Venous coronary artery bypass surgery: a more than 20-year follow-up study.

AIMS: Atherosclerosis in venous coronary artery bypass grafts begins early and accelerates from the fifth post-operative year. We studied the influence of 18 variables existing at the time of operation, and of 'classical' risk factors present at 1 and 5 years after operation on the long-term outcome of this type of surgery. METHODS AND RESULTS: Four hundred twenty-eight consecutive patients who underwent isolated venous coronary bypass surgery between April 1, 1976 and April 1, 1977 were followed prospectively. Follow-up was 99.3% complete with a mean duration of 22.8 years for the survivors. Multivariate analysis was performed using the Cox regression model. Actuarial survival after 5, 10, 15 and 20 years is 95, 83, 63 and 47%, respectively. The cumulative probability of event-free survival for cardiac death, acute myocardial infarction and re-intervention at 5, 10, 15 and 20 years, respectively, are 98, 90, 74, 60%; 99, 91, 83, 77%; and 97, 86, 67, 57%. Age and left ventricular functions are continuous incremental risk factors for mortality. Left ventricular function and completeness of revascularization, and age and vessel disease are independent predictors of cardiac death and re-intervention, respectively. Hypertension, diabetes mellitus, hypertriglyceridemia, obesity and smoking, present after operation have an independent influence on the occurrence of cardiac events. CONCLUSIONS: Risk factors (still) existing 1 and 5 years after operation have a negative influence on the long-term results. This emphasizes the need of treatment of these 'classical' risk factors still present after operation.

Systolic blood pressure and (cardiac) mortality over 15 years after venous coronary bypass surgery.

OBJECTIVE: The aim of the present study was to determine the influence of pre-operative systolic blood pressure and systolic blood pressure 1 and 5 years after venous coronary bypass surgery on subsequent cardiac and non-cardiac mortality. DESIGN: A prospective 15 years follow-up study. PATIENTS: A series of 446 consecutive coronary bypass surgery patients, operated on between April 1976 and April 1977. According to their systolic blood pressure, patients were divided into five groups. MAIN OUTCOME MEASURES: Systolic blood pressure 5 years after surgery, but not pre-operative systolic blood pressure, was an independent predictor of cardiac mortality. RESULTS: Multivariate Cox proportional hazards analysis revealed that pre-operative systolic blood pressure was not associated with cardiac mortality, while higher systolic blood pressure 1 year after surgery showed a trend towards increased cardiac mortality. Systolic blood pressure 5 years after surgery appeared to be a strong independent predictor of cardiac mortality during the subsequent follow-up period. Patients with a systolic blood pressure of 130-139 mmHg had the lowest risk. Compared to this group, the cardiac mortality risk in patients with a systolic blood pressure 5 years after surgery of 140-149 mmHg, 150-159 mmHg and > or = 160 mmHg, was 2.3 (1.2 to 4.6), 3.4 (1.6 to 7.1) and 3.1 (1.4 to 6.5) times higher. Systolic blood pressure < 130 mmHg 5 years after surgery was also associated with a 2.3 times (1.1 to 4.7) times increased risk for cardiac mortality, compared to patients with a systolic blood pressure of 130-139 mmHg. CONCLUSIONS: These findings underline the importance of systolic blood pressure control in the initial years after coronary bypass surgery.

Progression of atherosclerosis after venous coronary artery bypass graft surgery: a 15-year follow-up study.

We investigated the influence of progression of atherosclerosis on clinical outcome in a cohort of 428 consecutive patients with isolated venous coronary artery bypass graft surgery followed prospectively for 15 years. In 189 patients 307 repeat coronary angiograms were performed because of recurrent signs of ischemia. Progression in the native coronary circulation only was found in 38 angiograms (12%), in both the native circulation and in venous grafts in 66 angiograms (21%), in venous grafts only in 135 angiograms (44%), and no progression was found in 68 angiograms (22%). In all the angiographies with a proven progression in the native coronary arteries, 40% was found to be distal to a vein graft insertion. In multivariate analysis the number of distal anastomoses predicts progression in both the native circulation and in venous grafts. Thus, progression is determined by the extensiveness of coronary artery disease at operation. Also, the interval between operation and repeat angiography predicts progression in the native circulation. We conclude that clinical outcome is also determined by progression in the native coronary circulation. Secondary prevention may, therefore, benefit not only the long-term result in patients with venous bypass grafts but probably also in patients with any type of coronary bypass surgery.

