We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction. Under these conditions, the treatment of choice would be surgical (myocardial revascularization surgery or by-pass). In the case of a patient with preserved LV function, the choice of surgical vs. percutaneous treatment would be more questionable, since today, thanks to drug-eluting stents, the differences in terms of morbidity and mortality between by-pass surgery and angioplasty are minimal.

We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction. Under these conditions, [HIDDEN]. In the case of a patient with preserved LV function, [HIDDEN], since today, thanks to drug-eluting stents, [HIDDEN].

A 60-year-old man reports precordial pain after medium exertion. Coronary angiography shows significant stenosis in the proximal segments of the three main vessels with good distal bed. Ventricular function is depressed (<30%). What is the best therapeutic option?

Implantation of balloon counterpulsation.

Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases.

Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease.

[Results of coronary surgery in mildly symptomatic patients with left ventricular dysfunction, multivessel disease and stenotic single residual patent vessel].

While efficacy of coronary artery bypass surgery in patients with depressed left ventricular function and myocardial ischemia is widely recognized, its results in patients in the absence of clinical evidence of myocardial ischemia remain uncertain. The purpose of this study was to evaluate the effects of coronary revascularization in comparison with conventional medical therapy in subjects with ischemic cardiomyopathy and myocardial ischemia presumed on the basis of angiographic anatomy but not demonstrated by functional testings. We selected retrospectively patients who underwent coronary angiography from 1986 trough 1993 and met the following criteria: presence of three-vessel coronary artery disease, occlusion of two and significant luminal narrowing (> or = 50%) of the third major epicardial artery, left ventricular dysfunction (ejection fraction < or = 40%), no angina or presence of mild angina, absence of inducible ischemia on exercise test and, when performed, of redistribution in the vascular territory of the patent vessel. Thirty-one consecutive patients underwent isolated surgical revascularization treatment, while thirty medically treated patients with matched clinical characteristics were selected. Age (61 +/- 10 vs 62 +/- 9), gender (M/F 27/3 vs 24/7), NYHA class I-II (53 vs 62%) or NYHA III-IV (47 vs 38%), incidence of previous infarction (87 vs 94%), number of reversible defects in the vascular territory of the patient vessel on stress scintigraphy (0.6 vs 0.5), patent vessel (right coronary artery 7 vs 10; left circumflex 14 vs 12; left anterior descending 9 vs 9) and left ventricular ejection fraction (28 +/- 8 vs 31 +/- 7), were similar in the two groups (medical vs surgical). Surgically treated patients exhibited a lower proportion of overall cardiac deaths (7/31, 23% vs 19/30, 63%; p < 0.001), and more prolonged survival (67 +/- 9.3 vs 34 +/- 2.5 months; p = 0.04, Mantel and Cox test) than medically treated patients, respectively. The incidence of perioperative myocardial infarction was 10% (3/31). Causes of cardiac death were myocardial ischemia (9/19; 47%), sudden death (5/19; 26%) and heart failure (5/19; 26%) in medical patients, while were surgery (3 cases) and surgery related infection (1 case) (total 4/7; 57%), myocardial ischemia (1/7; 14%), sudden death (1/7; 14%) and heart failure (1/7; 14%) in surgical patients. Cox proportional hazard regression analysis with survival as the dependent variable, identified treatment, surgical or medical, as the best predictor of cardiac events (chi square improvement 9.36, p = 0.002). The next most powerful predictors were NYHA class and ACE-inhibitors treatment (chi square improvement 4.47 and 2.79, respectively). In patients with left ventricular dysfunction, multivessel coronary artery disease and single patent but stenotic residual vessel, coronary artery bypass grafting appear to offer a better survival than medical therapy, even in the absence of clinically evident myocardial ischemia.

["Needle-to-scalpel"--the benefit of urgent CABG in significant left main coronary artery stenosis].

Left main coronary artery (LMCA) stenosis is a relatively infrequent but important cause of symptomatic coronary artery disease. The diagnosis of left main coronary artery disease is made by coronary angiography. Coronary artery bypass grafting is the first-line therapy, the standard treatment for LMCA stenosis, which improves the likelihood of survival, while percutaneous coronary intervention (PCI) is emerging as a possible alternative to surgery. We present the case of a patient with history and symptoms of stable angina pectoris, especially associated with exercise, variable threshold, since four years, and who describes a worsening of symptoms in the last month; the angina had become more frequent, more prolonged and occurred at a lower threshold. At about 20 hours from getting admitted to our hospital, the patient had severe and prolonged rest angina, associated with important changes on ECG, which led to the indication of emergency coronary angiography. This investigation showed severe left main coronary artery stenosis and significant lesions in other important vessels (three-vessel disease), in a patient with normal left ventricular function. The recurrence and the intensity of prolonged angina of our patient have necessitated urgent myocardial revascularization surgery with quadruple coronary-artery bypass grafting. After surgery, the patient was asymptomatic and he was discharged 8 days after in a good clinical state. The advantage of coronary artery bypass grafting performed as urgent surgery for the treatment of our patient with left main coronary artery stenosis and concomitant acute coronary syndrome, shortly after coronary angiography, was obvious, significantly improved the clinical outcome, without postoperative ischemic complications.

