Videometric analysis of regional left ventricular function before and after aortocoronary artery bypass surgery: correlation of peak rate of myocardial wall thickening with late postoperative graft flows.

The peak rate of systolic wall thickening (pdTw/dt) in regions of the left ventricle was determined by biplane roentgen videometry in 60 patients before and a median of 14 mo after aorto-coronary bypass graft surgery. The left ventricular ejection fraction, stroke volume, and end-diastolic volume and pressure did not change significantly after surgery in the presence of patent or occluded grafts (P greater than 0.05). Statistically significant increases occurred in the peak rate of systolic wall thickening regions supplied by patent bypass grafts, and significant decreases occurred in regions with occluded grafts (P less than 0.01). Of 42 preoperatively hypokinetic regions (pdTw/dt greater than 0 less than 5.0 cm/s) supplied by a patent graft, 30 improved by an average of 2.6 cm/s after operation; 18 returned to normal. Failure of 24 hypokinetic regions to improve to normal was associated with myocardial infarction in 11 or with late postoperative graft blood flows of less than 60 ml/min measured by videodensitometry, in 10. All seven preoperatively akinetic (pdTw/dt=0) or dyskinetic (pdTw/dt less than 0) regions did not improve after the operation despite the fact that, in five of the seven, coronary bypass flows were over 60 ml/min. All eight preoperatively hypokinetic regions supplied by coronary artery graft flows of less than or equal 40 ml/min failed to improve to normal after operation. All nine preoperatively hypokinetic regions supplied by coronary artery graft flows of over 60 ml/min improved to normal after surgery. Late postoperative coronary artery bypass graft flows, the functional status of the myocardium, the status and distribution of the native coronary circulation, and decreased regional function elsewhere in the ventricle must all be considered when regional left ventricular function is interpreted.

Application of percutaneous transluminal coronary angioplasty to the internal mammary artery graft.

Between June 1982 and August 1987, 45 patients underwent percutaneous transluminal coronary angioplasty within the internal mammary artery graft (group 1) or had coronary angioplasty performed beyond the graft insertion with the internal mammary artery used as a conduit (group 2). Previous coronary artery bypass surgery was performed at a mean of 29.8 months (range 2 to 199) in group 1 and 51.3 months (range 2 to 134) in group 2. Sixteen (62%) of 26 patients in group 1 and 17 (71%) of 24 patients in group 2 had multivessel angioplasty; multilesion angioplasty was performed in 20 patients (77%) in group 1 and in 19 patients (79%) in group 2. Within group 1, 12 (37.5%) of 32 lesions were in the body of the internal mammary artery graft and 20 lesions (62.5%) occurred at the distal anastomosis. Angioplasty was successful in 30 (94%) of 32 attempts in group 1 and in 25 (96%) of 26 attempts in group 2. Procedure-related complications were limited to emergent bypass surgery in one patient in group 2. At a mean follow-up period of 12.7 months in group 1 and 18.2 months in group 2, 39 (90%) of the 45 patients had no or only mild angina. There were two late cardiac deaths (mortality rate 4.9%) in the 41 patients with successful angioplasty. The results of this study demonstrate that percutaneous transluminal coronary angioplasty of internal mammary artery grafts combined with multilesion angioplasty is technically feasible, can be performed with a high primary success rate and a low incidence of complications and achieves sustained clinical improvement in the majority of patients.

Repeat coronary angioplasty: efficacy of a third angioplasty for a second restenosis.