Usefulness of hypertriglyceridemia in predicting myocardial infarction late after coronary artery bypass operation.

We prospectively followed 446 consecutive patients who had coronary bypass operations 15 years earlier. Serum levels of cholesterol and triglycerides were measured before and 5 years after bypass, and we established the relation between these lipid levels and the incidence of myocardial infarction (MI) and cardiac mortality during 15 years of follow-up. Follow-up was complete in 99.8% of the patients and averaged 15.4 years for the survivors. Multivariate Cox proportional-hazards analysis revealed that patients with preoperative hypertriglyceridemia (> or = 2.0 mmol/L [176 mg/dl]) had a 2.1 times increased risk for MI during follow-up (p = 0.04). Hypertriglyceridemic patients 5 years after surgery had a 2.2 times increased risk for MI during the subsequent follow-up period, although this difference was not statistically significant (p = 0.09). The only significant risk factor for MI 5 years after surgery was smoking. Hypercholesterolemia (> or = 6.5 mmol/L [254 mg/dl]) both before and 5 years after surgery was not a risk factor for MI during follow-up. Cardiac mortality was not significantly related to either hypercholesterolemia or hypertriglyceridemia. Independent predictors for cardiac mortality were poor left ventricular function, diabetes mellitus, incomplete revascularization, and the use of sequential bypass grafts. These data provide evidence that hypertriglyceridemia, both before and 5 years after surgery, have predictive value for the incidence of MI during long-term follow-up after venous coronary bypass surgery.

Clinical outcome in venous coronary artery bypass grafting: a 15-year follow-up study.

OBJECTIVE: We investigated the clinical outcome of venous coronary artery bypass graft surgery. METHODS: A study group consisting of 428 consecutive patients-operated on between 1 April 1976 and 1 April 1977-was followed prospectively. Single or sequential saphenous vein grafts were performed with a mean of 3.2 coronary anastomoses per patient. A left ventricular aneurysmectomy was performed in 25 patients. RESULTS: Complete revascularisation was achieved in 78% of the patients. Follow-up was 99.8% complete and averaged 15.4 years for the survivors. Actuarial survival after 5, 10, and 15 years was 91.4%, 79.9%, and 61.1%, respectively. The cumulative probabilities of event-free survival at 10 years were as follows: cardiac death, 87.3%; acute myocardial infarction, 84.1%; reoperation, 88.6%; coronary artery balloon angioplasty, 94.1%; angina pectoris, 48.7%; and any event, 40.8%. CONCLUSIONS: The results are comparable with those of the few other long-term studies that have been published. With isolated venous bypass grafting, satisfactory results can be obtained until approximately 7 years after operation. Thereafter mortality increases, as does the rate of myocardial infarction, reoperation, and balloon angioplasty.

Different clinical outcome in coronary artery bypass with single and sequential vein grafts: a fifteen-year follow-up study.

OBJECTIVE: In trying to answer the question about the controversial use of sequential grafts, we determined the long-term clinical outcome of patients in whom coronary artery bypass was done with different types of vein grafts. METHODS: A total of 428 consecutive patients who underwent isolated coronary artery bypass with vein grafts between April 1, 1976, and April 1, 1977, were prospectively observed. In these patients three groups could be defined with single grafts only, sequential grafts only, and combined single and sequential grafts. Follow-up was 99.8% complete and averaged 15.4 years for the survivors. The Kaplan-Meier method and multivariate analysis done with the Cox regression model were used for survival, myocardial infarction, reintervention, and "any event." RESULTS: Perioperative mortality and perioperative myocardial infarction rate were not statistically different among the three groups. During follow-up more myocardial infarctions (hazard ratio: 2.06; 95% confidence interval: 1.08 to 3.93; p = 0.0293) or any events (hazard ratio: 1.54; 95% confidence interval; 1.01 to 2.36; p = 0.0450) occurred in patients with sequential grafts only than in patients with single grafts only. CONCLUSION: Although more complete revascularization was obtained in patients with sequential vein grafts only, more events during a 15-year follow-up occurred in these patients than in patients with single vein grafts only.

