Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina.

BACKGROUND: Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society). METHODS: In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients). RESULTS: After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning. CONCLUSIONS: Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Preoperative and postoperative comparison of patients with univentricular and biventricular support with the thoratec ventricular assist device as a bridge to cardiac transplantation.

OBJECTIVES: The goal of this study was to determine whether there are differences in populations of patients with heart failure who require univentricular or biventricular circulatory support. METHODS: Two hundred thirteen patients who were in imminent risk of dying before donor heart procurement and who received Thoratec left (LVAD) and right (RVAD) ventricular assist devices at 35 hospitals were divided into three groups: group 1 (n = 74), patients adequately supported with isolated LVADs; group 2 (n = 37), patients initially receiving an LVAD and later requiring an RVAD; and group 3 (n = 102), patients who received biventricular assistance (BiVAD) from the beginning. RESULTS: There were no significant differences in any preoperative factors between the two BiVAD groups. In the combined BiVAD groups, pre-VAD cardiac index (BiVAD, 1.4 +/- 0.6 L/min per square meter, vs LVAD, 1.6 +/- 0.6 L/min per square meter) and pulmonary capillary wedge pressure (BiVAD, 27 +/- 8 mm Hg, vs LVAD, 30 +/- 8 mm Hg) were significantly lower than those in the LVAD group, and pre-VAD creatinine levels were significantly higher (BiVAD, 1.9 +/- 1.1 mg/dl, vs LVAD, 1.4 +/- 0.6 mg/dl). In addition, greater proportions of patients in the BiVAD groups required mechanical ventilation before VAD placement (60% vs 35%) and were implanted under emergency conditions than in the LVAD group (22% vs 9%). The survival of patients through heart transplantation was significantly better in patients who had an LVAD (74%) than in those who had BiVADs (58%). However, there were no significant differences in posttransplantation survival through hospital discharge (LVAD, 89%; BiVAD, 81%). CONCLUSION: Patients who received LVADs were less severely ill before the operation and consequently were more likely to survive after the operation. As the severity of illness increases, patients are more likely to require biventricular support.

Placement of a Greenfield filter in the superior vena cava.

A 75-year-old man with a Greenfield filter in the inferior vena cava for previous pulmonary emboli had recurrent pulmonary emboli. He was unable to take anticoagulants due to gastric ulcer disease. Contrast studies revealed a large thrombus in the left brachiocephalic vein. A Greenfield filter was placed in the superior vena cava through the right internal jugular vein using the femoral insertion apparatus.

The third time coronary artery bypass graft: is the risk justified?

Twenty-one patients undergoing a coronary artery bypass graft operation for the third time were retrospectively reviewed to assess the factors of importance in the management of these patients. The study spans 5.8 years and represents 6.2% of coronary bypass reoperations and 0.6% (21/3500) of total bypass operations during that time. The indication for reoperation was disabling angina pectoris not responsive to medical treatment in 20 patients (95%) and unstable angina pectoris with an intraaortic balloon pump present in one patient (5%). Median sternotomy was used in all and cardiopulmonary bypass in all but one who had an interposition vein graft without cardiopulmonary bypass. Internal mammary artery grafting was used in 86% of patients. There were no operative deaths. One patient died 12 months after his operation. Four patients (19%) required intraaortic balloon pump support postoperatively for up to 6 days. There were no reexplorations for bleeding. One patient required sternal rewiring for an early dehiscence (5%). Respiratory failure occurred in eight patients (38%). Average stay was 4.4 days in the intensive care unit and postoperative hospital stay was 13.7 days. No new Q waves were noted postoperatively. Detailed follow-up was obtained on 18 of the 20 survivors (90%). The two remaining are alive but declined interview efforts. All patients interviewed reported feeling subjectively better than before operation; however 61% of these interviewed continue to have some degree of angina pectoris. One patient has had a late myocardial infarction. This report suggests that the third time coronary bypass can be done with good results when myocardial revascularization is indicated.

Coronary artery bypass after recent myocardial infarction.

During a five-year period, 280 patients underwent myocardial revascularization within 60 days of having suffered an acute myocardial infarction. Eighty-six percent of them had angina. Twelve patients had calculated ejection fractions of less than 20%; 79, 21% to 40%; and 105, from 41% to 60%. Ten patients had one graft; 33, two; 74, three; and 163, four or more. Twenty-four patients had concomitant ventricular aneurysm repair. The intra-aortic balloon pump was used in only seven patients. There was one postoperative death secondary to respiratory insufficiency and sepsis, resulting in a hospital mortality of 0.4%. Myocardial revascularization is a safe procedure following recent myocardial infarction, with results comparable to elective revascularization. Our long-term results suggest that revascularization may decrease the incidence of recurrent myocardial infarction.

Emergency coronary revascularization in the early postoperative coronary artery bypass patient.

A patient underwent myocardial revascularization for acute ischemia following early postoperative graft closure and ventricular fibrillation. Extensive myocardial infarction was prevented by electrocardiographic and enzyme criteria. The time lapse between onset of the ischemic episode and revascularization is critical. Our knowledge of the patient's coronary anatomy obviated the need for angiography; the graft occlusion was diagnosed by electrocardiogram.

Improved operative risk after myocardial revascularization.

At Ochsner Medical Institutions from 1970 to 1979, 96 patients who had previously had myocardial revascularization later had a total of 136 noncardiac operations. There were no postoperative myocardial infarctions and only one noncardiac death. Transitory postoperative arrhythmias occurred in 3.6% of patients. It appears that myocardial revascularization protects the cardiac patient from myocardial infarction and cardiac-related deaths during and after noncardiac operations. Patients with cardiac disease scheduled for elective surgery should have exercise testing or coronary cineangiography or both to evaluate the severity and significance of the coronary disease. If significant coronary lesions are demonstrated that are amenable to a bypass procedure, the operative risk will be lessened by prior revascularization.