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Ann Thorac Surg 1995;59:283-286
© 1995 The Society of Thoracic Surgeons

Have PTCA Failures Requiring Emergent Bypass Operation Changed?

Mary J. Boylan, MD, Bruce W. Lytle, MD, Paul C. Taylor, MD, Floyd D. Loop, MD, William Proudfit, MD, Judith A. Borsh, Delos M. Cosgrove, III, MD

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Methods and Results
 Comment
 References
 
From 1980 through 1990, 9,145 patients had balloon angioplasty with failure of the procedure requiring emergent surgical revascularization within 24 hours occurring in 253 patients (2.8%). Patients were divided into two cohorts based on the date of the percutaneous transluminal coronary angioplasty (PTCA): 1980 to 1985 (n = 109) and 1986 to 1990 (n = 144). The incidence of PTCA failure was 3.8% during 1980 to 1985 (109/2,903) and decreased to 2.3% (144/6,242) for 1986 to 1990. Comparison of pre-PTCA patient characteristics between the two periods showed that only a history of a previous PTCA and class III or class IV symptoms were more common in the recent years (p <= 0.05). In-hospital mortality after emergency operation was 4.6% (5/109) during 1980 to 1985 and 7.6% (11/144) from 1985 to 1990 (p = not significant). This trend toward increased mortality appeared to be related to an increased number of patients who underwent operation in a state of severe hemodynamic compromise in the more recent period. The in-hospital mortality rate for patients in shock or undergoing cardiopulmonary resuscitation was 28.3% (13/46) compared with 1.4% (3/207) for patients with less severe hemodynamic derangement (p < 0.001). Use of the intraaortic balloon pump preoperatively increased from 12.8% to 32.6% (p < 0.01). Late survival was 92% at 2 and 87% at 5 postoperative years. Although the incidence of PTCA failure necessitating emergent surgical intervention has decreased over time, there has been a trend toward an increased in-hospital mortality rate for those patients that does not appear to be related to more severe pre-PTCA characteristics. This trend does correlate with an increased prevalence of severe hemodynamic compromise in patients needing emergent operation and has occurred despite increased use of intraaortic balloon pump support.


   Introduction
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 Footnotes
 Abstract
 Introduction
Methods and Results
 Comment
 References
 
See also page 287.

Since its introduction in 1978 [1], percutaneous transluminal coronary balloon angioplasty (PTCA) has found an expanding role in the management of coronary atherosclerosis with well over 400,000 procedures performed in 1990. The role of emergency coronary artery bypass grafting in treatment of acute PTCA failure has been well documented [2–13]. Although increased experience with PTCA has been associated with a decrease in the proportion of patients undergoing PTCA who receive emergent surgical intervention, patients who do require emergency operation represent a complex segment of the surgical population [14]. This study evaluates a 10-year experience with 253 patients undergoing emergency operation for acute failure of balloon angioplasty.


   Methods and Results
Top
 Footnotes
 Abstract
 Introduction
 Methods and Results
Comment
 References
 
Patient Population
During the interval from January 1, 1980, through December 31, 1990, 9,145 patients at The Cleveland Clinic Foundation underwent isolated PTCA. There were 253 patients (2.8%) who experienced failure of balloon angioplasty and underwent emergency surgical revascularization within 24 hours of the procedure. These patients were divided into two cohorts based on the year of PTCA. One cohort consisted of 109 patients treated from 1980 through 1985 whereas the other contained 144 patients treated from 1986 through 1990. The pre-PTCA patient demographics are listed in Table 1Go. Age, sex, hypertension, diabetes, history of myocardial infarction, previous open heart operation, left ventricular function, and extent of disease did not differ between the two periods. However, there was a trend toward an increasing proportion of patients with double- and triple-vessel disease in the later years. The significant differences were more patients with a previous PTCA and more with class III or IV symptoms in the more recent period (p < 0.05).


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  		Table 1. . Patient Characteristics
 
Angiographic Indications for Operation
The causes of angioplasty failure were similar during the two intervals (Table 2Go). The most common cause was dissection of the coronary artery (42.2% in the early period and 45.1% during the later years), followed by acute occlusion (24.8% versus 29.9%) and failure to dilate (16.5% versus 14.6%) (all p = not significant). Aside from these three types of events, 16.5% of patients in the early years and 10.4% in the later period experienced a variety of other events leading to emergency operation including technical problems with catheter placement, balloon rupture, and formation of thrombus at or near the angioplasty site.