To determine the efficacy of repeat percutaneous transluminal coronary angioplasty, 74 patients were studied who underwent a third angioplasty for a second restenosis of one coronary artery segment. The procedure was successful in 93% of patients. Procedural complications included emergency bypass surgery (three patients) and in-hospital death (two patients). At late follow-up (mean 18 months, range 7 to 49), 30 patients (43%) had a third restenosis treated with either a fourth angioplasty (16 patients), coronary bypass surgery (11 patients) or medical management (1 patient). Thirty-nine patients (57%) had no restenosis on the basis of follow-up angiography or absence of symptoms previously attributed to restenosis. Factors associated with a third restenosis included a shorter time interval (less than 3 months) between previous angioplasty procedures and dilation of the left anterior descending coronary artery. Among the 16 patients undergoing a fourth angioplasty for a third restenosis, the procedural success rate was 94%. One patient required emergency bypass surgery. At late follow-up (mean 16 months, range 7 to 38), eight patients (53%) had a fourth restenosis treated with either a fifth angioplasty (one patient), bypass surgery (five patients) or medical management (two patients). Considering all 74 patients undergoing a third angioplasty for a second restenosis, 27% had bypass surgery, 5% died, 4% were managed medically and 64% were free of angina at late follow-up after either a third, fourth or fifth angioplasty. Restenosis rates after a third or fourth angioplasty procedure for recurrent restenosis are higher than those for the initial procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct coronary angioplasty in acute myocardial infarction: outcome in patients with single vessel disease.

Percutaneous transluminal coronary angioplasty was performed as primary therapy in 215 consecutive patients (aged 56 +/- 11 years, 75% male) with acute myocardial infarction and single vessel coronary artery disease. Wide patency of the infarct-related artery was restored in 212 patients (99%). Complications consisted of one urgent coronary bypass operation (0.5%); there were no procedural deaths. A recurrent ischemic event before discharge occurred in eight patients (4%). The in-hospital mortality rate was 1%; five of six patients presenting with cardiogenic shock were alive at discharge. In 126 patients in whom predischarge angiography was performed, the ejection fraction improved from 55 +/- 12% to 61 +/- 12% (p less than 0.005) and increased by greater than or equal to 5% units in 66 patients (52%). Regional wall motion improved in 60 patients (48%). By multivariate analysis, a depressed initial ejection fraction, a limited increase in serum creatine kinase, young age and sustained patency of the infarct-related artery were found to be independent predictors of improvement in left ventricular function. Follow-up data were available in 214 patients (99.5%) at a mean interval of 35 months. The actuarial 3 year cardiac survival rate was 92%. By multivariate analysis, only the baseline ejection fraction correlated with long-term cardiac survival. Nine patients (4%) sustained a late nonfatal myocardial infarction, and 11 patients (5%) underwent subsequent coronary bypass surgery. At late follow-up study, 149 (77%) of 194 patients alive were free of angina. In summary, in patients with acute myocardial infarction and single vessel disease, coronary angioplasty without prior thrombolytic therapy can be performed with a high success rate and few procedural complications. After direct angioplasty, regional wall motion and global ejection fraction improve in 50% of patients, especially in those with depressed initial left ventricular function. This approach results in an excellent early and late event-free survival.

Procedural outcome of angioplasty for total coronary artery occlusion: an analysis of 971 lesions in 905 patients.

This study analyzes the results of angioplasty in 905 consecutive patients with 971 total occlusions. The procedures were performed by five cardiologists from January 1980 to January 1989 at one institution. The overall success rate per lesion was 72%. Even the most experienced operator (524 occlusions attempted) has continued to improve on a learning curve, with 83% of his most recent 100 occlusions successfully dilated. Procedural death occurred in seven patients (0.8%), five patients (0.6%) sustained a myocardial infarction and seven patients (0.8%) required urgent coronary bypass surgery. Complications were significantly more likely to occur in the elderly, in women and in patients with triple vessel disease and depressed left ventricular function. Compared with angioplasty in 6,950 patients with nonoccluded stenoses, angioplasty of total occlusions had a lower success rate (72% versus 96%, p = 0.001), although the complication rate was also lower (1.9% versus 3.5%, p = 0.01). Multivariate analysis of 20 clinical and angiographic variables in 100 consecutive patients undergoing angioplasty of 104 total occlusions in 1988 identified only bridging collateral vessels (85% success rate if absent versus 18% if present, p less than 0.001) and a tapered occlusion morphology (88% success rate if present versus 59% if absent, p = 0.01) as independent correlates of procedural outcome. Other variables, including the estimated duration of occlusion, lesion length and location, and extent of disease were unrelated to technical success. With present techniques and sufficient operator experience, 70% to 80% of total occlusions can be successfully recanalized by coronary angioplasty with a complication rate of less than 2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Supported "high risk" coronary angioplasty using intraaortic balloon pump counterpulsation.

