Multiple Vessel Disease Research Articles

Clinical characteristics affecting success or failure of PTCA in patients with multiple vessel disease and poor candidates for surgery

A special form of complex coronary angioplasty is represented by the extension of indications for percutaneous transluminal coronary angioplasty (PTCA) to patients with multivessel disease (MVD) for whom surgery is not indicated, and thus for whom surgical standby is not available. Over a two-year period, 254 consecutive coronary patients with multivessel disease underwent PTCA under such conditions. These patients could not benefit from surgery for various reasons. Of the 612 arteries involved, 155 were occluded, 47 had been previously bypassed. A distal nonbypassable lesion in one of the three major arteries was found in 244 patients, 61 had suffered from a previous infarct, 24 demonstrated an ejection fraction below 0.40, and in 19 a single patent vessel was found. Fifteen patients were in cardiogenic shock and 69 procedures were undertaken for unstable angina. Of this latter group, 25 emergency PTCA were attempted for refractory unstable angina, and 44 additional emergency procedures were directed to the treatment of acute infarct. A total of 40 intra-aortic counterpulsations were needed. As far as possible the procedure aimed at full revascularization. Immediate outcome is strongly affected by the clinical context, and despite a rather constant initial success rate (88-95%), the procedural mortality (directly related or not) can change dramatically with clinical factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined internal mammary artery graft for coronary artery revascularization

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.

Failed elective percutaneous transluminal coronary angioplasty requiring coronary artery bypass surgery. In-hospital and late clinical outcome at 5 years.

This study was performed to define the in-hospital and late clinical outcome at 5 years in 430 patients who had a failed elective percutaneous transluminal coronary angioplasty (PTCA) and underwent coronary artery bypass graft (CABG) surgery during their hospitalization. This group comprised 5.9% of 7,246 patients undergoing elective PTCA. CABG surgery was performed in 346 patients with ongoing myocardial ischemia (80.5%) and in 84 patients without ischemia (19.5%). Their mean age was 56 +/- 9 years, and 76.3% were male. One-vessel disease was present in 72.3%, and the mean left ventricular ejection fraction was 59 +/- 11%. Overall, 1.9 +/- 0.9 bypass grafts were placed. There was increased use of the internal thoracic artery in the nonischemic group. A new nonfatal postprocedural Q wave myocardial infarction occurred in 21.2% and occurred more frequently in the ischemic (25.4%) than in the nonischemic (3.6%) group (p less than 0.0001). There were six in-hospital deaths (1.4%), an incidence that did not differ between the two groups. Follow-up was 99.8% complete. There were 25 deaths (93.2 +/- 1.5%, 5-year survival), including 16 of cardiac cause (95.3 +/- 1.3%, 5-year cardiac survival). Q wave myocardial infarction occurred in 111 patients (91 in-hospital), and freedom from cardiac death or nonfatal myocardial infarction at 5 years was 71 +/- 3%. In the group going to CABG surgery with ongoing ischemia, the 5-year cardiac survival was 94.9 +/- 1.6%, and in the group without ischemia, the corresponding survival was 96.2 +/- 2.2%. By multivariate analysis, the presence of preoperative myocardial ischemia, pre-PTCA diameter stenosis less than 90%, and the presence of multiple-vessel disease correlated with the occurrence of cardiac death or nonfatal myocardial infarction at 5 years. At this large-volume center with extensive PTCA operator and surgical experience, the excellent survival and low event rates over 5 years support the concept that despite the failed elective PTCA procedure, there was little effect on long-term survival provided the patient underwent prompt successful surgical revascularization.

Coronary Angiography and Thallium-201 Single Photon Emission Computed Tomography in Multiple Vessel Coronary Artery Disease

Polar presentations of selective coronary angiography and myocardial 201Tl SPECT were compared in 141 patients with multiple vessel disease, 80 with 3-vessel disease, 34 with 2-vessel disease and 27 post-bypass patients. Perfusion defects were present in 125/141 patients (89%) and were located within the area supplied by 194/359 stenotic arteries (54%) and 9 non-stenotic arteries. The type and extent of disease was correctly indicated by 201Tl SPECT in 16/80 patients (20%) with 3-vessel disease, 5/34 patients (15%) with 2-vessel disease and 8/27 post-bypass patients (30%). Perfusion defects indicated the artery with the most severe lesion in 107/125 patients (86%). False negative isotope studies were present in 15 patients (11%).

