Risk stratification of coronary revascularization patients by using clinical and angiographic data.

AIM: Patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) are still at a substantial risk of death after their procedures. A core group of preoperative and preprocedural risk factors and conditions contributes the majority of inherent mid- and long-term mortality risk in these patients. Therefore, we sought to develop a classification tree model as a practical and user-friendly method of predicting mid-term survival after coronary revascularization procedures. METHODS: We retrospectively analyzed data from a single, large-volume institution. Specifically, we examined all-cause three-year mortality in 3387 consecutive patients with multivessel or single proximal left anterior descending coronary artery disease who underwent either PCI with stenting or CABG. RESULTS: Recursive partitioning indicated that the best single predictor of death within three years was a history of heart failure (HF), followed by a proximal left circumflex artery (pLCX) lesion and age greater than 65 years for patients with and without a history of HF, respectively. With these variables, patients were readily stratified into low-, intermediate-, and high-risk groups whose risks of death over three years ranged from 2.3% to 36.2%. Among patients with a history of HF, pLCX stenosis was an independent predictor of mid-term mortality after adjustment for other known risk factors (hazard ratio, 1.46; 95% CI, 1.04-2.03). CONCLUSION: The constructed risk stratification scheme stratified patients into groups at low, intermediate, and high risk of death within three years. Stenosis of the pLCX seems to be an important prognostic factor for patients with a history of HF.

Risk factor analysis among Egyptian patients who underwent coronary artery bypass surgery.

We conducted a retrospective review of Egyptian patients who underwent coronary artery bypass graft surgery at our institution between 1980 and 1995. We examined the prevalence of coronary artery disease risk factors and evaluated the early postoperative results. We then compared these results with the corresponding data in a subset of American patients who underwent coronary artery bypass grafting at our institution in 1993. There were 290 Egyptian patients: 275 men and 15 women. The mean age was 54.5 years (range, 30 to 70 years). Angina was present in 258 (89%) of the Egyptian patients; of these, 186 (72.1%) were in Canadian Cardiovascular Society class 3 or 4. Risk factor analysis revealed a high prevalence of hyperlipidemia (69.7%), cigarette-smoking (66.6%), family history of coronary artery disease (53.1%), hypertension (46.9%), obesity (46.2%), and diabetes mellitus (32.4%). Comparisons between the 2 groups showed that the risk factors, except for hypertension, were significantly higher in the Egyptian patients, despite the older age of the Americans (mean, 65.5 years; range, 22 to 88 years). The prevalence of triple-vessel disease was 86.6% in the Egyptian patients and 51.0% in the American patients (p < 0.001). The operative morbidity rates in the Egyptian patients were low: these included arrhythmias (13.8%), bleeding (13.4%), infection (7.6%), low cardiac output (3.4%), myocardial infarction (3.4%), and cerebrovascular accident (1.4%). The hospital mortality rate was 1.4% for the Egyptians and 1.7% for the Americans (NS). These results show that, despite the high prevalence of risk factors among Egyptian patients with coronary artery disease, coronary artery bypass grafting can be performed with low operative morbidity and mortality rates.

Coronary artery ectasia in Egyptian patients with coronary artery disease.

We conducted a retrospective study of 45 Egyptian patients with coronary artery ectasia who underwent coronary bypass grafting at our institution between 1980 and 1995. We examined the anatomic distribution and type of coronary ectasia and its association with coronary risk factors in these patients, and evaluated the severity of their coronary artery disease. We compared these findings with those from a group of 230 Egyptian patients who did not have coronary ectasia. These patients also underwent coronary artery bypass grafting between 1980 and 1995 at our institution. Obesity was present in 60% of the patients who had coronary artery ectasia, compared with 42% of patients who did not have ectasia (P < 0.01). Coronary artery ectasia was not related to any coronary risk factors other than obesity. However, patients who had ectasia did have a higher rate of triple-vessel coronary artery disease than did patients without ectasia (82% vs 67%, P < 0.05). Of the coronary vessels affected by ectasia, 43% were left anterior descending arteries. Diffuse disease was noted in 84% of all ectatic segments. We conclude that in this patient population, 2 conditions had a positive correlation with coronary ectasia: obesity and the severity of coronary artery disease.

