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Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience
J M Craver1, W S Weintraub, E L Jones
1Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Insights
Emergency coronary artery bypass surgery is effective for patients with failed percutaneous coronary angioplasty, offering excellent long-term survival despite initial risks. This procedure ensures lasting cardiac health outcomes.
Area of Science:
- Cardiology
- Cardiovascular Surgery
Background:
- Percutaneous coronary angioplasty (PTCA) is a common procedure for coronary artery disease.
- Failed PTCA can necessitate emergency coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the outcomes of emergency CABG following failed elective PTCA.
- To identify risk factors for in-hospital mortality and long-term adverse events.
Main Methods:
- Retrospective analysis of 699 patients undergoing emergency CABG after failed PTCA (1980-1990).
- Comparison of outcomes between patients with and without refractory myocardial ischemia.
- Multivariate analysis to identify predictors of mortality and late events.
Main Results:
- Emergency CABG was required in 4% of PTCA procedures, primarily for acute refractory myocardial ischemia (82%).
- Hospital mortality was 3.1%, with higher rates in patients with refractory ischemia (3.7%).
- 5-year survival was 91%, with significantly lower myocardial infarction-free survival (56%) in patients with refractory ischemia.
Conclusions:
- Emergency CABG after failed PTCA provides excellent long-term survival and low cardiac event rates.
- Prompt CABG is effective in managing failed PTCA, demonstrating lasting benefits.
- Patient factors like age, multivessel disease, and refractory ischemia influence outcomes.
Abstract:
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.