William S. Weintraub

Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up.

BackgroundAngioplasty of chronically totally occluded vessels has been associated with a success rate well below and restenosis rate well above that for angioplasty of stenosed segments. However, long-term clinical outcome after successful revascularization of a chronically totally occluded vessel has not been reported in detail. Methods and ResultsAccordingly, data for 480 patients undergoing angioplasty for chronic total occlusion at Emory University Hospital, Atlanta, Ga., from 1980 to 1988 were analyzed for predictors of in-hospital procedural and clinical (procedural success and absence of in-hospital complications) success, restenosis, and 4-year clinical follow-up. The study population was grouped by procedural and clinical success and failure. The groups were then compared for outcome, both in hospital and long term. The initial clinical success rate was 66% (317 of 480 patients). Independent correlates of failure were the number of vessels diseased (p < 0.001), vessel location of the lesion (p = 0.016), and absence of any distal antegrade filling (p = 0.002). Follow-up data revealed 98% cardiac survival and 96% overall survival at 4 years for the group as a whole. Freedom from myocardial infarction or cardiac death was significantly greater in patients with clinical success (93%) than with clinical failure (89%, p = 0.0044). In the successful group, 87% were free from coronary surgery after 4 years compared with 64% in the failure group (p < 0.0001). Two thirds of the patients were free of angina at last follow-up. The presence of angina at follow-up was the same for patients successfully treated and for those with failed angioplasty, which may be related to the frequent use of coronary surgery in the failure group ConclusionsIn well-selected cases, the success rate for angioplasty of chronic total occlusion is acceptable. Furthermore, long-term clinical benefit is suggested by the high freedom from coronary surgery, myocardial infarction, and death in the patients who underwent successful revascularization.

Determinants of prolonged length of hospital stay after coronary bypass surgery.

The length of hospital stay after coronary surgery was studied in 4,683 patients undergoing cardiac catheterization followed by coronary surgery at Emory University Hospital or Crawford Long Hospital between the years 1981 and 1986. Length of stay after coronary surgery had a median and modal value of 7 days. There was, however, a long statistical tail of patients with a prolonged length of stay extending out to more than 180 days. Prolonged length of stay (greater than 10 days) could be correlated with preprocedural variables such as age, elective versus emergency status, angina class, ejection fraction, and gender. Length of stay increased from a mean of 6.9 +/- 1.4 days under the age of 40 years to 10.9 +/- 12.1 days over the age of 70 years (p less than 0.0001). Length of stay was correlated with the periprocedural variables of wound infection, neurologic event, arrhythmias, pneumonia, postoperative myocardial infarction, mortality, and pericarditis. Length of stay increased from 8.8 +/- 9.6 days without a neurologic event to 21.1 +/- 17.9 days with a neurologic event (p less than 0.0001). Similarly, without a wound infection, the average stay was 8.7 +/- 8.9 days; with a wound infection, the average stay was 32.2 +/- 25.8 days (p less than 0.0001). The correlates of prolonged stay were tested in another population comprising 781 patients undergoing cardiac catheterization followed by coronary artery bypass grafting in 1987. The predictors of prolonged stay in the 1987 population were wound infection, pneumonia, arrhythmias, age, neurologic events, postoperative infarction, and ejection fraction. Thus, length of hospital stay after coronary surgery may be predicted by multiple preprocedural and periprocedural variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing use of coronary angioplasty and coronary bypass surgery in the treatment of chronic coronary artery disease

Changes in the use of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) over the last several years have resulted in a new and different environment for the interventional treatment of coronary artery disease. This study explores these changes as applied to the treatment of chronic coronary artery disease. The study population comprised 14,078 patients undergoing diagnostic cardiac catheterization between 1981 and 1988. In 1981, 1,704 patients underwent a first known cardiac catheterization at Emory University Hospital or Crawford W. Long Hospital and were found to have significant coronary artery disease. Of these patients, 51.7% were treated medically, 44.0% by CABG and 4.3% with PTCA. A similar group comprised 1,719 patients in 1988. Of this group 41.2% were treated medically, 28.5% with CABG and 30.3% with PTCA. The data reveal a much more complex phenomenon than a simple increase in PTCA for the treatment of coronary disease at the expense of CABG. The CABG group aged such that the percent of the CABG population more than 65 years old increased from 26.0% of the total in 1981 to 44.9% of the total in 1988. The percent of patients with ejection fractions less than 50% in the CABG population increased from 24.5% in 1981 to 29.7% in 1988. The PTCA population had less severe disease, was younger and had better left ventricular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent changes in the management and outcome of acute closure after percutaneous transluminal coronary angioplasty