Early and late mortality of patients undergoing aortic valve replacement after previous coronary artery bypass graft surgery.

BACKGROUND: In a small number of patients who undergo coronary artery bypass graft surgery (CABG), a hemodynamically significant aortic valve lesion requiring aortic valve replacement (AVR) develops as they grow older. In a limited number of studies in small patient groups, high mortality has been shown in patients undergoing AVR after CABG. We undertook this study to determine the mortality risk factors for patients who undergo AVR after CABG procedures. METHODS AND RESULTS: The outcome of 104 patients treated at our institution between January 1983 and December 1993 was retrospectively reviewed. The initial surgery was CABG in all patients. The patient population included 86 men (83%) and 18 women (17%); their mean age was 67 years. Overall, 70% of patients had congestive heart failure, and 96% had multivessel coronary artery disease. The diagnosis was aortic stenosis in 68% of patients, aortic insufficiency in 16%, and combined aortic stenosis and aortic insufficiency in 16%. Postoperative complications included worsening congestive heart failure (35%), perioperative myocardial infarction (13%), and bleeding (28%). The early mortality was 14%, and the late mortality was 17% (mean follow-up, 35 months). The risk factors for early mortality were number of diseased vessels (P = .028), renal failure (0.000), and prior myocardial infarction (P = .028). A perioperative predictor of early mortality was cardiopulmonary bypass time (P = .000). The risk factors for late mortality included preoperative diabetes mellitus (P = .007), postoperative acute respiratory distress syndrome (P = .011), and ventricular arrhythmias (P = .0001). The survival at 1, 5, and 10 years was 96%, 75%, and 49%, respectively. CONCLUSIONS: Risk factors were identified for early and late mortality in patients undergoing AVR after previous CABG. Although early morbidity and mortality were high, the longterm outcome of the survivors was favorable.

Aortic valve replacement in patients 80 years and older. Operative risks and long-term results.

BACKGROUND: Forty percent of 7.4 million Americans aged 80 years and older have symptomatic heart disease. Controversy exists as to whether the health care resources allotted to this patient subset represent a cost-effective approach to attaining a meaningful quality of life. Although aortic valve surgery carries greater risks in older than in younger patients, published studies reveal that the elderly should not be denied this procedure. METHODS AND RESULTS: To determine the results of aortic valve replacement (AVR) in an elderly population, we retrospectively analyzed 171 consecutive patients aged 80 to 91 years (mean, 82.6 years; 86 men and 85 women) who underwent AVR at the Texas Heart Institute between 1975 and 1991. Seventy-seven patients had AVR only, and 94 patients had concomitant surgical procedures (coronary artery bypass graft surgery, 75 patients; mitral valve replacement, mitral valve repair, aneurysm repair, 19 patients). The overall 30-day early mortality was 17.5%. The early mortality was 5.2% for patients with AVR only and 27.7% for those with concomitant surgical procedures. Statistical analysis of 17 perioperative variables revealed that left ventricular ejection fraction of less than 45%, hypertension, congestive heart failure, angina, and concomitant surgical procedures were significant univariate predictors of early mortality. Multivariate analysis revealed that left ventricular ejection fraction of less than 45%, hypertension, and concomitant surgical procedures were independent predictors of operative mortality. Mean follow-up of survivors was 39 months. The overall actuarial survival at 1, 3, and 5 years was 90.8%, 84.2%, and 76.0%, respectively. CONCLUSIONS: These results show that AVR can be performed with acceptable operative risks in the elderly. This study further shows that isolated AVR can be done with low operative mortality and that the performance of concomitant surgical procedures exposes elderly patients to higher operative risks.

Collateral circulation in coronary artery disease.

