Left Main Stem Stenosis Research Articles

Risk factors for early and late mortality in surgical treatment of coronary artery disease

A total of 1025 patients who had coronary bypass surgery at the Surgical Department A, Rikshospitalet, Oslo, between 1982 and 1986, were analysed for factors associated with early mortality and long-term survival. The cumulative follow-up time accounted for 6553 patient-years; the median follow-up was 6.45 years and ranged from the day of admission to 10 years. In total, 31 patients (3%) died within 30 days of surgery. Some 30 possible risk factors were analysed. Univariate analysis followed by a multivariate analysis defined six independent risk factors for early mortality. These were lack of sinus rhythm, previous heart surgery, mitral regurgitation, left main stem stenosis, unstable angina, and an elevated left ventricular end-diastolic pressure. Estimation of attributable risk showed that these factors could identify all patients who died early. Independent risk factors for late death were: lack of sinus rhythm, resection of a left ventricular aneurysm, left main stem stenosis. New York Heart Association (NYHA) class IV on admission, an elevated end-diastolic pressure, and prolonged cross-clamping time. The attributable risk analysis showed that independent risk factors for total mortality explained only about half of the patients who died. This appeared to be because of the competing effect of non-cardiac mortality. Results of the study show that risk factors for early mortality are good indicators for the outcome of coronary artery bypass surgery, identifying all deaths, whereas long-term mortality cannot be predicted. Stratification of independent risk factors allows a better comparison of mortality in different centres, and also better quality control of bypass surgery.

Correlation of Clinical and Electrocardiographic Variables with Coronary Lesions in Unstable Angina Pectoris

The relation of clinical and electrocardiographic variables to the severity of coronary lesions in unstable angina was studied in 84 men and 8 women, aged thirty-nine to seventy-five, who were subjected to coronary arteriography within two weeks. Eighty-seven patients (94.6%) had significant stenosis (50% of the diameter) of at least one vessel, whereas 5 (5.4%) had normal coronary arteries. Eleven (12%) had one-vessel disease, 13 (14%) had two-vessel, and 63 (68.5%) had three-vessel disease. Twelve (13%) had also significant left main stem stenosis. Except for 1 patient with artificial pacemaker, three-vessel and/or left main stem disease was present in 20 (100%) patients with ST segment deviation > or = 0.2mV as compared with 20 of 36 patients (55.5%) with ST segment deviation of 0.1-0.19 mV and 24 of the 35 (68.6%) with no additional ECG changes or with T wave inversion only (P < 0.005). The direction of ST segment deviation (elevation or depression) made no difference. Preexisting angina or infarction was associated with three-vessel disease and/or left main stem disease in 74.1% and 81.4%, respectively, as compared with 45.5% (P = 0.05) of the patients with angina of recent onset. Pain at rest persisting for more than forty-eight hours was associated with three-vessel and/or main stem disease in 93.1% of the patients as compared with 60.3% of patients in whom rest angina subsided within forty-eight hours (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperative Myocardial Revascularization: An Analysis of 458 Reoperations and 2645 Single Operations

A consecutive series of 2645 patients underwent primary coronary bypass grafting while 4S8 patients underwent reoperative bypass during a 9-year period. The mean age (61 years), sex distribution (83% men) and preoperative risk factors were identical in the two groups. Significantly more patients belonged to New York Heart Association (NYHA) class 4 and were clinically unstable in the reoperative group ( P&lt; 0.001). The internal mammary artery was used in 43% of the single operation group but in only 23% of patients who subsequently required reoperation (P&lt; 0.001). In reoperations 61 % of the patients had an internal mammary artery graft (P&lt; 0.001). The overall operative mortality rate for single operation was 2.3% (62/2645) versus 9.2% (42/458) for reoperations. Patients with a reoperative interval of more than 1 year had a 8.4% mortality rate, compared with 28% in those reoperated on 1 year or less after the initial operation (P&lt;0.01). Preoperative myocardial infarction, intra-aortic balloon pump insertion, prolonged ventilatory support and ventricular arrhythmias were all prevalent after reoperations (ail P&gt; 0.001), while postoperative myocardial infarctions and re-sternotomy for bleeding did not differ between the groups. Emergency operation, preoperative NYHA class 3–4 and poor left ventricular function were predictors of perioperative mortality in both groups. Left main stem stenosis was an added factor in the reoperative group. After reoperation 93% of the hospital survivors were alive at 5 years after surgery; the cardiac event-free rate was 59% and &gt; 90% of the patients showed improvement of their NYHA class during the follow-up. Reoperative coronary artery bypass grafting is effective, but has an Increased operative mortality and morbidity, especially in patients with unstable angina, left main stem stenosis and poor preoperative left ventricular function.

