(Fig. 1A). The patient did not complain of chest pain, and there were no electrocardiographic changes. Ten minutes after injecting 100 ,ug glyceryl trinitrate and 0-2 mg nifedipine in the pulmonary artery repeat angiography was performed. The narrowed segment in the vein had disappeared (Fig. 1B)
SUMMARY During the period between October 1980 and December 1982, percutaneous transluminal angioplasty of stenosed aortocoronary bypass grafts was attempted 44 times in 31 patients who had developed disabling angina pectoris four months to seven years after coronary bypass surgery. The primary success rate was 93%. Two (4-5%) patients developed myocardial infarction related to the procedure. No emergency aortocoronary bypass surgery was required and there was no mortality. Although the primary success rate was high, the incidence of recurrence after one or more angioplasties was 50%/o. Despite this recurrence rate the condition of 10 of the first 16 (62%) patients was clinically improved after a mean follow up of 26 months.Recurrence of angina in patients after aortocoronary bypass graft surgery is related to graft occlusion or stenosis or to progression of coronary artery disease. The management of such patients has been either conservative or by repeat cardiac surgery. Percutaneous transluminal angioplasty has been used as an alternative to repeat cardiac surgery for stenoses in the native coronary arteries as well as in the bypass grafts. This report deals exclusively with our experience of percutaneous transluminal angioplasty of stenosed bypass grafts. Patients and methodsBetween October 1980 and December 1982 we attempted percutaneous transluminal angioplasty of stenosed aortocoronary bypass grafts 44 times in 31 patients. These patients had developed disabling angina pectoris four months to seven years after coronary bypass surgery. The procedure was attempted in 26 left anterior descending grafts, 13 right coronary artery grafts, and five circumflex artery grafts. Angioplasty was performed using the technique described by Gruntzig et al. I A preformed guiding catheter (8 or 9F, Schneider Medintag or USCI) was used to insert the grafts. The following types (Fig. 1)
Seventy-two patients with stable or unstable angina treated since 1983 by multivessel-PTCA(MVP) were retrospectively compared with 44 similar patients that were suitable for MVP, but who had undergone bilateral mammary artery (BIMA) surgery (and additional vein grafts in 60.5% of the patients) since 1986. Both groups were comparable (P = not significant [NS]) for gender, age, most risk factors, objective ischaemia and left ventricular function; however, in the BIMA group there were more previous infarctions (P = 0.02), hypertension (P = 0.03), three-vessel disease (P = 0.0001), and less severe angina (P = 0.007). In the BIMA group, a mean of 3.1 (range 2-5) vessels were treated and in the MVP group 2.0 (range 2-3) vessels (P = 0.0001). Both groups were almost completely revascularized (NS). In 39.5% of the BIMA group, no veins were used and in 20.9% the BIMAs were used as sequential grafts. In-hospital mortality was comparable: 2.3% for BIMA and 1.4% for MVP, so were periprocedural infarctions (13.6% vs 8.3%), rethoracotomies (9.1% vs 0%), emergency procedures (0% vs 5.7%), low cardiac output (2.3% vs 5.6%) and other complications (18.2% vs 9.2%). The mean stay (days) on the ICU/CCU for BIMA was 2.3 and for MVP 1.6 (P = 0.005) and the mean hospital stay for BIMA 12.3 and for MVP 6.6 (P = 0.0001). The maximum and mean follow-up (months) of 43 BIMA and 71 MVP hospital survivors was 35 vs 72 and 9.5 vs 22.3 (P = 0.0001) with a late mortality of 0% and 4.2% (NS). MVP patients, including 12 with re-procedures, had more recurrent angina (17.7% vs 4.7%, P less than 0.05) and more often used anti-anginal medications (62.0% vs 18.6%, P less than 0.0001). Late complications (excluding re-procedures) were comparable for MVP and BIMA (20% vs 9.3%, 4.4% vs 0%, 9.2% vs 14%). MVP patients had more re-hospitalizations (34 vs 5, P less than 0.0001), re-catheterizations (33% vs 2.3%, P less than 0.0001) and cardiac re-procedures (16 vs 0, P = 0.0006) than BIMA patients. Recurrent-angina-free survival at 1 year was 96% after BIMA and 64% after MVP (P less than 0.01). Event-free survival at 1 year was 86% after BIMA and 58% after MVP (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)
From 1972 to 1979 intra aortic balloon pumping (IABP) was attempted in 181 patients; catheter insertion failed in 13 (8%). More complications occurred with prolonged treatment but all three lethal complications (2%) were related to catheter insertion. Seventy-six patients had clinical cardiogenic shock after myocardial infarction (CSM1). Haemodynamically, 23 were classified as preshock: 15 (66%) could be weaned, 12 (53%) survived over 3 months; whereas only 27/51 patients (51%) haemodynamically classified as shock could be weaned and 21 (40%) survived over 3 months. Of forty-two patients with refractory angina at rest, 41 had prompt relief of pain after IABP, and subsequently underwent coronary artery bypasss grafting (CABG). Perioperative infarction rate was 8% (4/41), perioperative mortality was 7% (3/41). Total infarction rate was 11% (5/42), and total mortality 7% (3/41). Pain relief was prompt in 14/17 patients (82%) with refractory angina after infarction. Pain persisted in three patients: all three sustained an infarction, one died. Two patients were excluded from surgery. Twelve patients underwent CABG; none died, none developed MI. In eight patients persistence of pain suggested a slowly evolving MI, IABP abolished pain in seven. Conclusion: IABP has demonstrated its efficacy both in pump failure and in refractory ischaemia. However, its use is not without risks. The effect of intra aortic balloon pumping (IABP) is which is related to myocardial oxygen consumptwofold!'!. The abrupt presystolic balloon deflation tiont 1 ' 4 ! is termed the endocardial viability ratio decreases afterload, while the post systolic balloon (EVR)t'l. EVR has been regarded a reflection inflation enhances coronary perfusion pressure, of this balance between oxygen availability and which is the major determinant of coronary blood consumption, flow in the presence of critical stenosis! 2 " 3 L The clinical use of IABP has been advocated for Reduction of afterload increases stroke volume cardiogenic shock following acute myocardial inand ejection fraction, and decreases wall tension farction (CSMI) and severe left ventricular failure and preload, and thus oxygen consumption. It has (LVF) after acute infarction! 5-14 1, with and without even been suggested, that counterpulsation may mechanical defects, for angina pectoris at rest open dormant collateral channelsl'l, and that IABP completely refractory to medical therapy! 15-16 1, for increases flow to the subendocardium by augment-severe LVF and cardiopulmonary bypass depening existing collateral circulation!'!. dence following open heart surgery!' 7 !, for LVF of Afterload reduction reduces oxygen demand; varying aetiological background!' 8 !, for life threatdiastolic augmentation increases oxygen avail-ening cardiac arrhythmias refractory to antiarrhyability. The ratio of the Diastolic Pressure Time thmic therapy, and as a supportive measure Index (DPTI) representing myocardial blood in critically ill cardiac patients undergoing major flow!'!, and the Systolic Time Tension Index (...
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