title: Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.
abstract: Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.
authors.affiliation: Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: J M
authors.initials: JM
authors.lastname: Craver
authors.forename: W S
authors.initials: WS
authors.lastname: Weintraub
authors.forename: E L
authors.initials: EL
authors.lastname: Jones
authors.forename: R A
authors.initials: RA
authors.lastname: Guyton
authors.forename: C R
authors.initials: CR
authors.lastname: Hatcher
mesh_terms: D000206:Actuarial Analysis; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass / Q000401:mortality; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007423:Intra-Aortic Balloon Pumping / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D012307:Risk Factors; D013997:Time Factors