Sténose bronchique récidivante au cours d'une granulomatose de Wegener : Obtention d'une rémission prolongée après traitement local par laser, endoprothèse et radiothérapie, par l'association corticoïdes-cotrimoxazole

We report a case of relapsing endobronchial left mainstem stenosis occuring in the course of treated Wegener's granulomatois. Long-sterm local remission was achieved after local therapy including endobronchial laser plus endoprothesis, radiation therapy and combination of corticosteroids and cotrimoxazole.

Degree of coronary artery disease predicted by exercise testing

The ability of exercise testing to predict the extent of coronary artery disease was examined in 268 male patients undergoing both coronary angiography and bicycle testing with electrocardiography before coronary artery bypass surgery. When maximal ST-depressions limited by symptoms increased from 0 to 4 mm or more, the percentage of patients with 'serious' coronary disease, defined as either triple vessel disease or left main stem stenosis, increased from 50% to 80% (P = 0.0001). The patients in the lowest third of physical work capacity showed only a slightly increased risk of serious disease. This tendency was abolished in patients who were using beta-blockers, whereas the relationship between ST-depression and disease was not affected by this medication. The probability of finding left main stem stenosis in a patient increased from 5 to 30% with increasing ST-depression: beta-blockers did not affect this relationship, but there was no additional predictive effect of implicating the level of physical work capacity. It is concluded that traditional electrocardiography during exercise is of value when selecting patients for angiography, but that the physical work level obtained during the test does not predict the degree of coronary pathology.

PTCA of the left main stem following protective coronary artery bypass grafting

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. Restenosis had occurred in 3 of 8 patients (38%) with total occlusion of the left main stem in 1 patient. All bypass grafts were found to be patent at follow-up. Clinical evaluation in all 14 patients revealed no serious events (death, myocardial infarction, repeat revascularization procedure) during a mean follow-up period of 27 months (range 6-39 months). PTCA of the left main stem following CABG can be considered a relatively safe and effective procedure with a marked restenosis-rate but beyond that, an uncomplicated long-term follow-up.

Early mortality after 2 902 coronary artery bypass operations

A review of 2,902 coronary artery bypass grafting operations is presented. During the 16-year study period the mean patient age rose from 51 to 59 years and the average number of grafts per patient from 1.5 to 3.0. There were 81 early deaths (2.8%, the most common cause being myocardial infarction (68%). Left main stem stenosis was present in 23 of these 81 patients and depressed left ventricular function in 30. Compared with the survivors, the deceased patients were characterized by higher age, proportionately large numbers of women, combined procedures and reoperations and less use of internal mammary artery grafts. Of the 94 patients aged greater than or equal to 70, 11 died (12%). The perioperative mortality was significantly greater (p less than 0.05) in women than in men (20/457 vs. 61/2445 viz. 4.4% vs. 2.5%). Combined operations were associated with 8.7% (27/311), reoperations with 6% (6/101) and coronary endarterectomy with 5% (4/75) early deaths. In the last year of the study there were three early deaths among 359 patients (0.8%) who underwent primary isolated coronary bypass grafting without endarterectomy. The perioperative risks fell steadily during 16 years, despite rising proportions of older patients, combined procedures, reoperation and coronary endarterectomy.

Coronary endarterectomy--angiographic and clinical results.

Of 75 patients who underwent coronary endarterectomy, 16% had left main stem stenosis, 4% one-vessel, 27% two-vessel and 53% three-vessel disease. On average 2.9 grafts per patient were inserted, in conjunction with 82 manual endarterectomies (38 right coronary, 35 left anterior descending, 9 circumflex branches). In 68/75 cases (91%) the endarterectomy was not preplanned and in 39 cases (52%) greater than or equal to 3 cm of the atherosclerotic core was removed. All four early deaths (5%) followed endarterectomy of LAD. Acute perioperative myocardial infarction was confirmed in 19% and probable in further 8%. At angiography 1-139 (median 25) months postoperatively, all three internal mammary artery grafts and 19/34 saphenous vein grafts (56%) to endarterectomized vessels were patent, though in 4 of the 19, the coronary artery was occluded distal to the anastomosis. In addition 17/18 conventional internal mammary artery (94%) and 48/59 conventional saphenous vein grafts (81%) were patent. The vein graft patency rate was not significantly influenced by postoperative anticoagulant therapy, but was significantly increased among patients with relief of angina: 44% reported freedom from angina and 92% at least some relief after a median of 3 years. The 5-year and 10-year survival rates were 85% and 68%. Despite the increased risk, endarterectomy can be recommended for severely diseased major coronary arteries.

Indications in angina pectoris--surgical therapy

Operation must be performed: in patients with postinfarction VSD or mitral insufficiency, with unstable angina and left mainstem stenosis, evolving infarction after PTCA. Operation should be performed: in patients with therapy resistant angina and 3 and 2-VD. Operation can be performed: if coronary angiography demonstrated localised diseases and poststenotic myocardial ischemia. Operation is contraindicated: in patients with endstage malignant diseases, acute infections and 4 h after onset of myocardial infarction?

