Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction.

OBJECTIVES: The goal of this study was to learn more about the risk factors and short- and long-term outcomes for primary angioplasty. BACKGROUND: Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has been an effective alternative to thrombolytic therapy for patients with acute myocardial infarction (AMI). However, most reported studies have been compromised by small sample sizes and short observation times. METHODS: New York's coronary angioplasty registry was used to identify New York patients undergoing angioplasty within 6 h of AMI between January 1, 1993 and December 31, 1996. Statistical models were used to identify significant risk factors for in-patient and long-term survival and to estimate long-term survival for all patients as well as various subsets of patients undergoing primary angioplasty. RESULTS: The in-hospital mortality rate for all primary angioplasty patients was 5.81%. When patients in preprocedural shock (who had a mortality rate of 45%) were excluded, the in-hospital mortality rate dropped to 2.60%. Mortality rates for all primary angioplasty patients at one year, two years and three years were 9.3%, 11.3% and 12.6%, respectively. Patients treated with stent placement did not have significantly lower risk-adjusted in-patient or two-year mortality rates. CONCLUSIONS: Primary angioplasty is a highly effective option for AMI.

A comparison of short- and long-term outcomes for balloon angioplasty and coronary stent placement.

OBJECTIVES: We sought to compare patient outcomes for coronary stent placement and balloon angioplasty. BACKGROUND: Since 1994, the number of patients treated only with balloon angioplasty has decreased nationally, whereas the use of coronary stents as an alternative has grown tremendously. The objectives of this study were to compare short- and long-term survival and subsequent revascularization rates for patients undergoing single-vessel balloon angioplasty and coronary stent placement. METHODS: New York's Coronary Angioplasty Registry was used to identify New York patients undergoing either balloon angioplasty or stent placement between July 1, 1994, and December 31, 1996. Statistical models were used to compare risk-adjusted short- and long-term survival and subsequent coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCIs). RESULTS: No significant differences were found in adjusted in-patient mortality, but patients who had balloon angioplasty were, on average, 1.36 times more likely to have died at any time during the two-year period after the index procedure (p = 0.003). The adjusted in-patient CABG rate was significantly higher for balloon angioplasty (2.72% vs. 1.66%, p<0.0001), and the adjusted two-year CABG rate was also significantly higher for balloon angioplasty (10.81% vs. 7.25%, p<0.001). The adjusted two-year rate for subsequent PCIs was also significantly higher for balloon angioplasty (19.6% vs. 14.3%, p<0.0001). Although measures were taken to eliminate or minimize the effect of selection bias, it should be noted that patients with stents were healthier at hospital admission than patients who had balloon angioplasty. CONCLUSIONS: Stent placement is associated with significantly lower risk-adjusted long-term mortality, CABG and subsequent PCI rates, as compared with balloon angioplasty.

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery.

OBJECTIVE: The study sought to determine if there were race/ethnicity or gender differences in access to coronary artery bypass graft (CABG) surgery among patients who have been designated as appropriate and as necessary for that surgery according to the RAND methodology. METHODS: RAND appropriateness and necessity criteria were used to identify a race/gender stratified sample of postangiography patients who would benefit from coronary artery bypass graft surgery. These patients were tracked for 3 months to determine if they had undergone coronary artery bypass graft surgery in New York State. Subjects were a total of 1,261 postangiography patients in eight New York hospitals in 1994 to 1996. Measures included percentages of patients for whom coronary artery bypass graft surgery was appropriate and necessary undergoing surgery by race/ethnicity and gender, as well as multivariate odds ratios for race/ethnicity and gender. RESULTS: After controlling for age, payer, number of vessels diseased, and presence of left main disease, African-American and Hispanic patients were found to be significantly less likely to undergo coronary artery bypass graft surgery than white non-Hispanic patients (respective odds ratios 0.64 and 0.60). When "necessity" was used as a criterion instead of "appropriateness," significant differences in access for African-American patients remained. The gatekeeper physician recommended surgery only 10% of the time that patients did not undergo "appropriate" coronary artery bypass graft surgery, and this percentage did not vary significantly by race/ethnicity or gender of the patient. CONCLUSIONS: Even after controlling for appropriateness and necessity for coronary artery bypass graft surgery in a prospective study, African-American patients had significant access problems in obtaining coronary artery bypass graft surgery. These problems appeared not to be related to patient refusals.

