Coronary angioplasty versus bypass surgery in patients > 70 years old matched for ventricular function.

OBJECTIVES: This study compared the relative risks and benefits of coronary angioplasty and coronary artery bypass graft surgery in patients > 70 years old. BACKGROUND: Few objective, comparative data exist to guide the clinician in the decision to use bypass surgery or angioplasty in elderly patients. METHODS: The study was a case-control, retrospective analysis of 195 consecutive patients who underwent bypass surgery in 1987 and 1988 and were compared with a concurrent cohort of 195 coronary angioplasty-treated patients. The groups were matched for left ventricular function, age and gender mix. RESULTS: The in-hospital morbidity and mortality rates were significantly lower in the coronary angioplasty-treated patients. Mean postprocedural hospital stay was 4.8 and 14.3 days for angioplasty and surgical group patients, respectively (p < 0.001). In-hospital death occurred in 2% of angioplasty-treated patients compared with 9% of surgically treated patients (p = 0.007). Serious in-hospital stroke occurred in no patient in the angioplasty group and in 5% of patients in the surgical group (p < 0.0001). Q wave infarction occurred in 1% of angioplasty-treated patients and 6% of bypass-treated patients (p = 0.01). The 5-year actuarial survival rate was similar in the two groups: 63% in the angioplasty group, 65% in the bypass group (p = NS). However, surgical group patients experienced less recurrent angina, required fewer repeat revascularization procedures and had fewer Q wave infarctions during follow-up compared with angioplasty group patients. CONCLUSIONS: When performed in patients > 70 years old, angioplasty and coronary bypass surgery result in similar long-term survival rates but otherwise distinctly different clinical courses.

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery.

OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.

Chyloptysis (chylous sputum) due to thoracic lymphangiectasis with successful surgical correction.

A 73-year-old woman with a two-year history of recurrent episodes of respiratory distress is described. The finding of an elevated triglyceride value of 23.4 mmol/L (2072 mg/dL) and a normal cholesterol value in her sputum led to the correct diagnosis of chyloptysis after lymphangiography was performed. It is thought that congenital incompetence of the lymphatic valves was the cause of chyloptysis.

Two dimensional echocardiographic detection and measurement of the right pulmonary artery in pulmonary atresia-ventricular septal defect: angiographic and surgical correlation.

This study assessed the value of two dimensional echocardiography in patients with pulmonary atresia-ventricular septal defect in order to detect the presence of true pulmonary arteries, measure the dimension of the visible proximal right pulmonary artery and correlate these echocardiographic observations with angiographic and surgical findings. The data from 65 patients (age range 16 months to 54 years) with pulmonary atresia-ventricular septal defect who had both two dimensional echocardiographic and angiographic evaluation to determine the presence of pulmonary arteries were reviewed. Echocardiography allowed visualization of a right pulmonary artery in 55 (85 percent) of the 65 patients. Echocardiography detected a measurable proximal right pulmonary artery in 52 (98 percent) of 53 patients who had confluent pulmonary arteries confirmed with angiography. In three patients without confluence, a large systemic to pulmonary collateral artery was misinterpreted as the right pulmonary artery on two dimensional echocardiography. Right pulmonary arterial measurements on echocardiography (range 3 to 21 mm) showed excellent correlation with angiographic (r = 0.95) and surgical (r = 0.84) measurements. These data indicate that two dimensional echocardiography can be used to visualize proximal true pulmonary arteries (specifically, a right pulmonary artery) in a large proportion of patients with pulmonary atresia-ventricular septal defect; this finding usually denotes the presence of confluent pulmonary arteries. The data also suggest that this method can be reliably used for serial follow-up studies with noninvasive measurement of proximal right pulmonary arterial growth.

Angioplasty versus bypass surgery for multivessel coronary artery disease with left ventricular ejection fraction < or = 40%.

Patients with multivessel coronary artery disease and left ventricular dysfunction represent a high-risk subgroup in whom coronary artery bypass grafting has been shown to improve survival compared with that of medically treated patients. The comparative benefits and risks of coronary angioplasty and bypass surgery in this subgroup of patients are unclear. This study retrospectively analyzes 100 consecutive patients treated with bypass surgery compared with a matched, concurrent cohort of 100 treated with multivessel angioplasty. Early results favored angioplasty; a hospital stay of 12.8 days was noted in the bypass group compared with 4.3 days in the angioplasty group (p < 0.001). In-hospital mortality rates were similar in the bypass (5%) and angioplasty (3%) groups (p = NS). Stroke was observed significantly more often in the bypass group (7 vs 0%). However, late follow-up favored bypass patients; repeat revascularization procedures and late myocardial infarction occurred more frequently during follow-up in the angioplasty group. During 5-year follow-up, superior relief from disabling angina (99 vs 89%; p = 0.01) and a trend toward improved survival (76 vs 67%; p = 0.09) were observed in the bypass group as compared with the angioplasty group. Multivariate correlates of late mortality included age and incomplete revascularization, but not mode of revascularization. Thus, in patients with multivessel coronary artery disease and left ventricular dysfunction, early results favor angioplasty, whereas late follow-up favors bypass surgery. However, late survival was similar in both groups of patients who were completely revascularized.