Hybrid cardiac surgery

Clinical applications Hybrid revascularization approach for coronary artery disease Surgical bypass grafting and percutaneous coronary artery revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Thus hybrid coronary revascularization and MIDCAB (minimally invasive direct coronary artery bypass surgery) have been developed. Revascularization of the left anterior descending artery with the left internal mammary artery is by far the best treatment option in terms of long-term results. Integrating this therapy with percutaneous coronary angioplasty (hybrid procedure) offers multi-vessel revascularization through a mini-thoracotomy. Particularly in high risk patients, morbidity and mortality decreases in comparison to conventional surgery. Completion angiography

[Indication for coronary revascularization for angina pectoris: correlation with prognosis of medically-treated patients].

To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease.

Revascularization

Applications For coronary artery disease (ischemic heart disease), coronary artery bypass surgery and percutaneous coronary intervention (coronary balloon angioplasty) are the two primary means of revascularization. When those cannot be done, transmyocardial revascularization or percutaneous myocardial revascularization, done with a laser, may be an option. Treatment for gangrene often requires revascularization, if possible. The surgery is also indicated to treat ischemic wounds (inadequate tissue perfusion) in some forms of chronic wounds, such as diabetic ulcers. References Vascular surgery

List of MeSH codes (E04)

– cardiovascular surgical procedures – cardiac surgical procedures – cardiomyoplasty – heart arrest, induced – circulatory arrest, deep hypothermia induced – heart bypass, right – fontan procedure – heart massage – heart transplantation – heart-lung transplantation – heart valve prosthesis implantation – myocardial revascularization – angioplasty, transluminal, percutaneous coronary – atherectomy, coronary – coronary artery bypass – coronary artery bypass, off-pump – internal mammary-coronary artery anastomosis – pericardial window techniques – pericardiectomy – pericardiocentesis – reperfusion – myocardial reperfusion – vascular surgical procedures – angioplasty – angioplasty, balloon – angioplasty, balloon, laser-assisted – angioplasty, transluminal, percutaneous coronary – angioplasty, laser – angioplasty, balloon, laser-assisted – atherectomy – atherectomy, coronary – angioscopy – arteriovenous shunt, surgical

[Surgical revascularization of the myocardium in patients with chronic coronary disease and depressed left ventricular function: 1-year observation].

Many reports confirm the importance and benefit of the surgical revascularization (CABG) in patients with ischemic heart disease and severely depressed left ventricular (LV) systolic function. This mode of treatment is better than medical therapy in patients with very low LV ejection fraction (LVEF) and can prolong the life. However, the effect of CABG on LV hemodynamics is still unclear. The aim of the study was: 1) to assess the effect of CABG on LV hemodynamics in patients with low LVEF and 2) to examine the influence of two types of cardioplegia-crystalloid (CC) and blood (BC) cardioplegia--on LV function during 1 year follow-up. 122 patients with stable angina pectoris qualified for CABG were included in the study. Patients were divided into two groups: group I-47 pts with LVEF < or = 40% and group II--75 pts with LVEF > 40% and then patients were randomized for two types of antegrade-retrograde cardioplegia (CC--subgroups Ia, IIa and BC--subgroups Ib, IIb). Before operation and 4 times after CABG (after 2-6 weeks, 3 months, 6 months and 1 year) echocardiographic examination was performed. Diameters of left atrium and ventricle, LVEF and wall motion score index (WMSI) were calculated. During 1 year 8 patients died (5 of them during perioperative period and 3 patients during follow-up). Patients in group I before operation were in higher NYHA and CCS class and had more often myocardial infarction. During each of the five echocardiographic examination the values of LVEF and WMSI did not differ between subgroups Ia vs Ib and IIa vs IIb. In group I, especially in patients with very low LVEF < or = 30%, the values of LVEF and WMSI improved significantly (p < 0.001) during 1 year of follow-up. But in group II a transient deterioration of LVEF (p < 0.05) 2-6 weeks after CABG was noted. We conclude that surgical revascularization in patients with severe depressed hemodynamics improves LV systolic function during 1 year follow-up. The use of CC or BC did not seem to make any difference to the early and long-term hemodynamic effect of the revascularization.

Intra-aortic balloon pump

Indications The following situations may benefit from this device. Cardiogenic shock when used alone as treatment for myocardial infarction. 9–22% survive the first year. Reversible intracardial mechanical defects complicating infarction, i.e. acute mitral regurgitation and septal perforation. Unstable angina pectoris benefits from counterpulsation. Post cardiothoracic surgery—most common and useful is counterpulsation in weaning patients from cardiopulmonary bypass after continued perioperative injury to myocardial tissue. Preoperative use is suggested for high-risk patients such as those with unstable angina with stenosis greater than 70% of main coronary artery, in ventricular dysfunction with an ejection fraction less than 35%. Percutaneous coronary angioplasty In high risk coronary artery bypass graft surgery where cardiopulmonary bypass time was shortened, as well as during intubation period and hospital stay. Thrombolytic therapy of acute myocardial infarction.

[Results of coronary surgery in patients over 70 years of age].

Among the 628 consecutive patients who underwent coronary bypasses performed by the same surgical group between January 1, 1982 and December 31, 1987, 71 (11 p. 100) were aged 70 years or more (mean: 72.5 years; range: 70-83 years). 99 p. 100 of the patients had a history of severe, disabling exertional angina (46 p. 100) or unstable angina (52 p. 100) of 55 months' duration on average; 35 patients (49 p. 100) had already experienced myocardial infarction. Coronary angiography showed a one-vessel disease in 1 case, a two-vessel disease in 1 case, a two-vessel disease in 31 cases and a three-vessel disease in 39 cases; 11 patients (15 p. 100) had stenosis of the left main coronary artery. The ventricular function was considered unaltered in 59 cases (83 p. 100). Altogether, 155 bypasses, including 25 internal mammary grafts, were performed, i.e. an average of 2.2 bypasses per patient. There was only one early (21st day) post-operative death. The post-operative period was uneventful in 57 patients (60 p. 100); 9 developed peri-operative necrosis. Seventy patients have been followed up for a mean period of 24 months: there were 3 late deaths of non-cardiac origin; 60 patients (84.5 p. 100) are now asymptomatic and 3 (4.5 p. 100) are suffering from residual angina. Early mortality excluded, the cumulative probability of survival at 5 years is 94 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease.

