Outcomes of patients with left main coronary artery disease undergoing medical or surgical treatment: a propensity-matched analysis.

OBJECTIVE: To evaluate the outcomes of patients with significant (≥ 50%) left main coronary artery disease (LMCAD) undergoing medical treatment (MT) or coronary artery bypass grafting surgery (CABG). METHODS: A total of 181 patients with significant LMCAD were followed for 4 ± 2 years. MT was done when patients refused CABG or because of either thin native vessels or high clinical risk. Events were defined as all-cause death, myocardial infarction, percutaneous coronary intervention, or subsequent CABG. Logistic regression analysis was used to identify independent predictors of death. A propensity score was created to compare outcomes of patients from the two treatment groups. RESULTS: CABG was performed in 78.5% of the patients. Overall, there were no significant differences in the incidences of death or other events between treatment groups. In patients with normal left ventricular (LV) function (ejection fraction, ≥ 45%), there were no significant differences in event rates with MT or CABG (death, 7.7 vs. 12.1%; myocardial infarction, 0 vs. 1.9%; percutaneous coronary intervention, 3.8 vs. 5.6%). For patients with LV dysfunction, death was more frequent with MT than with CABG (53.8 vs. 22.9%, P<0.001), whereas the incidence of other events was not statistically different. Age and LV dysfunction, but not treatment type, were independent predictors of death. When comparing propensity-matched patients from both treatment groups, there was also no difference in survival. CONCLUSION: Patients with 50% or more LMCAD and LV dysfunction had increased survival with CABG. However, outcomes of patients with 50% or more LMCAD and normal LV function were not significantly different with either MT or CABG.

Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.

BACKGROUND: This study compared the 10-year follow-up of percutaneous coronary intervention (PCI), coronary artery surgery (CABG), and medical treatment (MT) in patients with multivessel coronary artery disease, stable angina, and preserved ventricular function. METHODS AND RESULTS: The primary end points were overall mortality, Q-wave myocardial infarction, or refractory angina that required revascularization. All data were analyzed according to the intention-to-treat principle. At a single institution, 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT (P=0.089). The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT (P<0.010). The 10-year rates of additional revascularizations were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT (P<0.001). Relative to the composite end point, Cox regression analysis showed a higher incidence of primary events in MT than in CABG (hazard ratio 2.35, 95% confidence interval 1.78 to 3.11) and in PCI than in CABG (hazard ratio 1.85, 95% confidence interval 1.39 to 2.47). Furthermore, 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (P<0.001). CONCLUSIONS: Compared with CABG, MT was associated with a significantly higher incidence of subsequent myocardial infarction, a higher rate of additional revascularization, a higher incidence of cardiac death, and consequently a 2.29-fold increased risk of combined events. PCI was associated with an increased need for further revascularization, a higher incidence of myocardial infarction, and a 1.46-fold increased risk of combined events compared with CABG. Additionally, CABG was better than MT at eliminating anginal symptoms. Clinical Trial Registration Information- URL: http://www.controlled-trials.com. REGISTRATION NUMBER: ISRCTN66068876.

Myxoma of the mitral valve

Only rarely do myxomas originate from the mitral valve. This is the report of a 49-year-old woman presenting with congestive heart failure. The diagnosis of an intracardiac tumor involving the anterior cuspid of the mitral valve was mode by transesophageal echocardiography. The patient underwent surgery for tumor resection and plasty of the valve was made with reconstruction and preservation of the valve. The diagnosis of myxoma was confirmed by histology. This is the 23rd case of myxoma of the mitral valve reported in the literature.

Isquemia miocárdica silenciosa: experiência com a monitorizaçäo eletrocardiográfica ambulatorial / Silent myocardial ischemia: experience with ambulatorial electrocardiographic monitoring

Os autores apresentam sua experiência com monitorizaçäo eletrocardiográfica ambulatorial (Holter) na detecçäo de isquemia miocárdica (IM) anginosa 159 pacientes com doença coronária crônica: 76 com infarto prévio, 66 com cirurgia para revascularizaçäo miocárdica, 13 com lesäo obstrutiva na coronariografia e 4 submetidos à coronarioplasita. Em 51 pacientes (32%) foram registrados episódios de IM, embora estivessem sob medicaçäo anginosa profilática. Em 44 pacientes (86%) todos episódios foram de IMS, 6 pacientes tiveram 16 episódios de IMS e 12 episódios de IMA e 1 paciente só teve 1 IMA. Houve um total de 119 episódios de IM, 106 de IMS (89,1%) e 13 de IMA (10,9%). A duraçäo total dos episódios de IMS por pacientes variou de 1 a 235 min e a duraçäo máxima de 1 IMS foi de 221 min. Nos 6 pacientes com IMS e IMA a duraçäo total dos episódios de IMS foi de 461 min e de IMA de 306 min. A incidência no nictemero da IMS foi: de 6 às 12 h - 33,3%, de 12 às 18 h - 31,4%, de 18 às 24 h - 27,6% e de 24 h às 6 h - 7,7%. A atividade dos pacientes durante a IMS em 89 episódios foi: atividade física 46%, sono (23,6%), repouso (22,4%) e outra (8%). A depressäo do segmento ST nos 106 episódios de IMS foi em média de -2,25 mm e nos 13 de IMA, de - 3,25 mm. Os autores ressaltam que a medicaçäo antianginosa profilática foi incapaz de prevenir a IM em 32% dos pacientes. Assim, nesses pacientes a medicaçäo era antianginosa mas näo anti-isquêmica. O tratamento da IMS deve ser feito em todos os pacientes...