Relationships between the lung-heart ratio assessed from post-exercise thallium-201 myocardial tomograms, myocardial ischemia and the extent of coronary artery disease

Uptake of thallium (Tl)-201 in the lungs has been proposed as a measure of left ventricular dysfunction. In this study we were interested in pursuing two goals: 1) to assess possible relationships between the post-exercise Tl-201 lung-heart (LH)-ratio determined from the anterior view during SPECT-acquisition, myocardial ischemia and the extent of coronary artery disease; and 2) to explore the effects of coronary revascularisation procedures on the LH-ratio. The study group consisted of 145 patients with early and late postexercise Tl-201 tomograms, including 32 PTCA-patients with pre- and post-PTCA studies and 20 patients who underwent coronary artery bypass surgery (CABG) with corresponding pre- and post-CABG studies. Ischemia was defined as evoked angina during the exercise test in combination with greater than or equal to 1 mm horizontal or downsloping ST-depression on the ECG. The severity of coronary obstructions was assessed from coronary angiograms with a PC-based digital caliper technique; a stenosis was defined to be significant when its severity exceeded 50% diameter stenosis. The LH-ratio was defined by the ratio of the mean pulmonary counts and the mean myocardial counts assessed from corresponding regions of interest (ROI's) positioned over the left lung and the heart, respectively in the anterior view of a tomographic data acquisition procedure. Our results made clear that the LH-ratio was not significantly different between patients with and without ischemia during exercise, and between patients with single vs. multiple vessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

A basis for determining body surface potential patterns attributable to single-site coronary arterial occlusion

The authors focus on computational separation of the individual patterns of occlusion of the major segments of the right coronary artery. The raw patterns of occlusion throughout 15 standard subdivisions of the coronary arterial tree and body surface isoarea maps for 8 consecutive 10-msec intervals of QRS were examined in 200 patients with known coronary artery disease. Mean patterns of occlusion and of potential distribution were formed into 15 groups according to which patients showed ≧90% occlusion of the respective segments. By diagonalization of the occlusion matrix, individual potential map patterns were obtained to represent the effect of isolated occlusion of each segment. While these patterns appeared consistent with the known anatomy of ventricular myocardial perfusion, further correlative, study will be needed. The authors suggest that the use of such prototypical patterns of single-site obstruction may be helpful in forming and assessing recognition patterns in the clinical setting of multiple-site, multiple-vessel disease.

Evolving applications of coronary angioplasty: Technical and angiographic considerations

Coronary angioplasty (PTCA) is now applicable to selected patients with multiple vessel disease, total occlusions, tandem lesions and complex branch disease. Operator experience and skill contribute to a high success rate in complex anatomy, but equally important is appropriate case selection based on angiographic review of lesion morphology, branches, extent of coronary artery disease, and left ventricular function. Likewise, during and after the procedure similar angiographic assessment is important to determine resultant lesion morphology, branch anatomy, distal runoff, and adequacy of lesion dilatation. Thus, the outcome of angioplasty is dependent on the operator's ability to opacify the coronary arteries with minimal or no vessel/lesion overlap or foreshortening. Although coronary angiography has become more routine for many angiographers with the advent of angioplasty, the importance of high-quality angiography continues to be a major component for successful angioplasty.

Improvement in cardiac performance and exercise tolerance after left ventricular aneurysm surgery--a prospective study.

Forty two patients were studied prospectively by rest and exercise radionuclide ventriculography before and after (10 +/- 4 months) left ventricular aneurysm resection. Functional classification (NYHA) improved from 3.0 +/- 0.6 to 2.3 +/- 0.5 (p less than 0.0001) with an increase in double product (p less than 0.01) and total exercise workload (p less than 0.04) over preoperative values. End-diastolic volume was significantly reduced (p less than 0.0001) and resting global left ventricular ejection fraction (LVEF) improved significantly (p less than 0.03) after surgery, as did regional ejection fractions of the lateral/inferior wall (p less than 0.01). Cardiac index (CI) at rest, however, remained unchanged. Under exercise, improvement of global (p less than 0.0003) and regional ejection fractions (p less than 0.02) was more pronounced and a significant increase was also observed for CI (p less than 0.003). Improvement in left ventricular performance occurred both in patients with single and multiple vessel disease, but was more distinct in the latter group who additionally received coronary artery bypass grafts. These patients were furthermore postoperatively able to increase global LVEF at exercise (p less than 0.05). We conclude that aneurysm resection with or without coronary bypass relieves cardiac symptoms and improves exercise tolerance and left ventricular function at rest and on exercise in most patients.

Systolic and diastolic alterations of left ventricular function: prevalence in ischaemic heart disease and importance in the management of individual patients.