Angiographic changes produced by percutaneous transluminal coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) is being used with increasing frequency in the treatment of patients with symptomatic coronary artery disease. Balloon inflation results in diverse angiographic findings, reflecting the great variety of anatomic and pathologic changes produced. The long-term effects of inflation on the underlying atherosclerotic lesion and the clinical outcome are unknown but may depend in part on the anatomic changes caused by the dilatation itself. To facilitate communication and evaluation of the results of PTCA, a classification of the angiographic findings and their potential mechanisms is presented. Recognition and analysis of these angiographic findings may be helpful in evaluating the long-term outcome of patients undergoing PTCA.

Percutaneous transluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute PTCA Registry.

Because CABG results in a significantly higher morbidity and prolonged hospitalization in the older patient group, PTCA is an attractive alternative for providing myocardial revascularization in the small group of older patients with appropriate lesions for dilation. This analysis of the results of PTCA in 370 older patients in the NHLBI PTCA Registry reveals that PTCA can be performed with acceptably low mortality and morbidity. Therefore, PTCA may offer an alternative to CABG in the highly selected symptomatic older patient.

Trial of combined warfarin plus dipyridamole or aspirin therapy in prosthetic heart valve replacement: danger of aspirin compared with dipyridamole.

Despite the use of oral anticoagulation in patients with prosthetic heart valves, persistent thromboembolism over time warrants a search for improved methods of prevention. Thus, patients receiving 1 or more mechanical prosthetic heart valves were randomized to therapy with warfarin plus dipyridamole (400 mg/day) or warfarin plus aspirin (500 mg/day) on the basis of location and type of valve and surgeon, and followed up with a concurrent, nonrandomized control group taking warfarin alone. In 534 patients followed up 1,319 patient-years, excessive bleeding (necessitating blood transfusion or hospitalization) was noted in the warfarin plus aspirin group (23 of 170 [14%], or 6.0/100 patient-years) compared with warfarin plus dipyridamole (7 of 181 [4%], or 1.6/100 patient-years, p less than 0.001), or warfarin alone (9 of 183 [5%], or 1.8/100 patient-years, p less than 0.001). A trend was evident toward a reduction in thromboembolism in the warfarin plus dipyridamole group (2 of 181 [1%], or 0.5/100 patient-years) as compared with warfarin plus aspirin (7 of 170 [4%], or 1.8/100 patient-years), or warfarin alone (6 of 183 [4%], or 1.2/100 patient-years). Adequacy of anticoagulation (based on 12,720 prothrombin time determinations) was similar in all 3 groups with 65% of prothrombin times in the therapeutic range (1.5 less than or equal to prothrombin time/control less than or equal to 2.5), 30% too low, and 5% too high. Warfarin plus aspirin therapy resulted in excessive bleeding and is contraindicated. Longer follow-up study is needed to determine whether further separation of the incidence of thromboembolism can be detected.

Current techniques for the surgical management of malignant lesions of the thoracic esophagus and cardia.

Cancers of the esophagus and cardia remain serious conditions that cause many thousands of deaths every year throughout the world. In North America, cancer of the esophagus and gastric cardia is an endemic disease of low order and stable incidence. Nevertheless, it is responsible for many deaths and considerable suffering. With current methods of treatment, substantial palliation and amelioration of patient disability are possible, and some patients gain long-term survival with comfort and even cure. A combination of surgical resection and reconstruction is the chief modern method of management of such cancers. Herein we discuss a variety of standard surgical procedures that are currently available and present detailed illustrations of these procedures. The selection of a specific operation depends largely on the site of the neoplasm. With all these procedures, function is restored and the local and regional neoplastic tissue is removed without compromising the potential for cure. Associated operative mortality is approximately 7%. The late results of the operations illustrated depend primarily on the cell type, grade, and stage of the neoplasm encountered at the time of surgical treatment. For patients who have undergone resection, 5-year survival rates have ranged from 15 to 54%, the results depending on the stage of the cancer. Of equal importance is the fact that oral diet can be maintained in 93% of patients despite recurrence of the neoplasm.