Hemodynamic support may be desirable for selected patients with high risk characteristics undergoing elective coronary angioplasty. Twenty-eight high risk patients were studied with elective intraaortic balloon pump support over a recent 30 month period. Their mean age was 66 years; 10 patients were greater than or equal to 70 years old. Class III or IV angina was present in 23 patients (82%). The mean left ventricular ejection fraction was 24% (range 15% to 50%) and was less than 30% in 25 patients (89%). Three vessel disease was present in 26 patients (93%) and 7 patients had significant left main coronary artery disease. Ninety (96%) of 94 attempts to dilate stenoses were successful, including multivessel angioplasty in 21 patients (75%) and five left main coronary artery dilations. Decreases in systolic blood pressure to less than or equal to 70 mm Hg occurred in 11 patients (39%), but augmented diastolic pressure was greater than or equal to 90 mm Hg at all times. No deaths or myocardial infarctions occurred within 72 h of coronary angioplasty. Vascular complications requiring surgical repair occurred in three patients who had good operative results and no need for transfusions. Thus, intraaortic balloon pump support in patients with high risk features undergoing elective coronary angioplasty appears effective and relatively benign, although definite benefit cannot be proved without a randomized study. Newer techniques, such as in-laboratory cardiopulmonary bypass, must be compared with the results obtained with intraaortic balloon pump support alone.

Results of primary angioplasty for acute myocardial infarction in patients with multivessel coronary artery disease.

The influence of multivessel coronary artery disease on the outcome of reperfusion therapy for myocardial infarction has not been fully characterized. Direct coronary angioplasty without antecedent thrombolytic therapy was performed during evolving myocardial infarction in 285 patients with multivessel coronary artery disease at 5.2 +/- 4.2 h after the onset of chest pain. Two vessel disease was present in 163 patients (57%) and three vessel disease in 122 (43%). An anterior infarct was present in 123 patients (43%), cardiogenic shock in 33 (12%) and age greater than or equal to 70 years in 59 (21%). Angioplasty of the infarct-related vessel was successful in 256 patients (90%), including 92% with two vessel and 88% with three vessel disease (p = NS). Emergency bypass surgery was needed in six patients (2%). In-hospital death occurred in 33 patients (12%), including 13 with two vessel and 20 with three vessel disease (p less than 0.05). The mortality rate was only 4% in the subgroup of 101 patients who met entry criteria for thrombolytic trials. The in-hospital mortality rate was 45% in patients in shock and 7% in patients not in shock (p less than 0.01). Logistic regression analysis identified shock and age greater than or equal to 70 years as independently associated with in-hospital death. In 135 patients who underwent predischarge left ventriculography, global ejection fraction increased from 50% to 57% (p less than 0.001) and regional wall motion in the infarct zone improved in 59% of patients. Follow-up data were available in 251 patients (99%) at a mean of 35 +/- 19 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Multivessel coronary angioplasty from 1980 to 1989: procedural results and long-term outcome.

From June 1980 to January 1989, 3,186 patients had coronary angioplasty of two (2,399 patients) or three (787 patients) of the three major epicardial coronary systems. A mean of 3.6 lesions (range 2 to 14) were dilated per patient, with a 96% success rate. Acute complications were seen in 94 patients (2.9%) and included Q wave infarction in 47 (1.4%), urgent coronary artery bypass surgery in 33 (1%) and death in 31 (1%). Multivariate correlates of in-hospital death included impaired left ventricular function, age greater than or equal to 70 years and female gender. Complete long-term follow-up data were available for the first 700 patients and the follow-up period averaged 54 +/- 15 months in duration. Actuarial 1 and 5 year survival rates were 97% and 88%, respectively, and were not different in patients with two or three vessel disease. By Cox regression analysis, age greater than or equal to 70 years, left ventricular ejection fraction less than or equal to 40% and prior coronary artery bypass surgery were associated with an increased mortality rate during the follow-up period. Repeat revascularization procedures were required in 322 patients (46%). Restenosis resulted in either repeat angioplasty or bypass surgery in 227 patients (32%). Repeat coronary angioplasty was performed for isolated restenosis in 126 patients (18%), for restenosis and disease progression at new sites in 85 patients (12%) and for new disease progression alone in 54 patients (8%). Coronary bypass surgery was required in 110 patients (16%) during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial and long-term outcome of 83 patients after balloon angioplasty of totally occluded bypass grafts.