Graft coronary disease (GCD) remains the single greatest limitation to long-term survival of heart transplant recipients. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited; palliative coronary revascularization has been attempted. Because of the high mortality rate associated with advanced forms of GCD our institution offers the option of retransplantation in selected cases. The aim of this study was by analyzing retrospectively the outcomes of angioplasty, coronary bypass grafting, and retransplantation in cardiac transplant patients to attempt to identify subgroups of transplant recipients with graft coronary disease who may profit from myocardial revascularization. Of the 989 patients undergoing 1016 heart transplantations (HTx) at our institution between 10/86 and 12/97, all were screened for the development of GCD. Analyzing routinely annual angiography, intracoronary ultrasound in defined study patients, and autopsy findings, GCD was diagnosed in 124 patients (110 male, 14 female) 2 to 107 months after HTx (mean 30 months). PTCA: Fourty-six out of 124 patients underwent 76 angioplasties at a mean of 50 +/- 30 months (range 4-91 mo) following cardiac transplantation. The primary success rate was 96% (73/76). The reason for the unsuccessful angioplasty attempts (n = 3) was failure to completely penetrate a stenosis of LAD in 2 patients and severe dissection of RCA, which required emergency surgery, in one. Angiographic restenosis occurred in 42% (31 of 76 lesions) and was diagnosed 11 +/- 11 months after the first angioplasty. There was no procedure-related death. CABG: Seven patients underwent bypass surgery at a mean of 67 months (range 6-128 months) after HTx. Elective surgery was performed in 2 patients with proximal severe triple-vessel disease (Type A lesion) and in 1 patient with severe tricuspid regurgitation who received a tricuspid valve replacement and concomitant single-vessel bypass surgery for proximal GCD (Type A lesion). One patient with combined Type A and B/C lesions required emergency surgery for dissection of RCA after an angioplasty procedure. Three patients with post-infarction unstable angina developed worsening congestive heart failure which required emergency surgery. Angiographically all these patients showed diffuse, distal arteriopathy (combined Type B/C lesions). The electively operated patients and the patient with dissection of RCA were successfully treated and survived beyond hospital discharge (overall survival for CABG in GCD patients 4/7 = 57%). After a mean follow-up of 10 months (range 2-32 months) all are in good clinical condition. All 3 patients with distal arteriopathy and emergency surgery died in hospital of left-ventricular failure (43%). Retransplantation: Eight patients underwent retransplantation at a mean of 54 months (range 6-96 months) after HTx. Six of 8 patients had successful operations and survived beyond hospital discharge with a one-year-survival rate of 75%. In a mean follow-up of 31 months (5-68 months) 3 of 6 retransplant recipients developed a recurrence of GCD. The presence of angiographic distal arteriopathy should be considered a significant factor in patient selection for coronary revascularization procedure. Coronary angioplasty is to be considered as a method of treatment for severe, local stenoses (Type A lesion). PTCA may be applied in these selected cardiac transplant recipients with primary success and complication rates comparable to routine angioplasty but with an increased rate of restenosis especially in small vessels (diameter < 2.5 mm). The distinction between Type A lesions in large (diameter > or = 2.5 mm) and small vessels may be important not only with respect to restenosis but also with respect to long-term benefit. The overall survival did not differ between GCD patients with and without PTCA, suggesting this treatment to be largely palliative. (ABSTR

[Symptomatic and silent myocardial ischemia during drug therapy and after aortocoronary bypass].

In 53 patients with stable angina pectoris 24-hour ambulatory electrocardiographic monitoring (Holter) and bicycle ergometry were used before and six months after a coronary bypass. The examination before operation was made while anti-ischaemic medication was administered, the examination after revascularization was done without medication. The patients were divided into group A (31 patients where complete revascularization of the myocardium was made) and group B (22 patients with incomplete revascularization) and the results were compared during medication and after aortocoronary bypass. In patients of group A revascularization prolonged significantly the load period during ergometry, as compared with medication (from 7.2 +/- 2.2 min. to 9.1 +/- 2.4 min., p < 0.01), the depression of the ST segment in lead V5 was reduced (from 1.3 +/- 0.8 mm to 0.8 +/- 1.0 mm, p < 0.05) and the number of painful episodes during Holter monitoring (from 1 +/- 1 to 0, p < 0.01). In patients of group B none these parameters improved. Medicamentous treatment eliminated ischaemia during a load in 16% of patients in group A, while revascularization did so in 61% (p < 0.01). In patients of group B the success rate of medication was 9%, in revascularization 14% (p = n.s.). During Holter monitoring after revascularization no episodes of ST depressions associated with anginous pain were recorded, although the mean number of silent episodes of ST depressions per 24 hours was 6 +/- 8 in patients of group B and 1 +/- 2 in patients of group A. In patients with stable angina pectoris complete revascularization is significantly more effective than anti-ischaemic medication as regards tolerance of loads and suppression of myocardial ischaemia. Silent myocardial ischaemia is frequent after aortocoronary bypasses and its possible occurrence should be taken into account, in particular in patients with incomplete revascularization.