Platypnea-orthodeoxia: clinical profile, diagnostic workup, management, and report of seven cases.

Platypnea-orthodeoxia is a rare and poorly understood syndrome of orthostatic accentuation of a right-to-left shunt, usually across a patent foramen ovale. The syndrome is most commonly recognized in patients with a history of a major pulmonary disorder such as pneumonectomy, recurrent pulmonary emboli, or chronic lung disease. Pulmonary artery pressures are typically normal. The physiologic mechanism is unknown. We recommend that initial assessment consist of measurement of blood gases with the patient in the supine and upright positions. Orthostatic desaturation should prompt further investigation. A definitive diagnosis can most easily be obtained by tilt-table two-dimensional echocardiography with peripheral venous contrast medium. The shunt can be localized at the atrial level and directly visualized and semiquantitated. The decision about surgical closure of the patent foramen ovale is based on the degree of clinical disability. Because a significant shunt is manifest only in the upright position, astute clinical suspicion is of paramount importance for proper diagnosis. Increased awareness of this syndrome and ease of echocardiographic diagnosis will facilitate recognition of this potentially treatable cause of orthostatic hypoxia.

Balloon angioplasty in multivessel coronary artery disease.

Coronary angioplasty with use of the balloon catheter was initially performed only in patients with single-vessel coronary artery disease. Most symptomatic patients with coronary artery disease who require revascularization for control of their symptoms, however, have stenoses in more than one major coronary artery. Therefore, we have evaluated the results of balloon angioplasty in patients with multivessel disease. Of 261 patients who underwent percutaneous transluminal coronary angioplasty at our institution up to February 1983, 100 had multivessel disease. Of these 100 patients, 72 had an initially successful procedure, defined as successful dilation of one or more major coronary arteries without significant complication. Of the remaining 28 patients, 25 underwent coronary artery bypass grafting (6 on an urgent basis for coronary occlusion). No deaths occurred. In selected patients with multivessel disease, coronary angioplasty is associated with low morbidity and mortality and might be an excellent alternative to coronary artery bypass grafting when medical treatment fails. Percutaneous transluminal coronary angioplasty merits the critical comparison with standard therapy that can be achieved only in a properly designed clinical trial.

Roentgenographically occult lung cancer: pathologic findings and frequency of multicentricity during a 10-year period.

During the first 10 years of the Mayo Lung Project, 68 roentgenographically inapparent ("occult") lung cancers were localized and apparently completely resected. A pathologic classification was developed based on depth of tumor infiltration. The five categories were (1) in situ carcinoma confined to surface epithelium or ducts of mucous glands or acini (23 cancers), (2) intramucosal invasion not greater than 0.1 cm from mucosal surface (12 cancers), (3) invasion to bronchial cartilages (11 cancers), (4) invasion to full thickness of bronchial wall (10 cancers), and (5) extrabronchial invasion (12 cancers). Multicentricity of lung cancer was studied in 54 patients, none of whom had a history of cancer of the respiratory tract, and all of whom had had "complete" surgical resection of the initial occult lung cancer (or cancers). Neoplasms that were initially multicentric occurred in 4 patients, and a subsequent primary lung cancer developed in 11. The rate of detection of second primary lesions was 42 per 1,000 person-years of observation. A high incidence of unresectable cancers and a low survival rate were noted among patients who had a subsequent primary tumor. These findings were primarily attributable to invasiveness of the subsequent primary cancer or to respiratory insufficiency that resulted from obstructive lung disease or previous pulmonary resection. Because of the high risk of development of a second primary cancer after initial surgical resection, it is important to treat the initial occult cancer as conservatively as possible consistent with "cure."

Percutaneous transluminal coronary angioplasty, alone or in combination with streptokinase therapy, during acute myocardial infarction.

The treatment strategy in 66 consecutive patients who underwent invasive therapy for acute myocardial infarction was analyzed, and specific attention was focused on the role of percutaneous transluminal coronary angioplasty. The following four treatment regimens were used: angioplasty alone (11 patients), angioplasty followed immediately by administration of streptokinase (15), streptokinase therapy alone (11), and streptokinase therapy followed by angioplasty (29). Reperfusion was achieved in 91%, 80%, 82%, and 72% of these subgroups, respectively. Angioplasty was particularly helpful in patients with severe residual stenoses after intracoronary administration of streptokinase and in patients in whom streptokinase therapy failed to reopen the occluded artery. Angioplasty further reduced the residual stenosis in 11 of 15 patients (73%) with successful thrombolysis, and it restored blood flow in 10 of 14 patients (71%) in whom thrombolysis had failed to do so. The incidence of reinfarction after therapy was similar in all four treatment groups. Patients in whom angioplasty was used either alone or in combination with streptokinase therapy had a significantly decreased incidence of subsequent revascularization (less than 30% compared with 82%). Angioplasty is of considerable value in patients undergoing invasive therapy for acute infarction. In some patients, it may be used as the only treatment; in others, it may be used to treat severe residual stenosis after initial streptokinase therapy. Finally, angioplasty achieves reperfusion in most patients in whom streptokinase therapy has failed.