Lessons learned from the review of cardiac catheterization laboratories: a report from the Laboratory Survey Committee of the Society for Cardiac Angiography and Interventions.

The Laboratory Survey Committee of the Society for Cardiac Angiography and Interventions was created as a resource for physicians and administrators to provide comprehensive independent outside review services for cardiac catheterization laboratories. Since 1989, when the committee began its work, surveys of 23 catheterization laboratories have been completed. Our review of this experience identified several recurring problems among the laboratories. The purpose of this paper is to summarize our experience and highlight the lessons we learned in the hope that this information will benefit many other laboratories.

A comparison of three-year survival after coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty.

OBJECTIVES: The purpose of this study was to compare 3-year risk-adjusted survival in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty. BACKGROUND: Coronary artery bypass graft surgery and angioplasty are two common treatments for coronary artery disease. For referral purposes, it is important to know the relative pattern of survival after hospital discharge for these procedures and to identify patient characteristics that are related to survival. METHODS: New York's CABG surgery and angioplasty registries were used to identify New York patients undergoing CABG surgery and angioplasty from January 1, 1993 to December 31, 1995. Mortality within 3 years of undergoing the procedure (adjusted for patient severity of illness) and subsequent revascularization within 3 years were captured. Three-year mortality rates were adjusted using proportional hazards methods to account for baseline differences in patients' severity of illness. RESULTS: Patients with one-vessel disease with the one vessel not involving the left anterior descending artery (LAD) or with less than 70% LAD stenosis had a statistically significantly longer adjusted 3-year survival with angioplasty (95.3%) than with CABG surgery (92.4%). Patients with proximal LAD stenosis of at least 70% had a statistically significantly longer adjusted 3-year survival with CABG surgery than with angioplasty regardless of the number of coronary vessels diseased. Also, patients with three-vessel disease had a statistically significantly longer adjusted 3-year survival with CABG surgery regardless of proximal LAD disease. Patients with other one-vessel or two-vessel disease had no treatment-related differences in survival. CONCLUSIONS: Treatment-related survival benefit at 3-years in patients with ischemic heart disease is predicted by the anatomic extent and specific site of the disease, as well as by the treatment chosen.

Coronary angioplasty volume-outcome relationships for hospitals and cardiologists.

OBJECTIVE: To assess the relationship between each of 2 provider volume measures (annual hospital volume and annual cardiologist volume) for percutaneous transluminal coronary angioplasty (PTCA) and 2 outcomes of PTCA (in-hospital mortality and same-stay coronary artery bypass graft [CABG] surgery). DESIGN: Cohort study, using data from January 1, 1991, through December 31, 1994, from the Coronary Angioplasty Reporting System of the New York State Department of Health. SETTING: Thirty-one hospitals in New York State in which PTCA was performed during 1991-1994. PATIENTS: All 62670 patients discharged after undergoing PTCA in these hospitals during 1991-1994. MAIN OUTCOME MEASURES: Rates of in-hospital mortality and CABG surgery during the same stay as the PTCA. RESULTS: The overall in-hospital mortality rate for patients undergoing PTCA in New York during 1991-1994 was 0.90%, and the same-stay CABG surgery rate was 3.43%. Patients undergoing PTCA in hospitals with annual PTCA volumes less than 600 experienced a significantly higher risk-adjusted in-hospital mortality rate of 0.96% (95% confidence interval [CI], 0.91%-1.01%) and risk-adjusted same-stay CABG surgery rate of 3.92% (95% CI, 3.76%-4.08%). Patients undergoing PTCA by cardiologists with annual PTCA volumes less than 75 had mortality rates of 1.03% (95% CI, 0.91%-1.17%) and same-stay CABG surgery rates of 3.93% (95% CI, 3.65%-4.24%); both of these rates were also significantly higher than the rates for all patients. Also, same-stay CABG surgery rates for patients undergoing PTCA in hospitals with annual volumes of 600 to 999 performed by cardiologists with annual volumes of 75 to 174 (2.99%; 95% CI, 2.69%-3.31 %) and 175 or more (2.84%; 95% CI, 2.57%-3.14%) were significantly lower than the overall statewide rate (3.43%). CONCLUSIONS: In New York State, both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.