Management of acute coronary syndrome

Patients without ST segment elevation are said to suffer from non-ST-elevation acute coronary syndrome and tend not to have full occlusion of a coronary artery. If there is evidence of myocardial cell death (especially elevated cardiac biomarkers) they are considered to have a non-ST-elevation myocardial infarction (NSTEMI); otherwise they are classified as suffering from unstable angina. Their management is based on the estimation of their risk for adverse events. Patients at low risk can be adequately treated with medical therapy, in many ways similar to the one used for STEMI (but excluding thrombolytics). Those at moderate to high risk benefit from an early invasive strategy, which includes coronary angiography and, if necessary, revascularization with percutaneous coronary intervention or coronary artery bypass surgery.

[Involvement of the common trunk of the left coronary artery].

This work describes the observations made in a group of 32 patients suffering from left main coronary stenosis (narrowing of 70% or more). 28 patients underwent surgical treatment: they represent 14% of 200 consecutive surgical cases. The diagnosis of left main narrowing is not possible on clinical ground only. However, several common features can be noted. Patients without myocardial infarction commemoratives all experienced unstable angina pectoris. When a bicycle ergometric test could be realized, it was positive for a low work load. It showed a mean 3 mm ST depression for a mean charge of 75 watts. The repolarisation disturbance lasted long after interruption of effort (more than 7 minutes). Coronarography very often showed multiple vessel disease. the anterior descending artery was stenosed in 25 patients, the circumflex artery artery in 23 and the right coronary artery in 27 patients out of the 32. In the majority of the patients, an anastomotic circulation was evidenced. The direction of the vicarious flow was determined by the relative degree of stenosis on the arteries implied in this collaterality. The mortality of coronarography was 1/32. Among the 28 operated patients, 1 died shortly after operation, giving an operative mortality of 3.6%. During a mean follow-up of 15 months, 1 death during the first postoperative year, 2 failures, 2 partial successes and 22 clinical recoveries were noted. Out of 18 patients socially susceptible to work again, 12 are effectively working, 3 are retired and 3 are still totally unable to work at the present time.

Atypical and delayed de Winter electrocardiograph pattern: A case report.

de Winter electrocardiograph (ECG) pattern signifies proximal left anterior descending coronary artery (LAD) occlusion and extensive anterior myocardial infarction, and it is found in about 2% of patients with proximal LAD occlusion. However, it is often unrecognized by physicians. In this case report, we present a patient with chest pain but showing an atypical and delayed de Winter ECG pattern. A previously healthy 61-year-old man attended our emergency department with chest pain radiating to the left arm and back for 4 hours, who was without serious cardiovascular risk factors. ECG at emergency department showed no significant changes. High-sensitivity cardiac troponin I (hs-cTnI) was within normal limit. At 5 hours after onset, ECG showed significant upsloping ST depression at J point in precordial leads V3 to V6, slight ST elevation in aVR and depression in inferior leads, and hs-cTnI peaked at 2.610 μg/L. The diagnosis of de Winter ECG pattern was confirmed by coronary angiography with an occlusion of the proximal LAD. A stent was implanted through percutaneous coronary intervention. The patient's chest pain was relieved without further increase of hs-cTnI. ECG after procedure showed ST segment back to baseline in leads V4 to V6, but persistent ST elevation in V1 to V3 with QS or Q wave. Timely diagnosis of de Winter ECG pattern is very important, especially the atypical and delayed ECG changes. It should be treated as ST elevation myocardial infarction equivalent and deserves emergent revascularization therapy.

[Constriction of the left main coronary artery. Early and long term treatment outcome].

Clinical presentation and course were studies in 45 consecutive patients (p)--39 males, 6 females with angiographically proven left main coronary artery stenosis (LMCA) > 50%. Mean age was 54.7 years. Three (6%) had no history of chest pain, 2 p (4%) had atypical chest pain, and the remaining (90%) had typical angina pectoris. 19 p (42%) had unstable angina, 20 p (44%) had suffered a myocardial infarction in the past. Outside an episode of chest pain most of the patients had an abnormal ECG with ST-T segment depression 2 mm or more in leads V3-6 and ST-T elevation in leads V1 and aVR. No significant differences were found when the abnormalities of the ST-T segment were compared to severity of LMCA obstruction. A symptom limited exercise test was performed in 17 (37%) p. It was abnormal in 13 p (29%). Thirty eight patients (85%) underwent bypass surgery and the mean number of bypass graft was 3.3. Seven patients were treated medically. In the surgical group four p (10.5%) died perioperatively. All of them had subtotal occlusion of LMCA, without significant lesions in the remaining coronary arteries, the ejection fraction (EF) was above 66%. Among thirty four living patients thirty have been asymptomatic. In the medically treated group 3 p (42%) died and only two of four survivors were asymptomatic at a mean follow-up 35.7 months. Left ventricle of all died patients were severely damaged (EF mean 28%), right coronary artery (RCA) was totally occluded and all had rythm disturbances. We conclude, that patients with significant LMCA stenosis had a good prognosis when treated surgically.(ABSTRACT TRUNCATED AT 250 WORDS)

The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses.

