Comparison of coronary artery bypass surgery and percutaneous transluminal coronary angioplasty including surgery for failed angioplasty

Abstract

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease and has thus redefined candidates for coronary artery bypass surgery. During our first years of experience with percutaneous angioplasty, 339 patients underwent the procedure and were compared with 338 patients who underwent isolated coronary artery bypass surgery. Patients who underwent PTCA had a shorter duration of angina and a lower number of prior myocardial infarctions and were found to have better left ventricular function ( p < 0.01). PTCA was considered initially successful in 87% (295 of 339) of patients. The most common finding at operation in those with failed angioplasty who underwent urgent or emergency revascularization was dissection of atheromatous plaque. Although the cumulative frequency of new Q waves in the entire 18-month angioplasty series was low (2.7%), the incidence was high (18%) in those with angioplasty failure and subsequent operation (N = 20) and significantly greater than in patients who had elective coronary artery bypass surgery (3.6%). Use of inotropic agents and lidocaine for ventricular arrhythmias was significantly higher in patients with unsuccessful PTCA who required operation than in those who underwent elective bypass surgery (10% vs 3% and 10% vs 1.5%, respectively; p < 0.01). In an analysis of our entire experience between October 1980 and June 1982, 777 patients who had PTCA and 2068 patients who underwent coronary artery bypass surgery were analyzed for differences in clinical complications and early outcome. Patients who had coronary artery bypass surgery were significantly older and had a higher incidence of hypertension (46% vs 32%), more multivessel disease (80% vs 12%), and more left ventricular dysfunction. Emergency coronary artery bypass was required in 5.3% of patients following PTCA. There were no deaths following the angioplasty procedure and nine deaths in 1162 patients who underwent coronary artery bypass surgery between 1980 and 1981 (hospital mortality, 0.8%). Facilities and staff available for expedient revascularization accounted for the low morbidity and lack of mortality in PTCA failures.