Avulsion of the left internal mammary artery after minimally invasive coronary bypass.

Minimally invasive direct coronary artery bypass grafting is a relatively new procedure. An unusual complication occurred in a patient after a period of heavy lifting, namely, avulsion of the left internal mammary artery graft. He presented with a clinical picture of myocardial infarction and shock. Diagnostic work-up and surgical management are described.

Safety and effectiveness of the Arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery stenosis.

The purpose of this study was to evaluate the safety and efficacy of Arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery (RCA) stenosis. A total of 15 stents was implanted in 13 right coronary arteries. For stenting of the RCA with marked superior orientation and shepherd's crook configuration of the proximal segment, a catheter with a 75 degrees primary curve was used. A catheter with a 90 degrees primary curve was usually the best choice for stenting of the RCA with slight superior, horizontal, or interior orientation of the proximal segment. These catheters provided excellent support in 12 of 13 cases (93%) and resulted in successful stent deployment in these patients. There was one dissection which occurred distal to the stent following poststent balloon dilatation, and which required emergency coronary artery bypass graft surgery. There were no complications attributed to these guiding catheters. An extraordinary formation of pseudostenosis occurred in one patient. We conclude that Arani curve guiding catheters provide strong support and are safe and effective in stenting of RCA stenosis.

Percutaneous transluminal coronary angioplasty in New York State. Risk factors and outcomes.

OBJECTIVE: To identify significant independent risk factors for major percutaneous transluminal coronary angioplasty outcomes. DESIGN: Retrospective analysis using univariate and logistic regression analysis to identify significant independent risk factors for adverse outcomes. SETTING: All 31 hospitals performing percutaneous transluminal coronary angioplasty in New York State in 1991. PATIENTS: All 5827 patients undergoing percutaneous transluminal coronary angioplasty between January 1, 1991, and June 30, 1991, in New York State. MAIN OUTCOME MEASURES: In-hospital mortality, major complication(s) (in-hospital mortality, myocardial infarction, and/or emergency coronary artery bypass graft), and absence of angiographic success (stenosis reduction of less than 20% on any attempted lesion or residual stenosis of at least 50% on any attempted lesion). MAIN RESULTS: Before discharge from the hospital, a total of 37 patients (0.63%) died; 67 patients (1.1%) suffered a myocardial infarction, with a mortality rate of 4.5%; and 97 patients (1.7%) underwent emergency coronary artery bypass graft surgery, with a mortality rate of 2.1% (no deaths in 85 patients who were hemodynamically stable and two deaths among 12 patients who were hemodynamically unstable). A total of 187 patients (3.2%) experienced a major complication. Angiographic success was achieved for 88% of all patients. Multivariate analysis found four independent preprocedural variables related to death: female gender, hemodynamic instability, shock, and ejection fraction. CONCLUSIONS: Percutaneous transluminal coronary angioplasty outcomes in New York compare favorably with other recent results reported in the literature. Several preprocedural variables markedly increase the incidence of adverse events.

Effectiveness of the Arani double-loop guiding catheters in angioplasty of aorto-coronary vein grafts.