Myocardial perfusion and contractile performance are strictly interrelated. Conclusive experimental data show that changes in perfusion cause immediate changes in function, and conversely, that changes in contraction affect both total and regional myocardial blood flow. In ischaemic heart disease, both transient and permanent changes in global and/or regional left ventricular (LV) function have been described. In myocardial ischaemia, an impairment of LV relaxation, as indicated by a reduction of negative dP/dt, is the first appreciable haemodynamic event. When ischaemia is sustained, impairment of LV contraction follows, as indicated by a drop of positive dP/dt, reduction of systolic LV pressure, rise of end-diastolic LV pressure. Unrestricted reperfusion, as in experimental coronary occlusion and in Prinz-Metal angina, is associated with a transient rebound in regional systolic function. Spontaneous and/or induced changes of regional ventricular function provide relevant information for the management of the individual patient. In PTCA candidates monitoring regional contractile performance by mono and two-dimensional echocardiography during dypiridamole infusion has proven to be a sensitive and specific test for (1) assessing the haemodynamic significance of a coronary stenosis in patients with single-vessel disease, (2) identifying the 'culprit' lesion in patients with multiple-vessel disease. During PTCA, right and left ventricular function assessed by radionuclide angiography both at rest and during atrial pacing appears to be a sensitive method for the immediate evaluation of the efficacy of the procedure.

Operative strategy in combined coronary and carotid artery disease

In the period between the opening of our heart center in November 1984 and May 1986, 2001 cardiac operations were performed with the aid of cardiopulmonary bypass. Almost three quarters (73.5%, n = 1471) of the patients had coronary artery disease and 20% (n = 359) had acquired valvular heart disease. In 47 of 1471 patients who underwent coronary artery bypass grafting, a simultaneous carotid endarterectomy was performed. They included 36 men and 11 women, aged between 51 and 78 years (mean 64 years). Preoperatively, 12 patients had cerebrovascular symptoms and 35 were neurologically asymptomatic. Twenty-three had unilateral carotid stenosis and 24 had bilateral or multiple vessel disease of the extracranial arteries. All except four patients had triple-vessel coronary artery disease. In three patients with aortic valve disease, coronary bypass, carotid endarterectomy, and aortic valve replacement were performed simultaneously. Cardiopulmonary bypass was instituted before carotid endarterectomy was performed, with mild hypothermia and hemodilution for added protection. Electroencephalographic monitoring was used throughout the operation. Forty-six of the 47 patients survived the operation without neurologic or cardiac complications. One patient had a neurologic deficit with hemiplegia and coma, which was lethal. We conclude that simultaneous endarterectomy of significant extracranial artery stenosis in candidates for coronary bypass is a method safe enough to justify its routine use.

Diagnostic accuracy of rest-exercise first pass ventriculography with a fast single crystal gamma camera in detecting coronary artery disease

Rest and exercise radionuclide ventriculograms were performed in 61 non infarcted, male, patients who underwent cardiac catheterization for chest pain and in 16 normal control subjects. Studies were performed using the first pass method with a fast single crystal gamma camera, which allowed a count rate of 140 +/- 19 Kcounts/sec to be reached during left ventricular filling; the count integral on left ventricular area was 10.8 +/- 1.6 Kcounts and the maximum count/pixel 155 +/- 16. We analyzed sensitivity, specificity, positive and negative predictive value of global ejection fraction (EF) and of the regional wall motion in identifying ventricular function abnormalities due to obstructive coronary artery disease. The regional wall motion was evaluated with four functional images: regional ejection fraction (REF), amplitude (A) and phase (PH) from Fourier analysis and systolic transit times (TT). Sensitivity was near 90% for EF, REF, A and TT, while PH was less sensitive (80%); all functional images were more specific (nearly 90%) than EF (80%). Both sensitivity and specificity were lower for the exercise EKG (59% and 63%, respectively) in this patient group. Significant differences between single vessel and multiple vessel disease were also observed either for the EF increase/decrease (-1.34 +/- 7.4 and -7.82 +/- 9.96; P less than 0.05) or for the number of segments which developed wall motion abnormalities during exercise (1.22 +/- 0.73 and 2.15 +/- 1.04; P less than 0.02). In conclusion, with our method, a fast single crystal gamma camera is suitable for obtaining optimal first pass radionuclide ventriculograms with a count density sufficient either for global or regional left ventricular function evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Variable neurohumoral and hemodynamic responses to exercise in patients with exertional angina: influence of the severity of coronary artery disease.

