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Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome
K S Naunheim1, A C Fiore, D C Fagan
1Division of Cardiothoracic Surgery, St. Louis University Medical Center, Missouri 63110-0250.
Insights
Emergency coronary artery bypass grafting (CABG) after failed percutaneous transluminal coronary angioplasty significantly increases operative mortality and perioperative infarction risks compared to routine CABG.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Percutaneous transluminal coronary angioplasty (PTCA) is a common procedure for coronary artery disease.
- Emergent CABG following PTCA failure has been debated regarding its associated risks.
- Routine CABG is typically performed electively for stable coronary artery disease.
Purpose of the Study:
- To compare the risks of emergency CABG after failed PTCA with routine CABG.
- To identify independent predictors of mortality in patients undergoing emergency CABG post-PTCA.
Main Methods:
- Retrospective review of 103 patients undergoing emergency CABG for failed PTCA (Group 1).
- Comparison with 103 consecutive routine CABG patients from 1987 (Group 2).
- Multivariate analysis of 36 preoperative and operative variables for risk factor identification in Group 1.
Main Results:
- Group 1 patients had a lower preoperative risk profile (younger, fewer diseased vessels, better ventricular function).
- Despite lower risk profiles, Group 1 experienced significantly higher mortality (11% vs. 1%) and perioperative infarctions (22% vs. 6%).
- Left ventricular score, need for inotropic support post-PTCA, and age were independent predictors of mortality in emergency CABG patients.
Conclusions:
- Emergency CABG following failed PTCA carries a substantially higher risk of operative death and perioperative infarction.
- These findings highlight the increased risks associated with emergent CABG in this specific patient population.
- Risk stratification using LV score, inotropic support, and age is crucial for patients undergoing emergency CABG after PTCA failure.
Abstract:
It has been suggested that coronary artery bypass grafting (CABG) performed in the setting of emergent failure of percutaneous transluminal coronary angioplasty causes minimal increased risk compared with routine CABG. We reviewed the records of 103 patients undergoing emergency CABG for failed percutaneous transluminal coronary angioplasty (group 1) and compared them with an identical number of consecutive CABG patients from 1987 (group 2). Group 1 had a lower risk profile evidenced by lower mean age (p less than 0.01), fewer diseased vessels (p less than 0.0001), better ventricular function (p less than 0.001), fewer left main lesions (p less than 0.0001), and fewer patients with acute ischemia requiring intravenous administration of nitroglycerin (p less than 0.01). Despite these differences, the group 1 patients had a higher mortality rate (11% versus 1%; p less than 0.01) and a higher rate of perioperative infarctions (new Q wave) (22% versus 6%; p less than 0.01). An analysis of risk factors was performed in the group 1 patients using 36 preoperative and operative variables. Multivariate analysis revealed that left ventricular score (p less than 0.0001), preoperative (after percutaneous transluminal coronary angioplasty) need for inotropic support (p less than 0.005), and age (p less than 0.025) were independent predictors of operative mortality. In conclusion, emergency CABG after failed percutaneous transluminal coronary angioplasty carries a significantly greater risk of operative death and perioperative infarction than elective CABG.