Double-loop guiding catheters have been used for angioplasty of aorto-coronary vein grafts (VG) or grafted arteries through the VG in 31 cases. A catheter with a 90 degrees primary curve was usually the best choice for angioplasty of the VG to the right coronary artery (RCA). For angioplasty of the VG to the left coronary artery branches (LCA), a 90 degrees primary curve was used when the proximal segment of the VG was oriented horizontally and a 75 degrees (USCI, C.R. Bard, Inc., Billerica, MA) was used when the proximal segment was directed superiorly. Angioplasty of 32 lesions was attempted in 31 patients. These catheters provided good "back-up" in angioplasty of 30 lesions (94%). The lesions were crossed with balloon catheters in 29 cases (91%). There was one acute VG occlusion requiring coronary artery bypass graft (CABG) surgery, a complication not attributed to the guiding catheter. We conclude that Arani guiding catheters provide strong back-up, are helpful in angioplasty of the vein grafts, and could be used as the primary choice for VG angioplasties.

Double loop guiding catheter: a primary catheter for angioplasty of the right coronary artery.

Double loop guiding catheters have been used for percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) in 42 consecutive cases. A catheter with a 90-degree primary curve was used when the proximal RCA had horizontal or inferior orientation. When the proximal segment of the RCA was oriented superiorly (shepherd's crook), the catheter with a 75-degree primary curve was used. Catheters were fabricated with short (1.5 cm) or long (2.3 cm) (USCI, C.R. Bard, Inc., Billerica, MA) distal tips. Short-tip catheters were satisfactory in the majority of cases. When the RCA had a complex course and more backup was necessary or when the ascending aorta was wide, long-tip catheters were found to be the best choice. Angioplasty of 49 lesions was attempted in 42 consecutive patients. In 39 patients successful dilatation was achieved (93%). In three patients the procedure was unsuccessful. In one patient, the lesion could not be crossed with the guidewire despite an excellent backup. In another patient, two of three stenoses were dilated successfully; the distal lesion was crossed with a guidewire but could not be crossed with the balloon catheter in spite of a good backup. The lack of a satisfactory engagement and inadequate backup were responsible for the failure in only one patient. There were no complications related to these guiding catheters. We conclude that double loop guiding catheters are safe and can be the primary choice in all right coronary angioplasties. These catheters provide an excellent backup with consequent high success rate.

Adjustments in regional coronary perfusion accompanying reductions in regional coronary arterial pressure.

Regional flow per unit weight has been found to be reduced under basal conditions in areas of human myocardium which are supplied by severely stenotic coronary arteries or are entirely collateral-dependent. Coronary arterial pressure within these areas is presumably reduced substantially in relation to systemic arterial pressure. In experimental animals it has recently been demonstrated that reductions in local coronary arterial pressure can result in reductions in regional myocardial flow (in all transmural layers) before vasodilator reserve is exhausted. Although the functional and metabolic accompaniments of regional flow reductions occurring in the face of vasodilator reserve remain incompletely defined, a reduction in regional metabolic demand is among the possibilities deserving consideration.

A new catheter for angioplasty of the right coronary artery and aorto-coronary bypass grafts.

We have developed a new guiding catheter for angioplasty of the right coronary artery (RCA) and venous bypass grafts (VG). This catheter is easy to manipulate, provides a good "backup", and is unusually helpful in angioplasty of the RCA with a usual as well as a complex course. The catheter is equally successful in angioplasty of bypass grafts. We have used this guiding catheter for angioplasty of the RCA and VG in 27 consecutive cases. In 22 patients (81%), successful dilatation was achieved. Inadequate "backup" was responsible for two of the five unsuccessful angioplasties; therefore, the catheter provided a good "backup" in 25/27 (93%) cases. No major complication occurred in this group of patients.

Reductions in coronary flow under resting conditions in collateral-dependent myocardium of patients with complete occlusion of the left anterior descending coronary artery.