This study sought to evaluate, in a prospective and randomized trial, the relative efficacies of three possible therapeutic strategies for patients with a single severe proximal stenosis of the left anterior descending coronary artery and stable angina. Although percutaneous transluminal coronary angioplasty and coronary artery bypass surgery are often performed in patients with a single proximal stenosis of the left anterior descending coronary artery, it is unclear whether revascularization offers greater clinical benefit than medical therapy alone. At a single center, 214 patients with stable angina, normal ventricular function and a proximal stenosis of the left anterior descending coronary artery > 80% were randomly assigned to undergo mammary bypass surgery (n = 70), balloon angioplasty (n = 72) or medical therapy alone (n = 72). Angioplasty had to be considered technically feasible in every case. The predefined primary study end point was the combined incidence of cardiac death, myocardial infarction or refractory angina requiring revascularization. At an average follow-up period of 3 years, a primary end point had occurred in only 2 patients (3%) assigned to bypass surgery compared with 17 assigned to angioplasty (24%) and 12 assigned to medical therapy (17%) (p = 0.0002, angioplasty vs. bypass surgery; p = 0.006, bypass surgery vs. medical treatment; p = 0.28, angioplasty vs. medical treatment, all by log-rank test). There was no difference in mortality or infarction rates among the groups. However, no patient allocated to bypass surgery needed revascularization, compared with eight and seven patients assigned, respectively, to coronary angioplasty and medical treatment (p = 0.019). Both revascularization techniques resulted in greater symptomatic relief and a lower incidence of ischemia on the treadmill test; however, all three strategies eventually resulted in the abolition of limiting angina. The more aggressive therapeutic approach with initial bypass surgery for patients with a single severe proximal stenosis of the left anterior descending coronary artery is associated with a lower incidence of medium-term adverse events than coronary angioplasty or medical treatment. However, all three strategies resulted in a similar incidence of death and infarction during an average follow-up period of 3 years. This information should be taken into consideration when physicians and patients make therapeutic choices in this setting.

Percutaneous transluminal coronary angioplasty in patients with silent myocardial ischemia during exercise testing.

Silent myocardial ischemia was present in 50 of 507 patients undergoing PTCA. Of these patients, five had type 1 (asymptomatic with no previous myocardial infarction), 27 had type 2 (asymptomatic after myocardial infarction) and 18 had type 3 silent myocardial ischemia (angina present in addition to silent episodes). Ischemia was documented in all patients in the exercise ECG, in 18 patients with thallium scintigraphy and in four with radionuclide ventriculography. The indication for PTCA was considered established in patients with type 1 silent ischemia based on ECG changes in the presence of high grade stenosis of the left anterior descending artery under the assumption of improved prognosis. The fact that patients with myocardial infarction have a poorer prognosis in the presence of ST-segment depression served as the basis for the indication for PTCA in type 2 patients. In type 3 patients, PTCA was carried out to ameliorate the symptomatic as well as asymptomatic episodes of ischemia. The follow-up period averaged 12 +/- 6 months. The primary rate of success was 92% with no differences between the groups. There were no complications in type 1 and type 2 patients; in two patients with type 3 silent ischemia, immediate bypass surgery was carried out due to acute occlusion of the dilated vessel. One patient in the latter group had myocardial infarction in the region perfused by the dilated vessel four months after the procedure. The angiographically-documented rate of restenosis was 33% in type 1 patients, 26% in type 2 and 40% in type 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

InternalMed_Harrison

Embolic distal protection devices decrease the risk of distal embolization, as well as the incidence of no-reflow and myocardial infarction associated with saphenous vein graft interventions. CASE 5: UNPROTECTED LEFT MAIN PCI IN A HIGH-RISK PATIENT (Figs. 297e-6 and 297e-7; Videos 297e-27 to 297e-34) An 89-year-old woman presented with a NSTEMI associated with 5-mm ST-segment depression in the apical leads occurring 2 weeks after hospitalization for a NSTEMI that was treated conservatively. Chronic obstructive lung disease, elderly age, and the patient’s refusal to consider cardiac surgery restricted the choice of therapeutic options to medical and/or percutaneous interventions. Diagnostic catheterization revealed a left dominant circulation with a heavily calcified 80% distal left main coronary artery stenosis extending into the LAD and into the proximal LCx coronary arteries. A 70% proximal LAD lesion was also present.

[Short- and medium-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery disease in patients who are poor candidates for surgical revascularization].

Surgical revascularization is the procedure of choice for unprotected left main coronary artery stenosis, but it may be unsuitable in some patients. We report short- and medium-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis in a series of patients who were poor candidates for surgery. Descriptive study of a historic cohort of consecutive patients with unprotected left main coronary artery stenosis who were not candidates for surgery, treated with percutaneous coronary intervention at a single center between April 1999 and December 2003. A total of 83 patients (mean age 72 [9] years) were included. Twenty patients (24%) were in shock on presentation. Surgery was considered unsuitable because of unacceptable surgical risk, poor condition of the distal vessels or comorbid conditions in 61 (73.5%) patients, or acute myocardial infarction in 22 (27%). An intraaortic balloon pump was used in 34 (40%); abciximab in 30 (36%) and stenting in 79 (95%) procedures. The intervention was considered successful in 76 patients (92%). Total in-hospital mortality was 28.9% (55% in patients with acute myocardial infarction and 20% in those without acute myocardial infarction). Median follow-up was 17 months. Average survival was 19.7 (2) months. Eighteen (22%) patients were hospitalized again for a new ischemic event, and 14 (17%) underwent revascularization. In 9 cases (10.8%) a new angioplasty was performed, and in 5 (6.0%) surgical revascularization was necessary. Percutaneous coronary intervention is an option for revascularization in left main coronary artery stenosis in patients who are poor candidates for surgery, although in-hospital and long-term mortality remain high.

