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A profile of candidates for repeat myocardial revascularization: implications for selection of treatment
S J Brener1, F D Loop, B W Lytle
1Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
Insights
Repeat revascularization decisions for coronary artery bypass grafting (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) depend on patient factors and graft status. Reoperation carried higher in-hospital risks but was preferred for extensive myocardial jeopardy.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are established revascularization strategies.
- Limited data exist on the optimal choice for repeat revascularization in patients with prior bypass grafts.
- Understanding patient and graft characteristics is crucial for guiding treatment selection.
Purpose of the Study:
- To compare clinical and angiographic characteristics of patients undergoing repeat revascularization via surgery or angioplasty.
- To identify predictors for choosing either reoperation or angioplasty.
- To inform treatment selection for repeat myocardial revascularization.
Main Methods:
- Retrospective analysis of 870 patients undergoing first isolated reoperation and 793 patients undergoing first balloon angioplasty after prior bypass surgery (1992-1994).
- Calculation of a jeopardy score (0-8) based on ischemic territory size.
- Analysis of clinical and angiographic data to determine associations with revascularization strategy.
Main Results:
- Reoperation patients more frequently had diabetes, hypertension, severe left ventricular dysfunction, and fewer functioning grafts (p < 0.01).
- Higher jeopardy score, diabetes, and fewer functioning grafts independently predicted reoperation (p < 0.01).
- In-hospital death and Q-wave myocardial infarction were more common in the reoperation group (p < 0.01).
Conclusions:
- Reoperation was favored for extensive myocardial jeopardy.
- Angioplasty was preferred with a patent arterial graft to the LAD or multiple functioning grafts.
- Reoperation was associated with increased in-hospital complications compared to angioplasty.
Objectives:
It is not known whether the results of randomized trials comparing coronary artery bypass grafting to percutaneous transluminal coronary angioplasty for initial revascularization apply to repeat revascularization in patients with prior bypass grafts. We studied the differences between the patients with prior bypass grafts referred for surgery or angioplasty to identify the clinical and angiographic characteristics that correlated best with either choice and to find clues that might aid in selecting one treatment over the other.
Methods:
Between 1992 and 1994, 870 patients underwent first isolated reoperation and 793 patients underwent first balloon angioplasty after a previous operation. A jeopardy score (0 to 8 points) was derived for each patient on the basis of the relative size of the ischemic territory. Clinical and angiographic data were analyzed for association with the revascularization strategy.
Results:
The following characteristics were more prevalent in the reoperation group: male sex, diabetes, hypertension, valvular disease, normocholesterolemia, and severe left ventricular systolic dysfunction; fewer functioning venous and arterial grafts; and a higher jeopardy score (p < 0.01 for all) than in the angioplasty group. A higher jeopardy score, diabetes, and a lower number of functioning arterial or venous grafts were strong, independent predictors of referral for reoperation (p < 0.01 for all). In hospital death and Q-wave infarction (p < 0.01 for both) were more frequent in the reoperation group.
Conclusions:
Reoperation was the revascularization procedure of choice when larger regions of myocardium were in jeopardy. Angioplasty was more frequently chosen in the presence of a patent arterial graft to the left anterior descending coronary artery or multiple functioning bypass grafts. Reoperation was associated with a higher risk of in-hospital complications than angioplasty.