To assess neurohumoral and hemodynamic responses to exercise in patients with exertional angina, we measured plasma norepinephrine (NE) concentrations in 23 patients with exertional angina (with no heart failure) and compared the results with their coronary arteriographic findings. The 23 patients were divided into two groups: 14 cases with multiple vessel disease (MVD) and 9 cases with one-vessel disease. At resting state there were no significant differences between the two groups in levels of NE. At maximal exercise there were no significant differences between the groups in increases of heart rate, blood pressure, and rate-pressure product, but exercise-induced increase of plasma NE (%) was significantly larger in MVD (131.6 +/- 95.4%) (mean +/- SD) than in one-vessel disease (69.0 +/- 45.3%) (p less than 0.01). In conclusion, plasma NE responses to exercise differ between patients with multiple vessel disease and patients with one-vessel disease.

Mortality Trends in Cases of Elective and Emergency Aorto-Coronary Bypass after Percutaneous Transluminal Coronary Angioplasty

Between October 1977 and March 1986 82 emergency and 113 elective revascularizations (aorta-coronary bypass = ACB) were performed after complicated or unsuccessful PTCA (n = 1633). Mortality in emergency ACB was 10.9%, in elective surgery 1.2%. If permanent transmural ischemia after complicated PTCA is present, mortality was high (12.6%) and postoperative infarction rate 70%. In intermittent ischemia mortality was 5.1% and total recovery of the myocardium was 94%. Mortality in emergency ACB after PTCA was directly related to the number of diseased vessels. In single vessel disease mortality was 3.5%, in multiple vessels disease 28%.

Evaluation of coronary revascularization for ischemic heart disease: in the consecutive 200 cases.

The elective simple coronary revascularization in the last consecutive 200 patients were analyzed in this study. Despite of the increase in older patients who have more high risk factors, including low left ventricular ejection fraction (LVEF) and multiple vessel disease, there were no operative deaths in the second 100 patients. The use of calcium antagonist in patients with a history of spastic angina eliminated episodes of spastic angina in the perioperative period. In the late postoperative period, there were no cardiac deaths during the 7-year follow-up period. Angina remained in two of three patients with the patent grafts, who had a history of spastic angina. Hyperlipidemia and diabetes mellitus influenced occlusion of the grafts and progression of atherosclerosis of native coronary arteries and then four of five reoperations. Exercise tolerance in patients, even those with preoperative low LVEF, has been improved although their was some increment of left ventricular end-diastolic pressure during exercise. Patency rate in sequential grafting with saphenous vein grafts or internal mammary artery grafts were 92% in the average follow-up period of 11 months. The increase of flow rate with nitroglycerine and atrial pacing in internal mammary artery grafts (IMAG) were comparable with saphenous vein grafts.

Exacerbation of angina pectoris with meto prolol (β-blocker) in a case of multiple vessel disease containing left main trunk stenosis

Exacerbation of angina pectoris with meto prolol (β-blocker) in a case of multiple vessel disease containing left main trunk stenosis

Early and late results of coronary endarterectomy: Analysis of 3,369 patients

The effectiveness of coronary revascularization has been questioned in patients with diffuse coronary disease. Over a 14 year period (1970 to 1984), 30,464 patients underwent surgical revascularization at our institution. Coronary artery bypass alone was done in 27,095 patients and was combined with coronary endarterectomy in 3,369 patients (12.4%). Analysis of preoperative variables revealed an increased incidence of male sex, diabetes mellitus, low ejection fraction (less than 30) and multiple vessel disease in patients requiring endarterectomy. The early results after revascularization indicated a small increase in surgical risk after endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4% for coronary endarterectomy (p less than 0.01). Multivariate analysis identified independent predictors of operative risk: ejection fraction less than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and female sex. Early mortality was significantly increased by endarterectomy in the left anterior descending coronary artery (8.5%) compared to endarterectomy in arteries other than the left anterior descending (4.2%) (p less than 0.01). In a sample of 4,473 patients, myocardial complications were also found to be increased after coronary endarterectomy. The incidence of perioperative myocardial infarction in patients undergoing bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01). This suggests the failure mode of unsuccessful endarterectomy. Early mortality after coronary endarterectomy decreased substantially from 1970-1976 (6.4%) to 1977-1984 (3.5%; p less than 0.01). Actuarial analysis at 5 years and longer has shown very little difference in the long-term survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%), and freedom from reoperation (coronary artery bypass, 97%; coronary endarterectomy, 98%). Despite the small increase in surgical risk, the early and late results support the selective application of coronary endarterectomy in patients with diffuse distal disease and demonstrate the beneficial long-term effects.

Myocardial blood flow and glucose uptake after myocardial infarction.