Main left coronary artery disease. Clinical experience from 1964-1974.

Obstructive lesions of the main left coronary artery (LCA) were demonstrated angiographically in 73 patients, comprising 4.3% of the total population referred to us for diagnostic evaluation of chest pain. Although there were no specific historical or clinical features which could absolutely distinguish this subgroup from the larger population of coronary artery disease patients, 81% (34/42) of the double Master's exercise tests, in which the patient achieved a heart rate of at least 110 beats/min. demonstrated greater than or equal 2 mm R-ST segmental depression. Of the total group of 73, 32 were evaluated during the six-year period from 1964 to 1971 and a preliminary report made in 1972. The diagnosis in the remaining 41 patients was established in the 1/2 year period from 1971 to 1973. The initial 32 patients were seen before the significance of a main LCA lesion was appreciated. In this subgroup there were five deaths at the time of cardiac catheterization. However, in the more recent group improved recognition of patients with possible main LCA disease prior to catheterization has led to a much lower death rate related to diagnostic catheterization. Only one of the last 41 patients undergoing coronary angiography has died. Nineteen patients were managed medically. Of this group 17 were considered to be under the same risk of death as the surgical candidates. Their mortality rate, as high. The risk of hying was 43.6% after 24 months, 51.1% after 36 months, and 73.6% after 42 months of observation. Although the initial surgical experience, using internal mammary artery implants and saphenous venin bypass grafts, was associated with a high mortality, direct revascularization surgery over the last 2 1/2 years has been accomplished with a perioperative mortality of only 6.2%. All deaths in the group of 40 patients receiving elective revasularization with saphenous vein bypass grafts occurred in the first six months following surgery. The risk of dying was 12.5% after six months of observation and was unchanged for the remainder of the follow-up period. After 21 months the difference in survival between the two groups is statistically significant (P less than 0.05). The one late death among the surgical survivors occurred four months after the operative procedure and was related to noncardiovaxcular surgical complications. The surgical survivors have been followed for an average of 27 months. Thus revascularization surgery has improved the prognosis for patients with main LCA disease. We currently advise prompt evaluation for any patient suspected of having this type of obstruction and urgent idrect revascularization surgery if this lesion is demonstrated angiographically.

List of MeSH codes (E04)

– thoracic surgical procedures – cardiac surgical procedures – cardiomyoplasty – heart arrest, induced – circulatory arrest, deep hypothermia induced – heart bypass, right – fontan procedure – heart massage – heart transplantation – heart-lung transplantation – heart valve prosthesis implantation – myocardial revascularization – angioplasty, transluminal, percutaneous coronary – atherectomy, coronary – coronary artery bypass – coronary artery bypass, off-pump – internal mammary-coronary artery anastomosis – pericardial window techniques – pericardiectomy – pericardiocentesis – mediastinoscopy – pulmonary surgical procedures – bronchoscopy – collapse therapy – pneumonolysis – pneumothorax, artificial – lung transplantation – heart-lung transplantation – pneumonectomy – pneumonolysis – thoracoplasty – thoracoscopy – thoracic surgery, video-assisted – thoracostomy – thoracotomy – thymectomy – tracheostomy

InternalMed_Harrison

CASE 4: SAPHENOUS VEIN GRAFT INTERVENTION WITH DISTAL PROTECTION (Fig. 297e-5; Videos 297e-23 to 297e-26) A 62-year-old male with a history of chronic stable angina. A four-vessel coronary artery bypass grafting (CABG) surgery was performed 17 years earlier with a left internal mammary artery graft to the LAD, a right internal mammary artery graft to the right coronary artery (RCA), a saphenous vein graft to the first obtuse marginal branch, and a saphenous vein graft to the first diagonal branch. The patient had a recent increase in angina with exertion and was found to have lateral ischemia on an exercise technetium-99m scan. Diagnostic cardiac catheterization revealed a significant stenosis in the body of the saphenous vein graft to the first obtuse marginal branch.

Mechanical and surgical interventions for the reduction of myocardial ischemia.

To reduce myocardial ischemia effectively, mechanical or surgical interventions must achieve either augmentation in coronary blood flow, a reduction in myocardial oxygen demand, or a combination of both. Coronary bypass graft procedures can achieve an immediate augmentation in coronary blood flow distally through the involved vessel and thereby improve myocardial perfusion and oxygen delivery and thus have the potential for reversing myocardial ischemia both acutely and for the long term. Although myocardial revascularization may resolve the ventricular functional alterations associated with acute myocardial ischemia it remains uncertain whether revascularization can reverse ischemic myocardial cellular injury and in what time framework, as related to reversible vs. irreversible ischemic cellular changes. Mechanical circulatory assistance (MCA) using diastolic counterpulsation effectively reduces myocardial ischemia by the physiologic mechanisms of 1) decrease in left ventricular after-load and left ventricular wall tension, 2) improvement is cardiac output by diastolic counterpulsation and 3) augmentation of coronary blood flow by diastolic pressure augmentation. The most effective indication for either MCA or myocardial revascularization is for interruption of myocardial ischemia prior to the development of infarction. Clinical sudies have demonstrated that acute myocardial ischemia can be effectively interrupted by intraaortic balloon pumping (IABP) including reversal of left ventricular dysfunction associated with acute myocardial ischemia. In most instances, cessation of IABP resulted in recurrence of myocardial ischemia indicating the need for urgent revascularization surgery. In the management of medically refractory myocardial ischemia. IABP has been effective in complete suppression of ischemia in 80 percent and resulted in marked improvement in all, allowing safe revascularization surgery with an operative mortality in the range of 5% and perioperative myocardial infarction incidence of 2%. In patients with acute myocardial infarction and cardiogenic shock (AMI-CS), IABP can resolve CS in 75 percent. The combination of IABP and surgery has resulted in survival approaching 45 percent indicative of a significant improvement in salvage in this group of patients where expected mortality approaches 100 percent.