The coronary arteriograms and left ventriculograms of 202 consecutive patients were reviewed. All had at least 75% diameter reduction of 1 or more major coronary arteries. In 127 patients (63%), at least 1 major branch was totally occluded. Collateral circulation was seen in 125 of these 127 patients (190 of 192 totally occluded arteries). Of the 75 patients without total occlusion, only 2 with 99% (or near-total) occlusion had demonstrable collateral circulation (2 of 208 arteries). In no patient with 75 to 98% diameter narrowing was collateral circulation demonstrated (0 of 164 arteries). An analysis was made of the relation between left ventricular (LV) segmental wall motion and the quality of collateral circulation in 190 totally occluded arteries among 125 patients. Of 126 arteries with good collateral circulation, LV contraction was normal in 21%, hypokinetic in 48% and akinetic/dyskinetic in 29%. Of 64 arteries with poor collateral circulation, LV contraction was normal in 23%, hypokinetic in 55% and akinetic/dyskinetic in 20%. There was no statistically significant difference between the effect of good or poor collateral circulation on LV function. These data indicate that collateral circulation cannot be seen angiographically unless there is total or near-total occlusion, and that the presence of collateral circulation does not correlate with LV wall motion abnormalities, i.e., akinetic area, despite good collateral flow or normal wall motion despite absent or poor collateral flow.

Coronary revascularization in the elderly patient.

A total of 1,275 elderly patients (70 years and older) underwent coronary artery bypass alone from 1970 to 1981. The percent of elderly patients who underwent coronary bypass surgery alone increased from 2.04% in 1971 to 8.2% in 1981. Most of the patients had severe, disabling or unstable angina pectoris. The overall early mortality rate was 5.8%. The early mortality rate was 13.9% in the first group (1970 to 1975) of 158 patients compared with 4.7% in the second group (1976 to 1981) of 1,117 patients. An average of 3.1 bypass grafts per patient were implanted. On follow-up examination, angina was relieved or decreased in 89% of the patients. The 5 year survival rate was 80.6% and the 10 year survival rate was 44.1%, with an average attrition of 3.9 and 5.6%/year, respectively. It is concluded that elderly patients are high risk surgical candidates, yet the risk has decreased progressively because of improved techniques of medical and surgical management and myocardial preservation. This decreasing operative mortality rate provides evidence that when medical management of the elderly patient with severe angina fails, coronary artery bypass becomes a successful alternative.

Unusual combination of total occlusion of left main coronary artery and heart failure with pulmonary hemosiderosis: case report.

A case of total occlusion of the left main coronary artery, congestive heart failure, and pulmonary hemosiderosis in a 54-year-old man is reported. Cardiac catheterization showed total occlusion of the left main coronary artery, subtotal occlusion of the right coronary artery, severely deranged hemodynamics, and an akinetic left ventricle except for a hypokinetic posterobasal segment. A radionuclide left ventricular performance study revealed an ejection fraction of 0.16 with diffuse biventricular hypokinesis and dilatation. Despite all the risk factors, the patient underwent a total of six saphenous vein grafts without perioperative or immediate postoperative complications.

Total occlusion of the left main coronary artery: report of seven cases from 5312 cardiac catheterizations and review of the literature.

Of the 5312 cardiac catheterizations performed at the Clayton Foundation for Research Cardiovascular Laboratories from 1974 to early 1981, seven patients (0.13%) had total occlusion of the left main coronary artery. All seven had a history of myocardial infarction, and were markedly symptomatic (New York Heart Association, Classes III and IV), with anginal pain that had existed from 2 to 13 years. Left ventricular end-diastolic pressure was notably elevated in all patients, and ejection fractions ranged from 16% to 69%. In all patients, there was significant collateral circulatory flow to the left coronary system from the right coronary artery and its branches. Six underwent coronary artery bypass at our institution, and one was operated on at another hospital. The six patients operated on in our institution were markedly improved after the operation. Our results support previously reported findings about patients with total occlusion of the left main coronary artery in that (1) no definitive clinical pattern leads to simple diagnosis, (2) the anomaly is rarely encountered during cardiac catheterization, and (3) myocardial revascularization alleviates symptoms and prolongs life.