The major cause of morbidity and mortality associated with percutaneous transluminal coronary angioplasty (PTCA) is acute closure. This study compared the clinical outcome of 2 groups of patients who experienced acute closure during PTCA. One group was treated during a period when intracoronary stents, laser balloons and perfusion balloons were available for treatment of acute closure (group II). These results were compared with the clinical outcome a group of similar patients who were treated for acute closure during a period that immediately preceded the availability of these devices (group I). One hundred sixty-six patients had acute closure in group I, whereas 156 patients experienced acute closure in group II. Baseline clinical characteristics were similar for both groups. There was no difference in ejection fraction, number of vessels diseased, degree of stenosis or number of vessels attempted between the 2 groups. Patients in group II had more balloon inflations and longer balloon inflation times when compared with patients in group I. Of the 156 patients in group II, 47% were treated with either an intracoronary stent, laser balloon or perfusion balloon. Group II patients had fewer Q-wave myocardial infarctions (9.1 vs 20.3%, p = 0.005). In addition, peak creatine phosphokinase levels (826 +/- 1,515 vs 517 +/- 1,050, p < 0.01) and mean residual stenosis (40.7 +/- 33.2 vs 58.0 +/- 34.4%, p < 0.0001) were also lower in group II patients. There was also less coronary artery bypass grafting during the same admission (38.6 vs 29.5%, p = 0.02) in group II patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision analysis concerning the application of echocardiography to the diagnosis and treatment of mural thrombi after anterior wall acute myocardial infarction.

The diagnostic and therapeutic approach to the problem of mural thrombi after acute myocardial infarction is uncertain. It is clear that the main therapeutic goal is the prevention of embolic strokes. Although it is known that the incidence of thrombi is greatest after anterior wall infarctions, there is uncertainty concerning (1) the probability of a mural thrombus; (2) the sensitivity and specificity of echocardiography in making the diagnosis; (3) the probability that a thrombus will embolize and result in a cerebrovascular accident (CVA); (4) the efficacy of warfarin in preventing embolization; and (5) the probability of bleeding with and without warfarin. To study this problem in patients who have had an anterior wall myocardial infarction, a model was created in which reasonable estimates for the unknown parameters were determined from published medical studies. The model was designed to consider patients if they were or were not treated during the initial hospitalization with heparin. The probability of thrombus was estimated at 0.30, sensitivity and specificity of echocardiography at 0.85 and 0.85, probability that a thrombus will embolize at 0.15, efficacy of anticoagulation of 0.75, probability of bleeding with warfarin at 0.03 and probability of bleeding without warfarin at 0.005. Probabilities of a CVA and of bleeding with and without warfarin were determined if all patients were anticoagulated, if patients with positive echocardiographic results were treated, if patients with negative echocardiographic results were treated and if echocardiographically guided therapy was instituted in which patients with positive echocardiographic results are treated and patients with negative results are not treated.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of patient characteristics, complications, and facility volume on the costs and time of cardiac catheterization and coronary angioplasty in 70 catheterization laboratories

Although over 1 million procedures are performed in cardiac catheterization laboratories (CCLs) annually, little comparative data exist on costs or resource use in these settings. In this study, data from 70 CCLs were used to profile CCL times and total direct costs for 2 high-volume procedures: left heart catheterization (LHC) and percutaneous transluminal coronary angioplasty (PTCA) with or without stent placement. In total, 70,677 consecutive patient examinations for a 12-month period from January 1, 1998 to December 31, 1998 were analyzed. For LHC mean total direct costs averaged

Presentation and late outcome of myocardial infarction in the absence of angiographically significant coronary artery disease

306, whereas for PTCA catheterization laboratory costs averaged

Cigarette Smoking as a Risk Factor for Coronary Artery Disease

3,172. The average total times for these procedures were 63 and 108 minutes, respectively. Seventy-two percent of the PTCA patients underwent coronary stenting with an associated incremental cost of

Design considerations in the study of restenosis after percutaneous transluminal coronary angioplasty

1,244. By multivariate linear regression, baseline patient characteristics such as age, gender, and clinical factors had little impact on total time and total costs. The major determinants of CCL time and cost were procedural factors (e.g., number and type of interventions) and in-lab complications, including profound hypotension, abrupt vessel closure, and emergency bypass surgery. Using facility procedure volume as a proxy for potential economies of scale, we found no relation between CCL volume and total direct CCL costs. There did appear to be a significant inverse relation between facility volume and total procedural time with CCLs that performed the highest volumes of LHC and PTCA procedures saving an average of 5 to 9 minutes per procedure. These findings may be useful in defining specific time and cost benchmarks for these commonly performed procedures and serve to underscore the critical role of reducing complications in both quality improvement and cost-saving efforts.

Economic aspects of transesophageal echocardiography and atrial fibrillation.

To determine the natural history of myocardial infarction (MI) in the absence of angiographically significant (no lesion greater than or equal to 50% diameter stenosis) fixed coronary artery disease (CAD), clinical and angiographic data and late outcome were studied in 43 such patients. The mean age was 45 +/- 11 years; 32 patients (74%) were cigarette smokers. Mild fixed CAD, present in 38 patients (88%), was more frequent in the artery supplying the MI zone (p less than 0.01). Filling defects or serial angiographic resolution of obstruction in the artery supplying the MI zone were present in 14 patients (33%). At late follow-up, 14 major cardiac events occurred in 9 patients, including revascularization in 3, recurrent MI in 6 and cardiac death in 5. Of 35 patients undergoing catheterization within 1 year of the index MI, cumulative risk of a major cardiac event was 9 +/- 4, 12 +/- 5 and 20 +/- 7% at 3, 19 and 37 months, respectively. Myocardial infarction in the absence of significant fixed CAD tends to occur in young smokers with mild CAD in the artery serving the MI zone. Superimposed intracoronary thrombus can be frequently implicated. In these patients, subsequent major cardiac events may occur more frequently than previously reported.