Flow per unit weight in collateral-dependent myocardium was quantified selectively in seven patients with complete occlusion of the proximal left anterior descending artery and prominent distal collateralization from the right coronary artery by infusing dissolved hydrogen into the right coronary artery for 10 to 15 minutes and monitoring hydrogen desaturation in the great cardiac vein. Coronary flow per unit weight in all myocardium draining into the great cardiac vein was quantified simultaneously by having the patient breathe helium and by monitoring arterial and great cardiac vein helium desaturation. Flow per unit weight in collateral-dependent myocardium averaged 38 +/- 8 (standard deviation) ml/min per 100 g and was in each case below the 95% confidence limit for normal individuals with the same rate-pressure product. Flow per unit weight in all myocardium draining into the great cardiac vein was systematically higher (51 +/- 8 ml/min per 100 g); because arteries other than the anterior descending had no stenoses greater than 30% in diameter, these values presumably reflect mixtures of subnormally perfused collateralized myocardium and adjacent normally perfused tissue. The findings suggest that coronary flow per unit weight is not maintained at usual basal values in densely collaterlized myocardium that is entirely collateral-dependent. The reductions in flow are presumably associated with marked reductions in local arterial pressure and raise the possibility of a chronic reduction in local myocardial metabolic demand.

Long-term survival after coronary bypass surgery. Comparison of various subsets of patients with general population.

Life-table analysis consecutive cases of isolated coronary bypass surgery at the Buffalo Hospital between 1973 and 1977 showed an estimated survival of 94 per cent at five years, equal to that of an age- and sex-matched group of the US population. Subsets of these patients divided according to sex, age, number of vessels narrowed, number of segments grafted, history of myocardial infarction, ejection fraction, and presence of unstable angina have estimated survivals not statistically less in any of these subsets than that of matched cohorts of the general population.

Dacron patch enlargement of anterior wall of left ventricle after aneurysmectomy with concomitant infarctectomy.

The basis for left ventricular aneurysmectomy with cardiopulmonary bypass was established 20 years ago. There is a higher risk in patients who undergo operation within 2 months of myocardial infarction. In these patients there may be no clear demarcation between devitalized tissue and residual healthy myocardium. A case is reported in which anterolateral aneurysmectomy with concomitant infarctectomy so compromised left ventricular size that the anterolateral wall of the left ventricle had to be reconstructed with a Dacron patch graft.

Coronary artery fistulas emptying into left heart chambers.

We present three cases of coronary artery fistulas entering into the left heart chambers. Coronary arteriography in one showed aneurysmal dilatation of the main left coronary artery and a fistulous communication with a large left atrium. Exploration during repair revealed an anomalous branch of the left circumflex emptying into the left atrium. In the second case the proximal left circumflex gave rise to a branch supplying a hemangioma which emptied into the left atrium. Coronary arteriograms of the third patient showed an enlarged left anterior descending artery with an anomalous branch emptying into the left ventricle. Shunt flow was estimated with hydrogen as a tracer in the last two cases and was two thirds and one third of the left coronary inflow, respectively. Review of the literature shows 32 previously reported cases of a fistula draining into the left side of the heart.

Renal carbuncle: simulation of tumor response to epinephrine.

A case of renal carbuncle with unusual angiographic findings is presented. The abscess showed abnormal vessels on selective angiogrpahy which were enhanced after intra-arterial epinephrine. New foci of abnormal vessels were also seen on the postepinephrine angiogram.

Lordotic right posterior oblique projection of the left coronary artery: a speical view for special anatomy.

The lordotic right posterior oblique projection of the left coronary artery is obtained by combining cranial angulation of the X-ray beam with rotation of the patient into the right posterior oblique position. This projection is helpful for separation of the main left coronary artery and the proximal portions of the left anterior descending and circumflex divisions, especially in patients in whom the left anterior descending artery is directed cephalad early in its course. The obtaining of an image from the lordotic right posterior oblique projection adds less than two minutes to the procedure and improves arteriographic assessment of the left coronary artery.