OBJECTIVES: This study was designed to evaluate the safety and short- and long-term results of coronary angioplasty of totally occluded bypass grafts in patients with clinical conditions other than acute myocardial infarction. BACKGROUND: Total occlusion of bypass grafts after coronary artery surgery often causes recurrent ischemia. The safety and results of percutaneous transluminal coronary angioplasty in occluded bypass grafts are controversial. METHODS: All patients with dilation of a totally occluded bypass graft attempted between 1981 and 1991 were retrospectively identified from a data base. Patients treated in the setting of an acute myocardial infarction were excluded. Eighty-three patients met these criteria and constitute the study group. Hospital records, office charts and procedural reports were reviewed in all patients to supplement details available in the data base. RESULTS: The time from bypass surgery to attempted coronary angioplasty ranged from 1 to 226 months (mean time 88 months). The mean (+/- SD) duration of graft occlusion was 31 +/- 46 days (range 1 to 180). In 27 attempts the bypass graft was the only site dilated, and in 56 attempts (68%) one to six other sites (n = 101) were dilated. Angiographic success (< or = 40% residual lumen stenosis) was achieved in 61 grafts (73%) and 98 of the additional sites (97%) (p < 0.001). Major complications included one procedural death and two Q wave infarctions. Follow-up for a mean of 32 months demonstrated a 1- and 3-year actuarial survival rate of 94% and 80%, respectively. At 3 years, only 34% of patients were free of repeat angioplasty or surgery. CONCLUSIONS: Angioplasty of totally occluded bypass grafts can be successful in the majority of selected patients, although major complications can occur. Strategies for sustained patency are needed to improve the long-term results.

Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience.

OBJECTIVES: The study compared procedural outcomes and long-term survival for patients undergoing percutaneous coronary intervention (PCI) of a chronic total coronary artery occlusion (CTO) with a matched non-CTO cohort to determine whether successful PCI of a CTO is associated with improved survival. BACKGROUND: Percutaneous coronary intervention of a CTO is a common occurrence, and the long-term survival for patients with successful PCI of a CTO has not been clearly defined. METHODS: Between June 1980 and December 1999, a total of 2,007 consecutive patients underwent PCI for a CTO. Utilizing propensity scoring methods, a matched non-CTO cohort of 2,007 patients was identified and compared to the CTO group. The cohorts were stratified into successful and failed procedures. RESULTS: The in-hospital major adverse cardiac event (MACE) rate was 3.8% in the CTO cohort. Technical success has improved over the last 10 years (overall 74.4%, slope 1.0%/yr, p = 0.02, R2 = 49.9%) as did procedural success (overall 69.9%, slope 1.2%/yr, p = 0.02, R2 = 51.5%) without a concomitant increase in in-hospital MACE rates (slope 0.1%/yr, p = 0.7). There was a distinct 10-year survival advantage for successful CTO treatment compared with failed CTO treatment (73.5% vs. 65.1%, p = 0.001). The CTO versus non-CTO 10-year survival was the same (71.2% vs. 71.4%, p = 0.9). Diabetics in the CTO cohort had a lower 10-year survival compared with nondiabetics (58.3% vs. 74.3%, p < 0.0001). CONCLUSIONS: These data represent follow-up of the largest reported series of patients undergoing PCI for a CTO. The 10-year survival rates for matched non-CTO and the CTO cohorts were similar. Success rates have continued to improve without an accompanying increase in MACE rates. A successfully revascularized CTO confers a significant 10-year survival advantage compared with failed revascularization.

Failed direct coronary angioplasty for acute myocardial infarction: in-hospital outcome and predictors of death.

