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Have PTCA failures requiring emergent bypass operation changed?
M J Boylan1, B W Lytle, P C Taylor
1Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio 44195.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) failure rates requiring emergency surgery decreased from 1980-1990. However, in-hospital mortality for these emergent cases showed an increasing trend, linked to patient hemodynamic compromise.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Balloon angioplasty, or percutaneous transluminal coronary angioplasty (PTCA), is a common procedure.
- PTCA failure can necessitate emergent surgical revascularization.
- Understanding trends in PTCA failure and outcomes is crucial for improving patient care.
Purpose of the Study:
- To analyze trends in PTCA failure rates requiring emergent surgery.
- To evaluate changes in patient characteristics and outcomes over time.
- To identify factors associated with in-hospital mortality after emergent surgical revascularization.
Main Methods:
- Retrospective analysis of 9,145 patients undergoing PTCA between 1980 and 1990.
- Patients were divided into two cohorts: 1980-1985 and 1986-1990.
- Comparison of PTCA failure rates, pre-procedural characteristics, and in-hospital/late survival.
Main Results:
- PTCA failure incidence decreased from 3.8% (1980-1985) to 2.3% (1986-1990).
- In-hospital mortality for emergent surgery increased from 4.6% to 7.6%, though not statistically significant.
- Higher mortality was strongly associated with severe hemodynamic compromise (28.3% vs 1.4%).
- Preoperative intraaortic balloon pump use increased significantly.
Conclusions:
- While PTCA failure rates have declined, emergent surgical revascularization carries significant risk.
- Increased mortality in later years appears linked to sicker patients undergoing surgery, not necessarily pre-PTCA characteristics.
- Severe hemodynamic compromise is a major predictor of mortality in this high-risk group.
Abstract:
From 1980 through 1990, 9,145 patients had balloon angioplasty with failure of the procedure requiring emergent surgical revascularization within 24 hours occurring in 253 patients (2.8%). Patients were divided into two cohorts based on the date of the percutaneous transluminal coronary angioplasty (PTCA): 1980 to 1985 (n = 109) and 1986 to 1990 (n = 144). The incidence of PTCA failure was 3.8% during 1980 to 1985 (109/2,903) and decreased to 2.3% (144/6,242) for 1986 to 1990. Comparison of pre-PTCA patient characteristics between the two periods showed that only a history of a previous PTCA and class III or class IV symptoms were more common in the recent years (p < or = 0.05). In-hospital mortality after emergency operation was 4.6% (5/109) during 1980 to 1985 and 7.6% (11/144) from 1985 to 1990 (p = not significant). This trend toward increased mortality appeared to be related to an increased number of patients who underwent operation in a state of severe hemodynamic compromise in the more recent period. The in-hospital mortality rate for patients in shock or undergoing cardiopulmonary resuscitation was 28.3% (13/46) compared with 1.4% (3/207) for patients with less severe hemodynamic derangement (p < 0.001). Use of the intraaortic balloon pump preoperatively increased from 12.8% to 32.6% (p < 0.01). Late survival was 92% at 2 and 87% at 5 postoperative years. Although the incidence of PTCA failure necessitating emergent surgical intervention has decreased over time, there has been a trend toward an increased in-hospital mortality rate for those patients that does not appear to be related to more severe pre-PTCA characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)