A process for ensuring optimal cardiovascular intervention and identifying candidates for glycoprotein IIb/IIIa receptor inhibitor therapy.

Data from trials with glycoprotein (GP) IIb/IIIa receptor inhibitors have led to a new standard of care for patients with unstable angina or non-wave myocardial infarction (MI) who are undergoing percutaneous coronary intervention. Additional data are necessary to compare patient responses to various GP IIb/IIIa agents in a nontrial setting with results from clinical trials. Seton Medical Center has designed a database to accommodate this task. Data from >20,000 patients have been collected since 1979 and the interventional experience from the years 1997 through 1999 has been analyzed for patients who were candidates for receiving these agents. The data are being used to evaluate the outcomes of therapy and to devise models that can stratify patients according to risk, thereby ensuring optimal cardiovascular intervention and choice of the most cost-effective GP IIb/IIIa inhibitor agent.

Emergency coronary artery bypass surgery following failed balloon angioplasty: role of the internal mammary artery graft.

During a 4-year period (1986-1989), 3,502 patients had percutaneous transluminal coronary angioplasty (PTCA) in our institution. One hundred nineteen (3.4%) patients required emergency coronary artery bypass graft surgery (CABG) because of abrupt vessel closure following PTCA. Factors associated with vessel closure included lesion angulation greater than or equal to 90 degrees (p less than 0.007), the presence of thrombus (p less than 0.02), or a long (greater than or equal to 2 cm) lesion (p less than 0.03). Of these 119 emergency CABG patients, 108 (91%) arrived in the operating room in a stable condition (group I) and 11 (9%) were in cardiogenic shock (group II). Five (45%) of the group II patients were admitted to the hospital with an acute myocardial infarction and all 11 patients had a higher incidence of multivessel disease (p less than 0.05) and lower left ventricular ejection fraction (p less than 0.001) than group I patients. The overall surgical mortality was 10.1%; however, in group I the mortality was 5.6% and in group II it was 54.5% (p less than 0.001). The vessel that abruptly closed ("culprit vessel") was the left anterior descending (LAD) in 60%, the right coronary artery in 27%, and the left circumflex in 13%. The internal mammary artery was utilized to bypass the culprit artery in 51 (43%) patients, including 50% of the culprit LADs. With group I culprit LAD patients, when the left IMA was the bypass conduit, there were no hospital deaths nor strokes and there was a 6.3% incidence of perioperative infarction.