OBJECTIVES: The purpose of this study was to compare the mechanisms, predictors and outcome of patients with failed direct coronary angioplasty of the infarct-related artery with those in patients with successful direct angioplasty. BACKGROUND: Direct coronary angioplasty of the infarct-related artery, without antecedent thrombolytic therapy, is an effective treatment for patients with acute myocardial infarction. Concern has been expressed over high mortality rates in patients with failed direct infarct angioplasty. METHODS: All patients treated by angioplasty were prospectively entered into a computer data base. The characteristics and outcome of all patients with failed direct angioplasty were reviewed and compared with those of patients with successful direct angioplasty. RESULTS: Direct angioplasty was successful in 705 (94%) of 750 patients and unsuccessful in 45 (6%). Patients in the failure group were more likely to be in cardiogenic shock (22% vs. 7%, p < 0.003), to have had a previous myocardial infarction (44% vs. 28%, p < 0.03) and to have three-vessel coronary artery disease (44% vs. 23%, p < 0.003). Age, gender, ejection fraction, previous bypass surgery and diabetes mellitus were similar in both groups. Only the presence of multivessel coronary artery disease (p < 0.004) and cardiogenic shock (p < 0.025) were independent predictors of failed direct angioplasty. In-hospital death (31% vs. 4.8%, p < 0.001) and the need for emergency coronary artery bypass surgery (27% vs. 0.5%, p < 0.0001) were more frequent in patients with unsuccessful than in patients with successful direct angioplasty. Patients with failed direct angioplasty and in-hospital death usually had multiple high risk characteristics, including cardiogenic shock (50%), previous myocardial infarction (43%) and multivessel coronary artery disease (93%). CONCLUSIONS: Direct coronary angioplasty is an effective method for establishing reperfusion in acute myocardial infarction. Procedural failure is infrequent, usually occurring in patients with high risk baseline characteristics.

The clinical course, early prognosis and coronary anatomy of subendocardial infarction.

The following prospective study was undertaken to observe the clinical course, early prognosis and coronary anatomy of patients with subendocardial infarction. Subendocardial infarction was defined as typical chest apin (greater than 15 minutes), serum enzyme elevation and persistent (greater than 48 hours) new T wave inversion and/or S-T segment depression in the absence of new pathologic Q waves. Fifty consecutive patients were defined, followed in a prospective manner and subjected to early coronary arteriography. A prior history of unstable angina was found in 33 patients (66 per cent); 22 patients (44 per cent) had significant dysrhythmias during the acute hospital phase, and seven patients (14 per cent) had evidence of mild left ventricular failure. Coronary arteriography demonstrated significant lesions (greater than 75 per cent narrowing in at least one vessel) in all 50 patients, with 30 patients (60 per cent) having either double- or triple-vessel disease. Follow-up (mean 10.6 months) revealed that 15 patients (30 per cent) had stable angina, 23 patients (46 per cent) unstable angina and only 12 patients (24 per cent) remained free of angina. Of 28 patients in a medically treated group, acute transmural infarctions developed in six (21 per cent) and one died (3 per cent). We conclude that subendocardial infarction is symptomatically an unstable entity, is associated with severe coronary artery disease and, in a medically treated group, is followed by a significant incidence of early transmural myocardial infarction (21 per cent). Therefore, these patients require in-hospital monitoring, careful follow-up and consideration for early coronary arteriography.

Percutaneous transluminal coronary angioplasty: application for acute myocardial infarction.

Seventy-eight of 1,000 consecutive PTCA procedures were performed in the setting of acute MI. Twenty-four of 26 patients with subtotal coronary occlusions underwent successful PTCA, including 9 patients with and 15 patients without previous intracoronary streptokinase infusions. Of 52 patients with total occlusions, PTCA was performed after reperfusion by streptokinase in 24 patients, after unsuccessful intracoronary streptokinase infusion in 6 patients and without previous thrombolytic therapy in 14 patients (27%). Six patients (7.7%) died. The immediate post-PTCA course was stable in 59 of 63 successfully dilated patients and 4 had coronary reocclusion. Late catheterization (mean 10 days) in 41 patients showed improved left ventricular function in most. At 6.5 months of follow-up, there were 9 restenoses that required PTCA, 1 reocclusion, 1 elective CABG and no deaths.

Retained percutaneous transluminal coronary angioplasty equipment components and their management.