Position emission tomography can picture the distribution of flow tracers as well as of metabolic substrates or analogs. Studies of the distribution of these tracers allow to infer information about regional myocardial clearance (flow X extraction) and substrate utilization. In a study of 32 patients after myocardial infarction, we have contrasted flow and substrate utilization to demonstrate ischemic but viable myocardium in the arterial territory of the infarct in a number of patients also specially after fibrinolytic reperfusion. Restoration of blood flow to the ischemic but viable myocardium through coronary bypass or dilatation improves flow from 56.3% to 84.2% of control and restores substrate utilization. In another group of 32 patients studied with the Strontium-82/Rubidium-82 generator, we have demonstrated perfusion changes both in the myocardial infarct area and at a distance. These changes predominate in patients with multiple vessel disease. Combined PET studies of flow and substrate utilization are new tools to study early intervention after myocardial infarction and to document the benefits of revascularization.

Myocardial infarction in young Indian patients: Risk factors and coronary arteriographic profile

One hundred four patients (101 men, three women), under 40 years of age, with myocardial infarction (MI), underwent coronary arteriography. Eighty patients had significant obstructive coronary artery disease (CAD) (group 1), 23 had normal coronary arteries (group 2), and one patient had coronary ostial stenosis as a result of nonspecific aortoarteritis (group 3). Coronary risk factors in group 1 included smoking (76.2%), hypercholesterolemia (36.3%), hypertension (32.5%), positive family history (28.7%), and diabetes mellitus (5%). Multiple risk factors were frequent (56.2%). Smoking was common ( p < 0.01) and diabetes mellitus less frequent ( p < 0.05) as compared to older (> 40 years) patients with MI and arteriographically proved CAD. The frequency of one-, two-, and three-vessel disease was 33.7%, 26.2%, and 40%, respectively, in group 1. Group 2 patients were almost devoid of coronary risk factors. The only group 3 patient had left coronary ostial stenosis with no risk factors. Similar to their counterparts in developed countries, young Indian patients with MI and obstructive CAD have a high frequency of coronary risk factors, especially smoking and severe multiple-vessel disease. Since normal coronary arteriograms are also frequent in this setting, a detailed evaluation is recommended for purposes of prgnosis and management.

Reperfusion Protocol and Results in 738 Patients with Evolving Myocardial Infarction

Reperfusion is an accepted therapy for evolving myocardial infarction (MI), as successful reperfusion reduces morbidity and mortality. A team approach between the cardiologists and cardiac surgeons must be applied to achieve reperfusion within a finite time from the onset of coronary thrombosis. Analysis of 738 patients grouped them by successful reperfusion in the catheterization laboratory versus the operating room. Factors that predict wall motion recovery related to the onset of clinical symptoms, time to reperfusion, coronary anatomy, and collateral network were reviewed. Comparisons were made between patients with stable versus unstable hemodynamics and successful or unsuccessful reperfusion. Of the 738 patients, the initial attempt at reperfusion was made in the catheterization laboratory with success in 331. These patients all had primarily single-vessel disease. With multiple-vessel disease identified at catheterization, 189 patients were immediately treated by surgical reperfusion. This method also was used for an additional 72 patients in whom reperfusion could not be achieved in the catheterization laboratory. Of the entire group of 738 patients, 146 (20%) could not be reperfused. Overall mortality for the 592 patients reperfused was 4.9% compared with 17% for those who could not be reperfused. Time was critical for wall motion recovery if no collaterals were demonstrated on angiography. If collaterals were present, time to reperfusion was not critical. Wall motion recovered in 90% of the patients if the endocardial anatomy on the initial angiogram was smooth. However, if the endocardial anatomy looked mottled and irregular, less than 10% of patients had recovery of wall motion. Using our protocol as a guide, successful reperfusion achieved significantly lower morbidity and mortality in patients with evolving MI.

Intracoronary Thrombolysis and Early Aortocoronary Bypass Surgery for Acute Myocardial Infarction

Selective intracoronary thrombolysis was performed in 312 patients with acute myocardial ischaemia due to complete occlusion of a major coronary artery. Successful reperfusion was achieved in 86% (268 patients). Fifty-eight patients underwent early bypass surgery without mortality. Surgery was indicated primarily in patients with an ischaemic time interval of less than 4 h and multiple-vessel disease suitable for bypass surgery. Patients with single-vessel disease were primarily subjected to immediate PTCA. Late follow-up of the surgical group after 19·2 ± 12·2 months revealed one late death (1·7%). Fifty-four of 57 survivors are functional class I or II; three patients are class III. Late cardiac recatherisation studies show a graft occlusion rate of 10% but with only one clinically evident reinfarction. Combined medicosurgical treatment for acute myocardial infarction offers excellent early and late results and protects the patient best from the risk of reinfarction.