Joel K. Kahn

Supported "high risk" coronary angioplasty using intraaortic balloon pump counterpulsation.

Hemodynamic support may be desirable for selected patients with high risk characteristics undergoing elective coronary angioplasty. Twenty-eight high risk patients were studied with elective intraaortic balloon pump support over a recent 30 month period. Their mean age was 66 years; 10 patients were greater than or equal to 70 years old. Class III or IV angina was present in 23 patients (82%). The mean left ventricular ejection fraction was 24% (range 15% to 50%) and was less than 30% in 25 patients (89%). Three vessel disease was present in 26 patients (93%) and 7 patients had significant left main coronary artery disease. Ninety (96%) of 94 attempts to dilate stenoses were successful, including multivessel angioplasty in 21 patients (75%) and five left main coronary artery dilations. Decreases in systolic blood pressure to less than or equal to 70 mm Hg occurred in 11 patients (39%), but augmented diastolic pressure was greater than or equal to 90 mm Hg at all times. No deaths or myocardial infarctions occurred within 72 h of coronary angioplasty. Vascular complications requiring surgical repair occurred in three patients who had good operative results and no need for transfusions. Thus, intraaortic balloon pump support in patients with high risk features undergoing elective coronary angioplasty appears effective and relatively benign, although definite benefit cannot be proved without a randomized study. Newer techniques, such as in-laboratory cardiopulmonary bypass, must be compared with the results obtained with intraaortic balloon pump support alone.

Results of primary angioplasty for acute myocardial infarction in patients with multivessel coronary artery disease

The influence of multivessel coronary artery disease on the outcome of reperfusion therapy for myocardial infarction has not been fully characterized. Direct coronary angioplasty without antecedent thrombolytic therapy was performed during evolving myocardial infarction in 285 patients with multivessel coronary artery disease at 5.2 +/- 4.2 h after the onset of chest pain. Two vessel disease was present in 163 patients (57%) and three vessel disease in 122 (43%). An anterior infarct was present in 123 patients (43%), cardiogenic shock in 33 (12%) and age greater than or equal to 70 years in 59 (21%). Angioplasty of the infarct-related vessel was successful in 256 patients (90%), including 92% with two vessel and 88% with three vessel disease (p = NS). Emergency bypass surgery was needed in six patients (2%). In-hospital death occurred in 33 patients (12%), including 13 with two vessel and 20 with three vessel disease (p less than 0.05). The mortality rate was only 4% in the subgroup of 101 patients who met entry criteria for thrombolytic trials. The in-hospital mortality rate was 45% in patients in shock and 7% in patients not in shock (p less than 0.01). Logistic regression analysis identified shock and age greater than or equal to 70 years as independently associated with in-hospital death. In 135 patients who underwent predischarge left ventriculography, global ejection fraction increased from 50% to 57% (p less than 0.001) and regional wall motion in the infarct zone improved in 59% of patients. Follow-up data were available in 251 patients (99%) at a mean of 35 +/- 19 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheterization laboratory events and hospital outcome with direct angioplasty for acute myocardial infarction.

To assess the safety of direct infarct angioplasty without antecedent thrombolytic therapy, catheterization laboratory and hospital events were assessed in consecutively treated patients with infarctions involving the left anterior descending (n = 100 patients), right (n = 100), and circumflex (n = 50) coronary arteries. The groups of patients were similar for age (left anterior descending coronary artery, 59 years; right coronary artery, 58 years; circumflex coronary artery, 62 years), patients with multivessel disease (left anterior descending coronary artery, 55%; right coronary artery, 55%; circumflex coronary artery, 64%), and patients with initial grade 0/1 antegrade flow (left anterior descending coronary artery, 79%; right coronary artery, 84%; circumflex coronary artery, 90%). Cardiogenic shock was present in eight patients with infarction of the left anterior descending coronary artery, four with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery. Major catheterization laboratory events (cardioversion, cardiopulmonary resuscitation, dopamine or intra-aortic balloon pump support for hypotension, and urgent surgery) occurred in 10 patients with infarction of the left anterior descending coronary artery, eight with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery (16 of 16 shock and six of 234 nonshock patients, p less than 0.001). There was one in-laboratory death (shock patient with infarction of the left anterior descending coronary artery).(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose contrast agent administration during complex coronary angioplasty