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  		Table 2. . Angioplasty Failure—Anatomic Findingsa
 
Immediate Preoperative Clinical Status
Patients were subgrouped and analyzed with respect to their clinical status during the time between recognition of PTCA failure and initiation of operation (Table 3Go). The clinical status was considered to be ``stable'' if the systolic blood pressure was greater than 90 mm Hg and ``unstable'' if less than this value. Within the stable group were two further subsets. The ``urgent'' patients had angiographic indicators of PTCA failure as the dominant feature although this was frequently accompanied by intermittent angina. The ``angina'' patients had persistent, unrelenting chest pain as the prime feature of their clinical status. The ``unstable'' group consisted of three subsets. Patients in the ``shock'' subgroup had a systolic blood pressure less than 90 mm Hg but did not have cardiac arrest. Patients in the ``arrest'' subgroup had experienced full cardiac arrest but had been resuscitated by the time they reached the operating room. Third, and most compromised, were ``cardiopulmonary resuscitation'' patients for whom active mechanical resuscitation was in progress at the initiation of operation. In the early years 12.8% (n = 14) were in ``shock/arrest/cardiopulmonary resuscitation'' versus 22.2% (n = 32) in the later years (p = 0.05). Use of the intraaortic balloon pump changed from 12.8% (n = 14) of patients in the early era to 32.6% (n = 47) of patients in the later era. The difference was in the incidence of preoperative intraaortic balloon pump use in the angiography suite, which increased from 9.2% to 25.7% from the early to later eras (p = 0.001).


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  		Table 3. . Preoperative Clinical Status
 
Surgical Strategies
Prompt institution of cardiopulmonary bypass (CPB) using moderate hypothermia, cold cardioplegia, and standard surgical techniques was employed. Retrograde cardioplegia was introduced in the later years of this study and has become standard practice. The number of bypass grafts constructed increased significantly from 2.0 grafts/patient in the early years to 2.5 grafts/patient in the later years (p < 0.01). Use of the internal thoracic artery was 17% in the earlier years and 22% in the later years (p = not significant). The mean units of red blood cells transfused rose from 4.0 to 7.1 units between the two intervals; in addition, the absolute number of patients receiving transfusions increased from 64.2% (n = 70) to 81.3% (n = 117) (p < 0.01).

Morbidity
The incidence of respiratory failure defined as inability to wean from ventilator support more than 48 hours postoperatively was 7.3% and 11.8% in the two intervals. Renal failure necessitating dialysis or some form of ultrafiltration was 2.8% and 4.9%. Stroke occurred in 11.1% and 5.8% of patients. Perioperative myocardial infarctions defined as elevation of serum glutamic-oxaloacetic transaminase level to more than 150 mg/dL, creatine kinase-MB fractions greater than 10%, and new electrocardiographic evidence of myocardial infarction was 21.1% and 20.8%. None of these differences were statistically significant. The occurrence of complications relative to preoperative hemodynamic status differed significantly. Among the ``urgent but stable/unstable angina'' category, 28.2% had any hospital morbidity compared with 65.2% in the ``shock/arrest/cardiopulmonary resuscitation'' category (p < 0.01).

Mortality
In-hospital mortality was 4.6% (5/109) in the early years and 7.6% (11/144) in the later years. The trend toward higher mortality in the later years did not attain statistical significance. Preoperative clinical status was significantly related to hospital mortality, 28.3% (13/46) for patients in the unstable category versus 1.4% (3/207) for stable patients (see Table 3Go). Mortality according to period for stable patients was 1.1% (1980 to 1985) versus 1.8% (1986 to 1990) and for unstable patients was 28.6% (1980 to 1985) versus 28.1% (1986 to 1990). A univariate analysis of factors influencing hospital mortality revealed that only the history of previous PTCA (p = 0.05) and preoperative clinical deterioration (p < 0.01 using Fisher's exact test) were significant. Factors that did not influence mortality included history of myocardial infarction, extent of disease, left ventricular dysfunction, year of procedure, New York Heart Association functional class, previous open heart operation, and use of the internal thoracic artery for bypass grafting. Mortality rates according to the vessels dilated were as follows: left anterior descending artery, 8/139 (5.8%); circumflex, 8/57 (14%); right coronary artery, 1/118 (0.8%); and multivessel disease, 1/25 (4%) (p = 0.009). Of the 16 hospital deaths (6.3%), 10 were due to cardiac failure, 5 were due to multiple systems failure, and 1 was due to neurologic causes. Of these hospital deaths, 81% (n = 13) were in patients who were unstable preoperatively. The one neurologic death was in a patient with acute occlusion of the left anterior descending coronary artery and subsequent cardiac arrest en route to the operating room from which he was resuscitated.

Late Survival
Follow-up was 100% complete at a mean post-operative interval of 69.7 months. For patients discharged from the hospital, 5-year survival was 95% and 91% for the early and later eras (p = not significant), with overall 93% survival (Fig 1Go). Event-free survival defined as no subsequent interventions, reoperations, nor myocardial infarctions did not have a statistically significant difference between the time intervals (Fig 2Go). It was 90% for the early years and 86% for the later years with an overall 87.8% event-free survival.