Intrathoracic transposition of extrathoracic skeletal muscle.

During the past 6 years, 31 patients (20 males and 11 females) underwent 45 intrathoracic muscle transpositions of extrathoracic skeletal muscle. Eleven patients had postpneumonectomy empyema, 11 had bronchopleural fistula, four had infection of the heart and great vessels, three had reinforcement of tracheal anastomoses, and two had perforation of the gastrointestinal tract. Life-threatening infection was present in 28 patients. Ages ranged from 16 to 80 years, with a mean of 58.1. The latissimus dorsi muscle was transposed in 18 patients, pectoralis major muscle in 15, serratus anterior muscle in eight, pectoralis minor muscle in three, and rectus abdominis muscle in one. Twelve patients had multiple muscle transpositions (six concurrently and six staged). Operative mortality was 12.9% (four patients). Follow-up of the 27 operative survivors ranged from 3 to 72 months with a mean of 17.3. Twenty-four patients had no further signs or symptoms of the original infection. All had a closed chest. Long-term survivors included 73% of patients with postpneumonectomy empyema, 64% of patients with bronchopleural fistulas, and 50% of patients with infections of the heart and great vessels. We conclude that intrathoracic transposition of an extrathoracic skeletal muscle is an excellent method of treatment for persistent, life-threatening intrathoracic infection.

Unexplained diaphragmatic paralysis: a harbinger of malignant disease?

The records of 103 male and 39 female patients with unexplained diaphragmatic paralysis were reviewed. A probable cause of the paralysis was not revealed by the initial history, physical examination, or review of plain chest roentgenograms. Paralysis occurred on the left in 82 patients (58%), on the right in 58 (41%), and bilaterally in two (1%). Initially, 64 patients (45%) had symptoms; dyspnea, cough, and chest wall pain were the most common. Long-term follow-up showed the best prognosis to be for patients with chest wall pain and cough (improvement in 82% and 78%, respectively); dyspnea improved in only 34% of patients with this complaint. Intrathoracic malignant lesions with phrenic nerve involvement were subsequently diagnosed in five patients (3.5%) and progressive neurogenic atrophy in one (0.7%). Roentgenographic follow-up showed return of normal diaphragmatic position in only 12 instances (9.2%). Patients with unexplained diaphragmatic paralysis are unlikely to have an underlying occult malignant or neurologic process, but recovery of diaphragmatic function is also unlikely and subsidence of related symptoms is variable.

Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results.

Operative treatment of dissections of the ascending aorta differs from that for the descending aorta, not only because of the need for cardiopulmonary bypass, but also because of the frequent occurrence of aortic valve insufficiency. To determine the early and late results of operative repair, we have reviewed the case histories of 121 consecutive patients who underwent repair of ascending aortic dissections between 1962 and 1985. Ages ranged from 16 to 79 years (mean 56 +/- 14 years); 54 patients had operation within 2 weeks of onset of symptoms (acute), and the remainder had later repair (chronic). Seventy patients (58%) had clinical evidence of aortic insufficiency at the time of admission. During repair of acute dissection, 10 patients (19%) had aortic valve resuspension and 15 patients (28%) had aortic valve replacement. During repair of chronic dissection, eight patients (12%) had resuspension and 43 patients (64%) had replacement. Overall operative mortality was 22%, significantly higher for patients with acute than for those with chronic dissections (39% versus 9%, p less than 0.01). Operative risk was similar for patients who underwent repair of ascending aortic dissections without valve resuspension or replacement (31%) versus those who had repair with aortic valve resuspension (17%) or replacement (17%). During a follow-up period ranging from 1 to 208 months, aortic regurgitation developed in only two patients who did not have aortic insufficiency at the time of repair. Late aortic regurgitation necessitating reoperation developed in one of the 15 survivors who had aortic valve resuspension. Eight patients undergoing aortic valve replacement had complications of their prostheses, including one periprosthetic leak and four mechanical failures. We conclude that resuspension or replacement of the aortic valve does not increase the risk of repair of ascending aortic dissections. Selective management of aortic insufficiency (with valve repair whenever possible) yields satisfactory long-term results.