Of 5,400 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures, 12 patients had complications resulting in retention of 1 or more PTCA equipment components. Eight patients had guidewire fragments retained within the coronary circulation, including one with a second wire segment within the abdominal aorta. A gold band catheter marker was retained within a coronary artery in 1 patient. Four of 5 extraction procedures in these patients were successful, including retrieval of a wire segment totally contained within the distal circumflex coronary artery. Bioptomes were used to retrieve guidewire segments from the abdominal aorta in 4 patients and a knotted guiding catheter from another. At late follow-up, 5 patients with wire segment retained for an extended time within the coronary circulation had no sequelae attributable to the PTCA component debris. We conclude that many fractured intracoronary wires with proximal portion extending into the ascending aorta can be extracted. Guidewire segments retained for a long time totally within the coronary circulation may be benign, particularly when entrapped within total coronary occlusions. Bioptomes can be used effectively to remove wire segments within the abdominal aorta and to assist in the removal of kinked guide catheters.

"High-risk" percutaneous transluminal coronary angioplasty.

Of 6,500 percutaneous transluminal coronary angioplasty procedures performed between June 1980 and June 1987, 3,501 (1,604 single lesion and 1,897 multiple lesion) were performed in "low-risk" patients with a procedure-related mortality of 0.2 to 0.3%. In comparison, several clinical variables were identified that increased procedural risk by up to 50-fold. These factors include left main dilatation (n = 103, mortality 3.9%), left main equivalent dilatation (n = 77, mortality 2.6%), ejection fraction less than or equal to 40% (n = 664, mortality 2.7%), age greater than or equal to 70 years (n = 1,038, mortality 1.4%), dilatation of all 3 vessels (n = 305, mortality 1.3%), combined diagnostic catheterization and angioplasty for unstable angina (n = 193, mortality 1.5%), and percutaneous transluminal coronary angioplasty for acute myocardial infarction (n = 446, mortality 8.5%). Important considerations in the selection and management of these high-risk patients are discussed.

Primary angioplasty for acute myocardial infarction in 1,000 consecutive patients. Results in an unselected population and high-risk subgroups.

Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has remained an exclusive and consistent method of infarct intervention at our institution over the past 13 years. A total of 1,000 consecutive patients were prospectively enrolled in our primary angioplasty database. Of patients presenting to our group with an acute myocardial infarction, 96% of those eligible received immediate angioplasty. Cardiogenic shock was noted in 79 patients (7.9%). The mean time from pain onset to reperfusion was 5.4 +/- 4.0 hours. Infarct-vessel recanalization was accomplished in 94% of patients. Recanalization rates were similar among the 3 native epicardial coronary systems but were lower in bypass grafts (86%; p < 0.0001). Overall in-hospital mortality was 7.8%; mortality with cardiogenic shock was 44%. Global ejection fraction increased from 49.7% preangioplasty to 57.4% at the time of dismissal. The amount of myocardial salvage was highly dependent on the size of the initial infarction (the largest infarctions benefiting the most). Patients reperfused in < 2 hours experienced a very low mortality (4%) and impressive myocardial salvage. Complications included stroke in 0.5%, significant bleeding in 2.8%, and early reocclusion of the infarct vessel in 13%. Primary angioplasty is broadly applicable to patients presenting with acute myocardial infarction and results in a very high rate of infarct vessel recanalization, with a mortality rate of 7.8%. This strategy may be uniquely effective in patients presenting with cardiogenic shock, large infarctions, contraindications to thrombolytic therapy, and prior bypass surgery.

Cardiovascular complications of pheochromocytoma crisis.

Two patients with hypertensive crises due to pheochromocytoma presented with unusual features suggestive of cardiovascular disorders other than pheochromocytoma. These features included transient cortical blindness and other neurologic deficits, electrocardiographic changes indicative of transmural infarction and peripheral arterial spasm. In both patients the diagnosis of pheochromocytoma was made later; removal of the tumor was followed by ready reversal of the clinical and biochemical abnormalities. Management of such cases includes suspicion of the diagnosis in the presence of atypical features, early initiation of therapy with alpha and beta adrenergic blocking agents and a definitive surgical procedure before peripheral vascular changes become irreversible. When an apparent myocardial infarction occurs, the diagnosis of coronary artery disease cannot always be excluded, but rapid stabilization of the clinical and electrocardiographic changes after adrenergic blockade would favor the diagnosis of a catecholamine-induced myocarditis. The coexistence of coronary artery disease and uncontrollable arrhythmias presents an increased risk but, if pheochromocytoma is suspected, surgery may be necessary despite the increased risk.