To examine the necessity and consequences of high-dose contrast media administration during coronary angioplasty, the records of 730 consecutive patients over a 6-month period were reviewed. The 54 patients (7%) requiring contrast agent doses greater than or equal to 400 ml were examined in detail. The mean contrast dose in this group was 496 +/- 76 ml (range 400 to 785 ml). Their mean age was 63 +/- 11 years (range 36 to 83 years), 10 patients had diabetes mellitus (19%), and four patients had a baseline creatinine level greater than or equal to 1.5 mg/dl (7%). Following coronary angioplasty, the serum creatinine rose from 1.1 +/- 0.2 to 1.2 +/- 0.3 (p = 0.08). The creatinine rose greater than or equal to 0.5 mg/dl in six patients (11%) and greater than or equal to 1.0 mg/dl in one patient (2%). Five of these six patients had either diabetes mellitus, baseline renal insufficiency, or both. Oliguria was not observed. The most important procedural factors contributing to the high doses of contrast media were multilesion and multivessel angioplasty in 96% and 83% of patients, respectively, prior bypass surgery in 52%, and combined diagnostic cardiac catheterization and angioplasty in 13%. Thus renal dysfunction following high-dose contrast agent administration during complex coronary angioplasty is infrequently associated with nephrotoxicity. Whenever possible, contrast doses in patients with diabetes mellitus and renal insufficiency should be minimized.

Usefulness of angioplasty during acute myocardial infarction in patients with prior coronary artery bypass grafting

The efficacy and risk of reperfusion strategies for myocardial infarction in patients with prior coronary artery bypass surgery are uncertain. In this study 72 patients with prior bypass grafting underwent direct percutaneous transluminal coronary angioplasty without antecedent thrombolytic therapy. There were 26 anterior and 46 inferior infarctions, including 11 patients (15%) in cardiogenic shock. The baseline ejection fraction was less than 40% in 47 (65%) patients. Angioplasty was successful in 41 of 48 (85%) vein grafts and 24 of 24 (100%) arteries (difference not significant) at 5.1 +/- 4.0 hours from the onset of symptoms (79% treated less than 6 hours). There were no urgent bypass operations, strokes or transfusions. In-hospital survival was 90% (nonshock 95% vs shock 64%, p less than 0.01). Symptomatic acute reclosure occurred in 1 patient. Predischarge coronary arteriography in 34 patients demonstrated continued vessel patency in 32 infarct vessels (94%), although 5 of these vessels were redilated for restenoses. Predischarge paired ventriculography in 26 patients showed an increase in ejection fraction from 44 +/- 16% to 51 +/- 18% (p less than 0.01). One- and 3-year actuarial survival was 89 and 87%. Thus, prior coronary surgery should not preclude reperfusion therapy by direct angioplasty, which can be accomplished with low procedural risk, improvements in ventricular function and excellent in-hospital and late survival.

Safety and efficacy of percutaneous transluminal coronary angioplasty in patients with left ventricular dysfunction

The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.

Initial and long-term outcome of 83 patients after balloon angioplasty of totally occluded bypass grafts☆

OBJECTIVES This study was designed to evaluate the safety and short- and long-term results of coronary angioplasty of totally occluded bypass grafts in patients with clinical conditions other than acute myocardial infarction. BACKGROUND Total occlusion of bypass grafts after coronary artery surgery often causes recurrent ischemia. The safety and results of percutaneous transluminal coronary angioplasty in occluded bypass grafts are controversial. METHODS All patients with dilation of a totally occluded bypass graft attempted between 1981 and 1991 were retrospectively identified from a data base. Patients treated in the setting of an acute myocardial infarction were excluded. Eighty-three patients met these criteria and constitute the study group. Hospital records, office charts and procedural reports were reviewed in all patients to supplement details available in the data base. RESULTS The time from bypass surgery to attempted coronary angioplasty ranged from 1 to 226 months (mean time 88 months). The mean (+/- SD) duration of graft occlusion was 31 +/- 46 days (range 1 to 180). In 27 attempts the bypass graft was the only site dilated, and in 56 attempts (68%) one to six other sites (n = 101) were dilated. Angiographic success (< or = 40% residual lumen stenosis) was achieved in 61 grafts (73%) and 98 of the additional sites (97%) (p < 0.001). Major complications included one procedural death and two Q wave infarctions. Follow-up for a mean of 32 months demonstrated a 1- and 3-year actuarial survival rate of 94% and 80%, respectively. At 3 years, only 34% of patients were free of repeat angioplasty or surgery. CONCLUSIONS Angioplasty of totally occluded bypass grafts can be successful in the majority of selected patients, although major complications can occur. Strategies for sustained patency are needed to improve the long-term results.