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  		Fig 1. . Survival curves show no significant difference (N.S.) in 5-year survival at 95% for the early years and 91% for the later years.

 


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  		Fig 2. . Event-free survival curves show no significant difference (N.S.) in 5-year survival at 90.3% for the early years and 85.5% for the later years. Event-free survival was defined as no subsequent interventions, operations, or myocardial infarctions.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Methods and Results
 Comment
References
 
There has been some evolution in the spectrum of patients being treated nationally with balloon angioplasty in the direction of patients with multivessel disease and having had either previous PTCA or a previous bypass operation [14]. However, in this study of patients undergoing emergent operation the only patient-related descriptors that occurred with increasing frequency in the more recent period were a history of PTCA and class III and class IV symptoms. Relatively early in the PTCA experience at our institution a substantial number of patients with left ventricular dysfunction and patients who had undergone previous bypass operations were undergoing PTCA, accounting in part for the lack of change in those descriptors with time.

At most major institutions the incidence of emergent operation after PTCA is 2% to 5%, figures in close agreement with the 3.8% and 2.5% incidence of emergent operation during the two periods at our institution. However, although there was a trend toward a decreasing incidence of emergent operations after PTCA there was also a trend toward an increased mortality (4.6% to 7.6%) for the patients who did undergo emergency operation despite increased surgical experience and new techniques for myocardial protection, most particularly the use of retrograde coronary sinus cardioplegia and blood cardioplegia.

This trend toward increased mortality did not seem to be based on higher risk patient-related characteristics that were present before PTCA but it was associated with an increased number of patients in an unstable condition after angioplasty. The risks of emergent operation relative to the degree of hemodynamic instability appeared to be the same in both periods, but there were more unstable patients during the 1986 to 1990 interval. This was true despite a significant increase in the deployment of the intraaortic balloon pump in the more recent period and, in particular, the more frequent placement of the intraaortic balloon in the cardiac catheterization laboratory.

It seems obvious that at least part of the price for the decrease in the number of patients undergoing emergent operation after PTCA has been a higher risk for the patients who do end up going to operation. The cause of death after operation has been almost entirely due to cardiac failure acutely or the sequelae of cardiac failure. It appears that once acute occlusion of a vessel has occurred that effective and rapid reperfusion is essential, and intraaortic balloon placement is, by itself, often not sufficient to salvage enough myocardium.

The advent of the concept of performing PTCA supported with CPB has brought another option for the management of patients with failed angioplasty. One argument in favor of the use of CPB in the management of PTCA failure is that circulatory support may preserve end-organ function for patients who do not have effective cardiac output, and avoid late death from complications such as stroke or renal failure. However, only 1 patient during this 10-year time frame died of a neurologic event, and although 4 patients died of multisystems failure, those patients also had continued compromise in their cardiac function after operation. Therefore, it is not clear that temporary CPB support between PTCA and operation would have prevented those problems. A second argument in favor of CPB support is that reduction of myocardial infarct size might be possible with a subsequent decrease in the mortality associated with PTCA failure. An argument against the use of CPB-supported PTCA is that interventional cardiologists might derive a false sense of security from the presence of CPB and prolong the ischemia of jeopardized myocardium in attempts to stabilize the vascular anatomy rather than proceed urgently to operation. It is not yet clear how the interaction of the advantages and disadvantages of CPB support for PTCA will influence risk.

A striking finding of this review was the high mortality rate associated with emergent operations for failure of a circumflex angioplasty. This is surprising, and the reasons for it are not clear. Possible explanations include the possibility that some of these patients may have experienced some vascular accident involving the left main coronary artery and prolonged attempts on the part of interventional cardiologists to avoid sending these patients to operation.

The use of the internal thoracic artery for only 22% of patients even in the 1986 to 1990 time frame is an obvious departure from our policy for patients undergoing bypass grafting in other circumstances. In addition to severe hemodynamic instability, ongoing ischemia noted by electrocardiography or intraoperative echocardiography and uncertainty about the post-PTCA coronary anatomy were the most common relative contraindications to internal thoracic artery use. For unstable patients dissection of the internal thoracic artery once cannulation and CPB has been established is possible, but for patients who have suffered an acute vessel occlusion institution of CPB does not necessarily eliminate ischemia.

Our conclusion from this review is that despite improved surgical techniques and experience, the risk of emergent operation for acute PTCA failure has not decreased and that effective and rapid reperfusion, either percutaneously or with more prompt emergency operation, is likely to be necessary to decrease the mortality rate.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Methods and Results
 Comment
 References
 
Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31–Feb 2, 1994.

Address reprint requests to Dr Lytle, The Cleveland Clinic Foundation, F25, 9500 Euclid Ave, Cleveland, OH 44195.


   References
Top
 Footnotes
 Abstract
 Introduction
 Methods and Results
 Comment
 References
 

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