Relationship between the degree of coronary artery disease and of left ventricular function and the duration of the QT-interval in ECG.

Advanced coronary artery disease (CAD), impaired left ventricular function and prolongation of the QT-interval are considered risk factors for sudden cardiac death in CAD-patients. So far, however, there are no studies investigating in detail whether there is a correlation between the QT-interval and changes in coronary anatomy or changes in left ventricular function. Therefore, coronary angiographic data were related to QT-intervals in 304 patients, who were catheterized because of suspected coronary artery disease. QT-intervals were expressed as QTc = QT/square root RR (Bazett's correction for heart rate), left ventricular function was assessed by the ejection fraction of the ventricular angiogram, and coronary angiograms were classified according to the Gensini score as well as into 1-, 2- and 3-vessel disease (stenoses greater than or equal to 50%). A multidimensional linear regression model was employed to eliminate the effects of varying mean rates still present after application of Bazett's formula. In patients with 1-, 2- and 3-vessel disease, significant changes of QTc were observed only in patients with impaired left ventricular function (EF less than 60%). In these patients the QTc-interval increased significantly from 1- to 3-vessel disease. If the critical degree of coronary stenosis was changed from greater than or equal to 50% to greater than or equal to 90% further prolongations of QTc were noted. In patients with 1-, 2- and 3-vessel disease the QTc-duration difference was further enhanced if either the proximal part of the descending branch of the left coronary artery (LAD) or the left main stem were affected (stenoses greater than or equal to 50%). The data reveal that prolongation in the duration of electrical systole correlates with known cardiac risk factors for sudden death, i.e. 3-vessel-disease, proximal LAD or left main stem stenosis and impaired left ventricular function. In the individual patient, however, the prognostic value of a single QTc-determination is limited because of a large interindividual variation of the data.

Unstable angina: A clinicoarteriographic correlation and long-term results of early myocardial revascularization

Between June, 1973, and June, 1978, 71 patients with unstable angina underwent emergency coronary artery bypass grafting. Fifty-four patients (76%) gave a previous history of stable angina. Seventy patients (99%) were found to have left main-stem stenosis or severe disease in the anterior descending artery proximal to the first septal branch. Intra-aortic balloon counterpulsation was instituted prior to angiography in 12 patients and in a further nine patients prior to induction of anesthesia as a result of intractable and continuous angina. There were no deaths associated with investigations. All patients underwent operation within 48 hours of admission to hospital. A total of 188 grafts were inserted (2.7 grafts per patient). There were three early deaths (4.2%) and two late deaths (2.8%) during a follow-up period varying between 6 and 62 months (mean 29 months). Actuarial analysis showed a 92% survival rate at 4 years. Five patients (7%) sustained perioperative infarction and four patients (5.9%), late myocardial infarction. All patients were symptomatically improved following operation and 51 (80%) are entirely asymptomatic. Fifty-two patients were electively reinvestigated following operation at times varying between 2 weeks and 58 months (mean 20 months). The overall graft patency rate was 91%. Changes in left ventricular function were analyzed by computerized radial analysis of segmental wall motion in 39 patients. Significant improvement in segmental wall motion occurred in 14 (70%) of 20 patients with abnormal wall motion preoperatively and appeared to be closely related to graft patency. There was a significant increase in ejection fraction from a mean of 0.59 to a mean of 0.69 following operation. Patients with unstable angina may be safely investigated during the acute phase and subsequent revascularization may be undertaken with low early and late mortality rates. Intra-aortic balloon counterpulsation is a valuable adjunct to the management of these patients.

Left main stem coronary artery disease. Retrospective review of 26 patients treated surgically or medically.

The clinical, angiographic, exercise testing, operative, and follow-up data of 26 patients found at angiography to have left main stem coronary artery stenosis, defined as a reduction in the lumen diameter of 50% or more, are reviewed. There was a high incidence of significant proximal stenosis in the branches of the left main stem. No clinical features were found to distinguish patients with left main stem stenosis. All patients were considered for saphenous vein bypass grafting, selection being based upon the severity of symptoms, left ventricular function, and suitability of the coronary vessels for grafting. Two patients died within 24 hours of coronary angiography. Nine patients were operated on with no mortality. There has been one late cardiac death during a mean follow-up time of 13 months. All patients were symptomatically improved with a significant (P less than 0-01) increase in exercise ability postoperatively. Fifteen patients were not operated on. Six of these patients were regarded as operable but surgery was deferred; five have died at a mean time of 7-2 months. Five of the nine patients regarded as inoperable have died at a mean follow-up time of 14-8 months. The five non-surgical survivors remain symptomatic with no significant change in exercise ability. Recently reported surgical and medical series of patients with left main stem stenosis are reviewed.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center.

Objective:Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery.Methods:A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student’s t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference.Results:Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group.Conclusion:This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.