Smoking and cardiac events after venous coronary bypass surgery. A 15-year follow-up study.

BACKGROUND: The long-term clinical effects of smoking and smoking cessation after venous coronary bypass surgery have not been well established. METHODS AND RESULTS: Four hundred fifteen patients who underwent venous coronary bypass surgery between April 1976 and April 1977 were followed up prospectively for 15 years. Multivariate Cox survival analysis revealed that patients who smoked at the time of surgery had no elevated risks for clinical events compared with nonsmokers. However, smoking behavior at 1 and 5 years after surgery appeared to be an important predictor of clinical events during the subsequent follow-up period. Compared with patients who stopped smoking since surgery, smokers at 1 year after surgery had more than twice the risk for myocardial infarction and reoperation. Patients who were still smoking at 5 years after surgery had even more elevated risks for myocardial infarction and reoperation and a significantly increased risk for angina pectoris compared with patients who stopped smoking since surgery and patients who never smoked. Patients who started to smoke again within 5 years after surgery had increased risks for reoperation and angina pectoris. No differences in outcome were found between patients who stopped smoking since surgery and nonsmokers. CONCLUSIONS: Our results show that smoking cessation after coronary bypass surgery may have important beneficial effects on clinical events during long-term follow-up.

Multivariate risk factor analysis of clinical outcome 15 years after venous coronary artery bypass graft surgery.

BACKGROUND: Knowledge is still lacking about pre-operative and postoperative factors which predict the long-term prognosis of patients who undergo venous coronary artery bypass graft surgery. METHODS AND RESULTS: Four hundred and twenty-eight consecutive patients who underwent isolated venous coronary artery bypass graft surgery with or without left ventricular aneurysm surgery between 1 April 1976 and 1 April 1977, were followed prospectively. Follow-up was 99.8% complete and averaged 15.4 years for the survivors. Two prognostic models were set up to illustrate the influence of 21 variables, present at and, 5 years after, surgery, on the occurrence of six different clinical events. Multivariate analysis was performed using the Cox regression model. Age, left ventricular function, pre-operative severity of angina and diabetes mellitus are continuous incremental risk factors for one or more events. Revascularization with sequential grafts only, and obesity at operation are incremental risk factors for acute myocardial infarction. From the 'classical' risk factors present 5 years after surgery hypertension is an incremental risk factor for both overall and cardiac mortality, diabetes mellitus for cardiac mortality, myocardial infarction, balloon angioplasty and smoking for all clinical events except mortality. CONCLUSIONS: Well-known pre-operative factors including 'classical' risk factors, present late after surgery, influence the occurrence of clinical events. Treatment of these factors may result in better long-term prognosis after venous bypass graft surgery.

Venous coronary artery bypass surgery. A 15-year follow-up study.