[Improved angina-free work tolerance up to 6 years following bypass operation according to degree of revascularization].

Bypass surgery improves exercise performance in a high percentage of patients with effort angina. The influence of the degree of revascularization on the extent and duration of improvement of exercise parameters was evaluated in 415 patients with angiographically determined degrees of revascularization (REV) by serial exercise testing 1-6 years after bypass surgery. Patients with three different degrees of REV are compared. REV I: All vessels up to 50% stenosed have a patent graft. REV II: The main vessel supplying the left ventricle (LV) has a patent graft. REV III: The main vessel supplying the LV has not a patent graft but at least one additional graft is patent. Angina-free exercise tolerance in watts, the maximum double product (HR X BP), and the percentage of patients with angina pectoris and ST-segment depression during exercise were recorded. In patients with REV I and II the angina-free exercise tolerance was improved up to 6 years after bypass surgery but in patients with REV III only 2 years afterwards. Patients with REV I, REV II, and REV III showed improvement of all three parameters for 6 years, 4 years and 1 year respectively. The completeness of revascularization is an important determinant in the longterm improvement of postoperative exercise parameters up to 6 years after surgery.

Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis.

The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients.

Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group.

This report presents the final results (follow-up 5--8 years) of a prospective study in 768 men aged under 65 with mild to moderate angina, 50% or greater stenosis in at least two major coronary arteries, and good left ventricular function. 395 were randomised to coronary artery bypass surgery, 373 to no treatment; 1 patient in the surgery group was lost to follow-up. These original groups were compared, whatever subsequently happened to the patients. Survival was improved significantly by surgery in the total population, in patients with three-vessel disease, and in patients with stenosis in the proximal third of the left anterior descending artery constituting a component of either two or three vessel disease, and non-significantly in patients with left main coronary disease. An abnormal electrocardiogram at rest, ST-segment depression greater than or equal to 1.5 mm during exercise, peripheral arterial disease, and increasing age independently point to a better chance of survival with surgery. In the absence of these prognostic variables in patients with eigher two or three vessel disease the outlook is so good that early surgery is unlikely to increase the prospect of survival. In terms of anginal attacks, use of beta-adrenergic blockers and nitrates, and exercise performance the surgical group did significantly better than the medical group throughout the 5 years of follow-up, but the difference between the two treatments tended to decrease.

[Reperfusion therapy and mechanical circulatory support in patients in cardiogenic shock].

Cardiogenic shock is a state of inadequate tissue perfusion due to cardiac dysfunction, which is most commonly caused by acute myocardial infarction. The pathophysiology of cardiogenic shock is characterized by a downward spiral: ischemia causes myocardial dysfunction, which, in turn, augments the ischemic damage and the energetical imbalance. With conservative therapy, mortality rates for patients with cardiogenic shock are frustratingly high reaching more than 80%. Additional thrombolytic therapy has not been shown to significantly improve survival in such patients. Emergency cardiac catheterization and coronary angioplasty, however, seem to improve the outcome in shock-patients, which most probably is due to rapid and complete revascularization generally reached by angioplasty. In addition to interventional therapy with rapid coronary revascularization, the use of mechanical circulatory support may interrupt the vicious cycle in cardiogenic shock by stabilizing hemodynamics and the metabolic situation. Different cardiac assist devices are available for cardiologists and cardiac surgeons: 1. intraaortic balloon counterpulsation (IABP), 2. implantable turbine-pump (Hemopump), 3. percutaneous cardiopulmonary bypass support (CPS), 4. right heart, left heart, or biventricular assist devices placed by thoracotomy, and 5. intra- and extrathoracic total artificial hearts. Since percutaneous application is possible with IABP, Hemopump and CPS, these devices are currently used in interventional cardiology. The basic goals of the less invasive intraaortic balloon counterpulsation (IABP; Figure 1) are to stabilize circulatory collapse, to increase coronary perfusion and myocardial oxygen supply, and to decrease left ventricular workload and myocardial oxygen demand (Figure 2). Since the advent of percutaneous placement, IABP has been used by an increasing number of institutions (Figure 3). In addition to cardiogenic shock, the system may be of use in a variety of other indications in the catheterization laboratory and intensive care unit, including weaning from percutaneous cardiopulmonary bypass, in ischaemic left ventricular failure, in unstable angina, in high risk PTCA, and in prophylactic support in patients with myocardial infarction and successful revascularization. Animal experimental data showed that IABP may improve success of thrombolysis and recent clinical data suggest that survival is enhanced and transfer for revascularization is facilitated when patients with myocardial infarction and cardiogenic shock undergo thrombolysis and IABP rather than thrombolysis alone. A lot of studies had demonstrated before, that combined use of counterpulsation and revascularization therapy (i.e. coronary bypass surgery or angioplasty) may improve prognosis in patients with myocardial infarction complicated by cardiogenic shock (Table 1). In such patients, early treatment with IABP is most important: Multivariate analysis identified early IABP-support with a duration of shock to IABP-treatment of > or = 4 hours as an independent predictor of a positive short-term outcome. In shock-patients with postinfarction ventricular septal defect, IABP provides a marked hemodynamic improvement, and a significant decrease in shunt-flow (Figure 5). However, despite initial stabilization with IABP, such patients need immediate surgical repair of the septal defect to avoid hemodynamic deterioration. The rate of complications related to percutaneous IABP was significantly attenuated by employing catheters of reduced size. Using 9.5-F catheters, a long duration of counterpulsation emerged as the most significant factor associated with complications. In our hospital, those patients with 9.5-F catheters in whom counterpulsation did not exceed 48 hours had a low complication rate of 3.9%. The Hemopump is a catheter-mounted transvalvular left ventricular assist device intended for surgical placement via the femoral artery (Figures 6 and 7). (ABSTRACT TRUNCATED)

