Surgical revascularization following unsuccessful percutaneous transluminal coronary angioplasty

From September, 1980, through August, 1981, 353 patients underwent attempted percutaneous transluminal coronary angioplasty (PTCA). Twenty-seven patients (7.6%) subsequently underwent elective myocardial revascularization without death or complicating PTCA. Surgical support in the first 2 months involved a fully-staffed operating room standing idle. During the last 10 months, patients requiring emergency revascularization were accommodated in the first operating room available. All 17 patients undergoing emergency revascularization had severe chest pain and 12 patients had ST-segment elevation on the electrocardiogram. The average time from onset of ischemia to revascularization was 135 minutes and did not change over the period of study. Improvement in the electrocardiogram and myocardial function were frequently noted with restoration of flow by the vein graft. Two patients (12%) required inotropic drug support following revascularization. All 12 patients with ST-segment elevation preoperatively had elevated myocardial enzyme levels postoperatively, including five patients (29%) with new Q waves on the electrocardiogram. Myocardial necrosis did not correlate with time to revascularization, number of diseased vessels, the artery being instrumented, the mechanism of ischemia, or the presence of collateral flow. There were no deaths. Because of the high incidence of myocardial infarction despite prompt revascularization, we now routinely insert the intra-aortic balloon pump in the catheterization laboratory in patients with refractory myocardial ischemia requiring emergency revascularization. Prompt safe revascularization for acute ischemia following PTCA can be achieved without expensive and inefficient standby of cardiac surgical facilities. Transmural myocardial ischemia following complicated PTCA is frequently associated with evidence of myocardial necrosis despite prompt surgical revascularization. Greater salvage of ischemic myocardium may be possible if the intra-aortic balloon pump is used in the interval between PTCA-induced injury and surgical revascularization.