The changing profile of the patient undergoing coronary artery bypass surgery.

The first 100 consecutive patients undergoing isolated coronary artery bypass surgery in 1975 were evaluated with respect to the incidence of operative risk factors and outcome. When compared with an identically selected group from 1985, there was significant worsening of the preoperative condition over the decade with regard to mean age (p less than 0.0005), presence of congestive heart failure (p less than 0.05), left ventricular dysfunction (p less than 0.05), severity of coronary artery disease (p less than 0.001) and incidence of emergency operation (p less than 0.05). More patients in 1985 had associated medical diseases such as diabetes (p less than 0.01) and chronic lung disease (p less than 0.005). There was an increase in the occurrence of vascular diseases (hypertension, renal dysfunction, peripheral vascular and cerebrovascular disease) (p less than 0.05). Overall operative mortality increased from 1 to 8% (p less than 0.05) over the decade. Despite the deterioration in the clinical profile of the patient undergoing coronary bypass surgery, elective procedures were still performed with low mortality. The significant increase in overall mortality was chiefly in patients undergoing emergency operation (p less than 0.05). There were also increases in operative morbidity including low output syndrome (p less than 0.01) and respiratory (p less than 0.005) and neurologic (p = 0.06) complications.

The changing mortality of myocardial revascularization: coronary artery bypass and angioplasty.

The risk factors and outcome for the first 150 consecutive patients undergoing coronary artery bypass grafting (CABG) in 1985 (CABG '85) were compared with those of the first 150 patients undergoing CABG in 1975 (CABG '75) and those of the first 150 patients to have percutaneous transluminal coronary angioplasty (PTCA) in 1985 (PTCA '85). The CABG '85 patients had a significantly higher (p less than 0.05) incidence of known operative risk factors including advanced age, female sex, severity of angina, history of recent infarction, triple-vessel disease, left ventricular dysfunction, and emergency operation than the CABG '75 cohort. The clinical profile of the PTCA '85 patients closely resembled the low-risk profile found in the CABG '75 patients. Overall mortality following CABG more than doubled during the decade studied (3% versus 7%, p = 0.07). This study suggests that the increased mortality associated with CABG in 1985 is due in part to the inclusion of more high-risk patients in the surgical population. In addition, the application of PTCA removes low-risk patients from the surgical candidate pool and adds more patients requiring emergency operations, thereby further contributing to the overall decline in the clinical status of patients referred for operation.

Preliminary experience with transluminal laser-induced intrahepatic portacaval shunts.

This study investigated the feasibility of performing an intrahepatic portacaval shunt (IHPCS) by means of transluminal laser angioplasty. In 10 anesthized dogs, a catheter was introduced into a mesenteric vein and threaded into the portal vein (PV). Under fluoroscopy, a Ross needle was passed through the PV catheter, liver, and into the intrahepatic IVC. Following guidewire exchange, a neodymium YAG laser hot-tip probe (power setting 8 W) was passed over the guidewire to accomplish a transluminal IHPCS. In five animals, an IHPCS could not be accomplished. Initial and subsequent patency was confirmed by fluoroscopy. These early data suggest that transvenous laser-induced intrahepatic portacaval shunts may be feasible as a means of decompressing portal hypertension. Further research is necessary, to investigate the long-term patency as well as this technique's ability to decompress the portal system.