BACKGROUND: Although the long-term results of isolated venous coronary artery bypass surgery are well known, there are few multivariate statistical data on such patient groups. METHODS AND RESULTS: We report on 428 consecutive patients, 383 men and 45 women with a mean age of 52.6 years, who underwent isolated venous aortocoronary bypass graft surgery with or without left ventricular aneurysm surgery between April 1, 1976, and April 1, 1977, and whom we followed prospectively. A multivariate analysis using the Cox regression model was performed to establish the determinants of long-term outcome. The hospital mortality and myocardial infarction rates were 3% and 6.3%, respectively. Complete revascularization was obtained in 77.6%. Follow-up was 99.8% complete and averaged 13.4 years (range, 1.5 months to 16.6 years). Actuarial survival after 5, 10, and 15 years is 94.2%, 82.4%, and 63%, respectively. The cumulative probability of event-free survival for cardiac death, acute myocardial infarction, reintervention, and angina pectoris at 5, 10, and 15 years, respectively, are 97.8%, 90.1%, 74.4%; 98.5%, 89.0%, 77.4%; 97.0%, 83.0%, 62.1%; and 77.8%, 52.1%, 26.8%. Left ventricular function and the number of vessels diseased are the independent preprocedural predictors of cardiac survival. Obesity and hypertriglyceridemia are preprocedural predictors of late myocardial infarction. Preoperative validity (Canadian Cardiovascular Society) and the number of diseased vessels are the predictors of recurrent angina. CONCLUSIONS: We conclude that the long-term results of isolated venous bypass graft surgery are dependent not only on well-known preprocedural factors such as number of vessels diseased, left ventricular function, and age but also on obesity and hypertriglyceridemia.

[Are the long-term results of venous aortocoronary bypass procedures really so bad? A prospective 13-year-long study of 428 patients]. / Zijn de lange-termijnresultaten van veneuze aortocoronaire overbruggingsoperaties wel zo slecht? Een prospectief onderzoek over 13 jaar bij 428 patiënten.

OBJECTIVE: To assess the long-term results of coronary surgery using venous bypasses. DESIGN: Prospective study. SETTING: St. Antonius Hospital, Nieuwegein, the Netherlands. METHOD: In 446 successive patients subjected to coronary surgery between 1 April 1976 and 1 April 1977, a complete long-term follow-up study was carried out after an average of 11.5 years (1.5 months-14.3 years). RESULTS: The peroperative mortality was 3%, a peroperative myocardial infarction occurred in 6.3% and complete revascularization was achieved in 77.6% of the patients. In 90 of 100 patients selected at random, cardiac catheterization was performed 13.5 months on average after the operation. The patency of the single grafts was 89.8%, that of the side-to-side and end-to-side anastomoses of the sequential grafts was 90.4% and 83%, respectively. Mortality, myocardial infarction, necessity of a second operation and angina pectoris occurred with low frequency during the first five years after the operation. Subsequently, complications increasingly occurred. Ten years after the operation 18.8% of the patients had died, 11.9% had suffered a myocardial infarction, 13.4% had been subjected to a second operation and 6.4% to balloon angioplasty, while 46.4% had once more developed angina pectoris. Thirteen years after the operation 29% of the patients had remained completely free from cardiac problems. CONCLUSION: Although arterial bypasses have been increasingly used in recent years, an indication for the use of venous transplants will continue to exist in the future, also, for certain groups of patients (those younger than 50 or older than 75 years). Our study clearly shows that with venous bypasses, also, satisfactory long-term results can be obtained.

[Experiences at a peripheral hospital with the intracoronary administration of streptokinase and urokinase in acute heart infarct]. / Ervaringen in een perifeer ziekenhuis met de intracoronaire toediening van streptokinase en urokinase bij het acute hartinfarct.

In 285 patients intracoronary fibrinolytic agents were administered 300 times during the acute phase of a myocardial infarction. The results and the complications of this therapy, as administered in a community hospital, did not differ from those obtained in a big randomized study performed by the Interuniversity Cardiological Institute of The Netherlands. Recanalization of a completely occluded coronary artery was obtained in 79% of the cases. Only 8.3% of the patients needed blood transfusion because of blood loss via the puncture in the femoral artery. No intracranial bleeding occurred. Actuarial total survival after 12 months was 90.5%. The incidence of recurrent myocardial infarction after successful intracoronary fibrinolytic therapy appears rather high; therefore, in some patient categories further therapy may be considered such as percutaneous transluminal coronary angioplasty or aortocoronary bypass surgery.

Myocardial bridging: a cause of myocardial infarction?

A 50-year-old man was admitted to hospital because of severe and progressive chest pain at rest. Selective coronary arteriography revealed occlusion of the left anterior descending artery at the origin of an intramural course. Intracoronary thrombolysis restored the patency of the otherwise completely normal vessel but did not fully prevent myocardial infarction.