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Can patients with left main stenosis wait for coronary artery bypass grafting?
D E Maziak1, V Rao, G T Christakis
1Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada.
Insights
Patients with significant left main stenosis (LMS) can safely wait for coronary artery bypass grafting (CABG) with low complication risks. Early surgery is reserved for those with severe symptoms or recent myocardial infarction.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Health Economics
Background:
- Healthcare reforms may lead to waiting lists for coronary artery bypass grafting (CABG).
- This study investigated clinical outcomes for patients with left main stenosis (LMS) placed on a waiting list for surgery.
Purpose of the Study:
- To evaluate the clinical results of patients with left main stenosis (LMS) on a surgical waiting list.
- To determine if waiting for CABG impacts patient outcomes.
Main Methods:
- Prospective data collection on 2,145 patients undergoing isolated CABG (1989-1994).
- Analysis of 281 patients with critical LMS (>=50% stenosis) versus 1,864 patients without LMS (<50% stenosis).
- Comparison of outcomes between early (<10 days) and late (>10 days) revascularization groups for LMS patients.
Main Results:
- Patients with LMS had shorter average wait times (38 days) than those without (84 days).
- LMS did not significantly affect operative mortality, low output syndrome, or perioperative myocardial infarction rates.
- Outcomes were similar for LMS patients undergoing early versus late revascularization; early group had more severe symptoms.
Conclusions:
- Selected patients with significant LMS can safely await CABG with minimal risk.
- Early surgical intervention is prioritized for LMS patients experiencing severe symptoms or recent myocardial infarction.
Background:
The economic impact of health care reforms may result in waiting lists for coronary artery bypass grafting. This study was designed to examine the clinical results of patients with left main stenosis who were placed on a triaged wait list for operation.
Methods:
Data were collected prospectively on 2,145 patients undergoing isolated coronary artery bypass grafting between 1989 and 1994. Critical left main stenosis (LMS, 50% or more stenosis) was present in 281 patients, and 1,864 patients had no left main disease, or a left main stenosis of less than 50% (no LMS).
Results:
The average time from angiography to operation was shorter in patients with LMS (LMS 38 +/- 46 days versus no LMS 84 +/- 71 days; p = 0.0001). Two patients in the LMS group died; they had declined operation. Four patients suffered non-Q wave myocardial infarctions, all of whom subsequently underwent operation with no perioperative complications. The presence of LMS did not influence operative mortality (LMS 2.8% versus no LMS 1.3%), the incidence of low output syndrome (LMS 8.3% versus no LMS 5.4%), or the incidence of perioperative myocardial infarction (LMS 3.8% versus no LMS 4.2%). To examine the effect of waiting time on outcomes, patients with LMS were divided into early (operation 10 days or less after angiography) and late revascularization groups (more than 10 days). Operative mortality, low output syndrome, and myocardial infarction were similar in the early and late groups. Patients in the early group were more likely to have New York Heart Association functional class IV symptoms (64% versus late 22%; p < 0.0001), unstable angina (87% versus late 65%; p < 0.0001), or a recent preoperative myocardial infarction (17% versus late 2%; p < 0.0001).
Conclusions:
Carefully selected patients with significant left main stenosis can safely wait for operation with a low risk of complications. Early surgical intervention is allocated to patients with severe symptoms or recent preoperative myocardial infarction.