the other patients. Patients who may benefit from PTCA but were not felt to be operable made up 13% of our PTCA experience. PTCA can be performed in these patients but risks were increased.