Pleural lavage after pulmonary resection for bronchogenic carcinoma.

A cytologic examination of pleural fluid was performed on a pleural lavage specimen collected at the completion of operation after pulmonary resection in 135 of 599 patients undergoing curative pulmonary resection for a non-small cell carcinoma of the lung between 1977 and 1982. The cytologic results of lavage was positive for malignant cells in 12 of the 135 patients (8.9%). The incidence of positive results was correlated with lymph node status (N2 greater than N1 greater than N0), cell type (adenocarcinoma greater than other non-small cell lung cancers), stage (III greater than II greater than I), and visceral pleural status (invaded greater than not invaded). No positive cytologic results were noted in 39 patients having a diagnostic excisional pulmonary biopsy prior to more definitive resection. The disease has recurred in nine of the 12 patients with positive cytologic results (only two in the ipsilateral pleural space), and eight have died. The prognostic role of pleural lavage cytology needs more study.

Reoperation on prosthetic heart valves. An analysis of risk factors in 552 patients.

Five hundred fifty-two patients underwent a total of 617 reoperations for repair or replacement of a prosthetic heart valve. Operative mortality for first reoperation (530 patients) was 5.9% for the aortic position and 19.6% for the mitral position. Overall operative mortality was 14% for second reoperation (69 patients) and 7% for third reoperation (14 patients). In addition to valve position, operative mortality for first reoperation appeared to be related to pre-reoperation functional class and urgency of operation. First reoperation for mitral valve patients in New York Heart Association (NYHA) Class II was 4.2%; for Class III, 9.3%; and for Class IV, 41%. In the aortic position, operative mortality was 2.4% for Class I, 1.6% for Class II, 6.3% for Class III, and 20.8% for Class IV. The mortality for elective mitral valve reoperation was 0%; for urgent operation, 20.3%; and for emergency procedures, 54.5%. Elective aortic valve reoperation carried a 1.4% mortality; urgent procedures, 8%; and emergency procedures, 37.5%. No significant differences in bleeding complications were noted between reoperations and initial valve replacement. The data appear to suggest that when significant valve dysfunction is first noted, reoperation should be undertaken to minimize operative risk.

En bloc (non-chest wall) resection for bronchogenic carcinoma with parietal fixation. Factors affecting survival.

Seventy-three patients (57 men and 16 women) underwent en bloc resection of lung and attached parietes between 1970 and 1982. All patients had documented malignant pleural invasion. Chest wall parietal pleura was invaded in 33 patients, pericardium in 14, phrenic or vagus nerve in nine, left atrium in five, superior vena cava in four, esophagus in two, diaphragm in one, and multiple structures in five. No patient underwent chest wall resection. Parietal pleurectomy was performed in all patients with involvement of the chest wall parietal pleura; 37 lobectomies and 36 pneumonectomies were performed. Operative mortality was 12.3%. The actuarial overall 5 year survival rate (Kaplan-Meier method) was 39.7%. We conclude that en bloc resection for primary bronchogenic carcinoma with invasion of adjacent intrathoracic structures, although associated with a significant mortality, can be performed with a reasonable likelihood of long-term survival.

Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course.

Surgical drainage for effusive pericardial disease is usually accompanied by pericardial resection to obtain tissue for analysis and to lessen the chance of recurrent effusion or late constriction. The purpose of this study was to determine the relationship between the extent of resection and the development of late complications. From 1960 through 1983, 145 patients with pure pericardial effusive disease underwent operative drainage. The effusions were malignant in 72 patients (49.7%) and benign in 73 (50.3%). The patients were divided into three groups according to the extent of resection: complete in 72 patients (49.7%), partial in 36 (24.8%), and window in 37 (25.5%). The 30 day mortality was 19.4% for patients with malignant effusions and 5.5% for those with benign effusions (p less than 0.05). All survivors had immediate improvement in symptoms. The actuarial 1 year survival rate was 23.4% (mean 4.2 months) for patients with malignant disease and 85.6% for patients with idiopathic effusions (p less than 0.001). Survival was not influenced by the extent of resection. Fifteen patients (10.3%) had late constriction or recurrent effusion. Six of these required reoperation, all after having had a window procedure. Actuarial probability of reoperation or late complication was greater with window procedures than other resections, both for all patients (p = 0.0001) and for those with benign disease (p = 0.0001). Transthoracic complete pericardiectomy is the procedure of choice for effusive pericardial disease. Subxiphoid drainage has immediate advantages for selected patients but has a statistically greater chance of late complications.