[Improved myocardial function after transluminal coronary angioplasty (author's transl)].

To assess the results of transluminal coronary angioplasty (TCA), 42 patients (mean age 50 years) with for coronary artery disease were investigated at rest and during exercise with the ECG (n = 40), thallium-201 myocardial scintigraphy (n = 23) and equilibrium-radionuclide ventriculography (n = 32). Each method of stress testing was quantified: the exercise ECG by means of an ischemia score, incremented with increasing ST-segment depression and decremented as a function of duration of exercise and workload in watts; thallium-201 scintigraphy by means of an index for minimal to maximal perfusion region (vitality index) and redistribution factors; equilibrium-radionuclide ventriculography by means of global ejection fraction and maximum systolic volume change with respect to the end-diastolic volume. The patients were divided into three groups: 30 had successful TCA defined as demonstrating at least a 20% reduction in the stenosis; six underwent aortocoronary bypass operation (nine grafts; complete revascularization in four patients); and in six patients TCA was unsuccessful. TCA was successful in 24 LAD stenoses, 5 RCA stenoses, and in one proximal anastomosis of an aortocoronary bypass graft. Dilatation could not be achieved in three LAD stenoses and three stenoses of the RCA. In those in whom it was successful, TCA yielded an average reduction of coronary artery stenosis from 84 to 43%. Both TCA and bypass operation (OP) led to comparable degrees of functional improvement. The ischemia score decreased from 2.8 to 0.9 after TCA and from 1.6 to 0 after OP. The vitality index increased from 67 to 77% and from 74 to 81% after TCA and OP respectively while the corresponding redistribution factors decreased (TCA: at 1 hour from 5 to 1% and at 3.5 hours from 11 to 4%; OP: at 1 hour from 2.2 to 1.4% and at 3.5 hours from 7.6 to 4.1%. The global ejection fractions at rest improved from 46 to 52% and from 38 to 45% and during exercise from 42 to 50% and from 36 to 43% after TCA and OP respectively. The maximum--dV/dt/EDV increased at rest (TCA: from 2.7 to 3.5 per second; OP: from 2.1 to 3.8 per second) and during exercise (TCA: from 3.1 to 4.0 per second; OP: from 2.6 to 3.3 per second). In the group with unsuccessful TCA, no significant differences in the latter parameters were observed. Ten of the 30 patients who had undergone successful dilatation were reinvestigated after three months. Maintenance of good functional results could be documented in eight while deterioration was seen in two patients, one with a significant restenosis and one who developed a new narrowing distal to the successfully dilated stenosis. Thus, the results show that in selected cases, TCA can render improved ventricular function and perfusion comparable to that of aortocoronary artery bypass surgery.

Coronary artery bypass surgery

A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization. The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization. A meta-analysis with over 6000 patients showed that coronary artery bypass was associated with lower risk for major adverse cardiac events compared to drug-eluting stenting. However, patients had a higher risk of stroke events.

[The fate of patients with stenosis of the trunk of the left coronary artery].

We have studied the fate of 49 patients with stenosis of the trunk of the left coronary artery of more than 50%. The follow-up period extends from 1,5 years to 5 years (with a mean of 33.83 +/- 13.55 months). The clinical picture was not characteristic. Unstable angina was found in 59% of cases. The exercice test (29 patients) was positive in 100%, with a mean depression of 3.3 mm. Stenosis of the trunk, which is rarely an isolated condition (8% of cases), is usually associated with disorders of the other main coronary vessels. Twenty six patients underwent surgery. Thirteen patients who were operable were treated medically. The performance of the left ventricle and the degree of involvement of the coronary arteries were comparable in these two groups. Seven inoperable patients were treated medically. Actuarial survival curves show a significant difference (p less than 0.01) in survival after two years between the operated cases (88%), the operable cases treated medically (60%), and the inoperable cases (57%). The decreased mortality of the operated cases corresponds also with a greater functional capacity in the survivors compared with that of the cases treated medically.

Drug-eluting stent

Two major randomized controlled trials comparing CABG and DES are either completed or ongoing, and have published results - Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) and Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease (FREEDOM). The five-year follow-up results of SYNTAX showed, depending on the complexity of coronary vessel disease, PCI was either equally effective or inferior to CABG. Similarly, results from the FREEDOM trial published after five years showed CABG to be superior to PCI in reducing rates of death and myocardial infarction. Both trials found either increased or insignificantly different rates of stroke with CABG as compared to PCI. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.