Left main coronary angioplasty: early and late results of 127 acute and elective procedures.

The results of 127 left main (LM) coronary angioplasties were reviewed to assess short- and long-term effectiveness. Three major subgroups were considered: (1) elective "protected" (defined as the presence of a patent bypass graft to the left coronary circulation) patients (n = 84); (2) elective "unprotected" patients (n = 33); and (3) acute patients, in whom LM coronary angioplasty was performed in the setting of an acute myocardial infarction (n = 10). Successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4 and 9.1% in protected and unprotected patients, respectively, p = 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90 and 36% in elective protected and unprotected subgroups, respectively (p less than 0.0005). In the acute subgroup, 3 patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option. In contrast, elective angioplasty of a protected LM coronary artery can be accomplished safely with good long-term results. LM coronary angioplasty for acute myocardial infarction can be effective as a salvage procedure; however, adjunctive coronary bypass surgery is important for long-term survival.

Usefulness of angioplasty during acute myocardial infarction in patients with prior coronary artery bypass grafting.

The efficacy and risk of reperfusion strategies for myocardial infarction in patients with prior coronary artery bypass surgery are uncertain. In this study 72 patients with prior bypass grafting underwent direct percutaneous transluminal coronary angioplasty without antecedent thrombolytic therapy. There were 26 anterior and 46 inferior infarctions, including 11 patients (15%) in cardiogenic shock. The baseline ejection fraction was less than 40% in 47 (65%) patients. Angioplasty was successful in 41 of 48 (85%) vein grafts and 24 of 24 (100%) arteries (difference not significant) at 5.1 +/- 4.0 hours from the onset of symptoms (79% treated less than 6 hours). There were no urgent bypass operations, strokes or transfusions. In-hospital survival was 90% (nonshock 95% vs shock 64%, p less than 0.01). Symptomatic acute reclosure occurred in 1 patient. Predischarge coronary arteriography in 34 patients demonstrated continued vessel patency in 32 infarct vessels (94%), although 5 of these vessels were redilated for restenoses. Predischarge paired ventriculography in 26 patients showed an increase in ejection fraction from 44 +/- 16% to 51 +/- 18% (p less than 0.01). One- and 3-year actuarial survival was 89 and 87%. Thus, prior coronary surgery should not preclude reperfusion therapy by direct angioplasty, which can be accomplished with low procedural risk, improvements in ventricular function and excellent in-hospital and late survival.

Outcome following emergency coronary artery bypass grafting for failed elective balloon coronary angioplasty in patients with prior coronary bypass.

To assess frequency and outcome of emergency coronary artery bypass grafting (CABG) for failed coronary angioplasty in patients with prior CABG, 2,136 elective angioplasty procedures in prior CABG patients were reviewed over a 10-year period. Emergency surgical revascularization was required in 19 patients (0.9%) with prior CABG, compared with 130 of 6,974 patients (1.9%) without prior CABG (p = 0.001). The interval from the most recent CABG to the failed coronary angioplasty was 6.8 years (range 1 to 16). Referral for emergency CABG was made on the basis of an acute closure not responding to repeat dilatation in 12 native coronary arteries and in 7 saphenous vein grafts. Severe hemodynamic instability after acute closure required the placement of an intraaortic balloon pump in 3 patients, including 2 who required cardiopulmonary resuscitation. A total of 34 saphenous vein grafts and 1 internal mammary artery graft were placed emergently. Three patients with high-risk features (3 prior CABG operations in 1 patient, single remaining vessel to heart in 2 patients) could not be weaned from cardiopulmonary bypass. The remaining 16 patients were discharged after a mean hospital stay of 16 days. Four patients developed new Q waves after CABG. At follow-up (mean 52 months, range 3 to 99), 1 patient died late from an acute myocardial infarction. The 15 survivors had no or mild angina and were free of further CABG. Thus, emergency CABG after failed angioplasty in patients with prior CABG is required infrequently. In patients without extreme high-risk features, emergency repeat CABG can be accomplished with good hospital and long-term results.