TIMING AND MECHANISM OF IN-HOSPITAL AND LATE DEATH AFTER PRIMARY CORONARY ANGIOPLASTY DURING ACUTE MYOCARDIAL INFARCTION

The effect of early myocardial reperfusion on patterns of death after acute myocardial infarction (AMI) is unknown. Thus, the mechanism and timing of in-hospital and late deaths among a group of 614 patients treated with coronary angioplasty without antecedent thrombolytic therapy for AMI were determined. Death occurred in 49 patients (8%) before hospital discharge. Four patients died in the catheterization laboratory. Death was due to cardiogenic shock in 22 patients, acute vessel reclosure in 5 patients, was sudden in 8 patients and followed elective coronary artery bypass surgery in 8 patients. Cardiac rupture was observed in only 2 patients after failed infarct angioplasty, and did not occur among the 574 patients with successful infarct reperfusion. Intracranial hemorrhage did not occur. Multivariate predictors of in-hospital death included failed infarct angioplasty, cardiogenic shock, 3-vessel coronary artery disease and age greater than or equal to 70 years. During a follow-up period of 32 +/- 21 months (range 1 to 87), 55 patients died. The cause of death was cardiac in 36 patients, including an arrhythmic death in 23 patients and was due to circulatory failure in 13 others. One patient died of reinfarction due to late reclosure of the infarct artery. Actuarial survival curves demonstrated overall survival after hospital discharge of 95 and 87% at 1 and 4 years, respectively. Freedom from cardiac death at 1 and 4 years was 96 and 92%. Multivariate predictors of late death included 3-vessel disease, a baseline ejection fraction of less than or equal to 40%, age greater than 70 years and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)

Early postoperative balloon coronary angioplasty for failed coronary artery bypass grafting

In a small number of patients, coronary artery bypass grafting (CABG) fails to relieve anginal symptoms. The usefulness of coronary angioplasty for the treatment of early (less than or equal to 90 days) recurrent ischemia after CABG was examined. Forty-five patients were treated from 2 to 90 days after CABG, including 8 patients studied emergently for prolonged ischemic symptoms. One-, 2- and 3-vessel native disease was found in 4, 10 and 31 patients, respectively. At the time of postoperative angiography, the major anatomic mechanism of recurrent ischemia was complete vein graft occlusion in 12 patients (27%), internal mammary artery occlusion in 3 (7%), vein graft stenoses in 13 (29%), internal mammary artery stenoses in 10 (22%), unbypassed disease in 4 (8%) and disease distal to the graft insertion site in 3 (7%). Angioplasty was successful at 91 of 98 sites (93%), including 95% of 41 lesions in native arteries, 89% of 46 lesions in vein grafts and 100% of 11 internal mammary artery lesions attempted. Complete revascularization was achieved in 84% of patients. There were 2 in-hospital deaths and 2 myocardial infarctions. Two additional patients underwent repeat CABG before discharge after uncomplicated but unsuccessful angioplasty. At late follow-up of the 43 survivors (mean 44 months), there were 4 deaths, 2 of which were noncardiac. Repeat CABG was required in only 3 patients and repeat angioplasty was performed in 10. Angina was absent or minimal in 35 patients; 17 patients were employed full time. Thus, percutaneous transluminal coronary angioplasty can relieve myocardial ischemia after unsuccessful CABG in the majority of patients.

FREQUENCY AND CAUSES OF FAILURE WITH CONTEMPORARY BALLOON CORONARY ANGIOPLASTY AND IMPLICATIONS FOR NEW TECHNOLOGIES

Abstract Over the past decade of percutaneous transluminal coronary angioplasty (PTCA), greater operator experience and improvements in balloon catheters and guidewires have resulted in lesion success rates of ≥90%. 1,2 Despite the improved success of contemporary PTCA, numerous new technologies, including lasers, stents and atherectomy devices, have recently been introduced and championed as potential alternatives to the balloon catheter. The ease and success of current balloon procedures mandate that new therapies must either increase the primary success rates of interventional approaches, eliminate or help manage complications, or reduce restenosis. To better appreciate deficiencies with contemporary PTCA techniques that may be addressed with non-balloon catheter technologies, we analyzed the frequency, cause and outcome of failed PTCA in our most recent experience.