A profile of candidates for repeat myocardial revascularization: implications for selection of treatment.
OBJECTIVE
It is not known whether the results of randomized trials comparing coronary artery bypass grafting to percutaneous transluminal coronary angioplasty for initial revascularization apply to repeat revascularization in patients with prior bypass grafts. We studied the differences between the patients with prior bypass grafts referred for surgery or angioplasty to identify the clinical and angiographic characteristics that correlated best with either choice and to find clues that might aid in selecting one treatment over the other.


METHODS
Between 1992 and 1994, 870 patients underwent first isolated reoperation and 793 patients underwent first balloon angioplasty after a previous operation. A jeopardy score (0 to 8 points) was derived for each patient on the basis of the relative size of the ischemic territory. Clinical and angiographic data were analyzed for association with the revascularization strategy.


RESULTS
The following characteristics were more prevalent in the reoperation group: male sex, diabetes, hypertension, valvular disease, normocholesterolemia, and severe left ventricular systolic dysfunction; fewer functioning venous and arterial grafts; and a higher jeopardy score (p < 0.01 for all) than in the angioplasty group. A higher jeopardy score, diabetes, and a lower number of functioning arterial or venous grafts were strong, independent predictors of referral for reoperation (p < 0.01 for all). In hospital death and Q-wave infarction (p < 0.01 for both) were more frequent in the reoperation group.


CONCLUSIONS
Reoperation was the revascularization procedure of choice when larger regions of myocardium were in jeopardy. Angioplasty was more frequently chosen in the presence of a patent arterial graft to the left anterior descending coronary artery or multiple functioning bypass grafts. Reoperation was associated with a higher risk of in-hospital complications than angioplasty.
Brener
S J
SJ
Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
Loop
F D
FD
Lytle
B W
BW
Ellis
S G
SG
Cosgrove
D M
DM
Topol
E J
EJ
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D003251:Constriction, Pathologic; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003657:Decision Making; D018450:Disease Progression; D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications / Q000601:surgery / Q000628:therapy*; D012086:Reoperation; D012307:Risk Factors