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Emergency Coronary Artery Bypass Surgery for Percutaneous Coronary Interventions
Journal of the American College of Cardiology © 2005 by the American College of Cardiology Foundation Published by Elsevier Inc.
Vol. 46, No. 11, 2005 ISSN 0735-1097/05/$30.00 doi:10.1016/j.jacc.2005.06.083
Interventional Cardiology
Emergency Coronary Artery Bypass Surgery for Percutaneous Coronary Interventions Changes in the Incidence, Clinical Characteristics, and Indications From 1979 to 2003 Eric H. Yang, MD,* Richard J. Gumina, MD, PHD,* Ryan J. Lennon, MS,† David R. Holmes, JR, MD,* Charanjit S. Rihal, MD,* Mandeep Singh, MD* Rochester, Minnesota The purpose of the current study was to evaluate the changes in incidence, clinical characteristics, and indications for emergency coronary artery bypass grafting (CABG) in patients undergoing percutaneous coronary intervention (PCI) from 1979 to 2003. BACKGROUND Emergency CABG after PCI is associated with significant morbidity and mortality. METHODS Data from 23,087 patients who underwent PCI at Mayo Clinic from 1979 to 2003 were analyzed. Patients were divided into three groups: the “pre-stent” era, 1979 to 1994 (n ⫽ 8,905); the “initial stent era,” 1995 to 1999 (n ⫽ 7,605); and the “current stent era,” 2000 to 2003 (n ⫽ 6,577). RESULTS Although patients undergoing PCI in the recent time periods had more high-risk features, there was a significant decrease in the incidence of emergency CABG from 2.9% to 0.7% to 0.3% across the groups (p ⬍ 0.001). Patients requiring emergency surgery in the recent time periods had a higher prevalence of hypertension, prior revascularization, and left ventricular dysfunction (ejection fraction ⬍40%), as well as more complex coronary lesions. Fewer patients in the current stent era had coronary artery dissections and abrupt vessel closure requiring emergency CABG. The in-hospital mortality rate for emergency CABG patients remains unchanged and ranges from 10% to 14%. CONCLUSIONS The current study demonstrates that despite the increase in high-risk patients undergoing PCI, there has been a marked decrease in the incidence of patients requiring emergency CABG. However, the in-hospital mortality rate for those requiring emergency CABG remains high and unchanged. (J Am Coll Cardiol 2005;46:2004 –9) © 2005 by the American College of Cardiology Foundation OBJECTIVES
Many technologic and pharmacologic advances in percutaneous coronary intervention (PCI) have been made over the past 25 years. Steerable guide wires, coronary artery stents, and new anti-platelet therapies have resulted in an increase in the success rate of PCI procedures (1–3). In addition, high-risk patients who in the past would have undergone surgical revascularization are now undergoing PCI (4,5).
We hypothesized that improvements in PCI technology and the inclusion of high-risk patients have resulted in a change in the incidence, clinical characteristics, and indications for emergency CABG in patients undergoing PCI from 1979 to 2003.
See page 2010
Study patients. Patients undergoing PCI at the Mayo Clinic have been followed in a prospective registry since 1979. Patients in this registry have undergone follow up at 6 months, 1 year, and then annually since their PCI. A total of 23,087 patients undergoing PCI from 1979 to 2003 were included in the study. Patients were divided into three groups on the basis of the time period of their PCI. Group 1 consisted of 8,905 patients who underwent PCI from 1979 to 1994 and represents the “pre-stent era.” During this period, the technology for percutaneous transluminal angioplasty was being developed and operator experience was being gained. Group 2 consisted of 7,605 patients undergoing PCI from 1995 to 1999 and is considered the “early-stent era.” This was a transition period where stents and new parentral anti-platelet agents were introduced. Group 3 included 6,577 patients who underwent PCI from
Despite the increase in the number of PCI procedures performed, the need for emergency coronary bypass grafting (CABG) has been decreasing (6). Emergency CABG, however, still occurs and is associated with significant morbidity and mortality (7–9). The impact of improvements in technology and the inclusion of high-risk patients on the need and outcome of emergency CABG following PCI are not well known. From the Divisions of *Cardiovascular Disease and Internal Medicine and †Biostatistics, Mayo College of Medicine, Rochester, Minnesota. Manuscript received April 11, 2005; revised manuscript received June 10, 2005, accepted June 20, 2005.
METHODS
Yang et al. Emergency CABG for PCI
JACC Vol. 46, No. 11, 2005 December 6, 2005:2004–9
Abbreviations and Acronyms ACC/AHA ⫽ American College of Cardiology/American Heart Association CABG ⫽ coronary artery bypass grafting CCS ⫽ Canadian Cardiovascular Society PCI ⫽ percutaneous coronary intervention
2000 to 2003 and represents the “current-stent era.” In this recent time period, there was more frequent use of baremetal stents, parentral glycoprotein IIb/IIIa inhibitors, and dual oral anti-platelet therapy. Definitions. Emergency CABG was defined as cardiac surgery performed within hours of PCI to avoid unnecessary morbidity or death. This surgery takes precedence over elective cases. Indications for emergency CABG included abrupt vessel closure, extensive coronary artery dissection, incomplete revascularization, coronary perforation, unsuccessful dilation, and other situations resulting in hemodynamic instability and requiring surgical intervention. Unstable angina was defined as new onset of chest pain at rest or progression of stable angina to an increased Canadian Cardiovascular Society (CCS) score. Patients presenting with chest pain within two months of coronary revascularization were also considered to have unstable angina if the last episode of pain occurred within one week of the PCI. The indication for the index PCI was classified as elective, urgent, or emergent. Emergent cases were those that required PCI within hours of presentation in order to avoid significant morbidity and mortality. Urgent cases required PCI before discharge from the hospital and usually occurred within one to three days after presentation with chest pain. All other cases were considered elective. Coronary lesions were classified according to the American
College of Cardiology/American Heart Association (ACC/ AHA) scoring system (10). Statistical analysis. Data are presented as mean ⫾ SD for continuous variables and frequency for discrete variables. Kaplan-Meier methods were used to estimate long-term survival. Group comparisons were made using one-way analysis of variance for continuous data and Pearson’s chi-square test for nominal data. Discrete ordinal data were compared with the Wilcoxon rank-sum test. For pairwise comparisons, a Bonferroni-adjusted significance level of 0.0167 was used so that the total Type 1 error rate from the pairwise comparisons was no more than 0.05. Predictors of emergency CABG were determined by using a backwards selection method with multiple logistic regression. Significant predictors (p ⬍ 0.05) were reported as odds ratios and 95% confidence intervals (CI).
RESULTS Characteristics of patients undergoing PCI. The baseline characteristics of the 23,087 patients who underwent PCI from 1979 to 2003 are shown in Table 1. Compared to Group 1, patients in Groups 2 and 3 were older (63.8 ⫾ 11.4 years vs. 65.5 ⫾ 11.9 years and 66.9 ⫾ 12.1 years for Group 1 versus Groups 2 and 3, respectively, p ⬍ 0.001), and more likely to have diabetes (17% vs. 22% and 26%, respectively, p ⬍ 0.001), hypertension (49% vs. 61% and 74%, respectively, p ⬍ 0.001), and a greater body mass index (27.8 ⫾ 4.6 kg/m2 vs. 29.0 ⫾ 5.2 kg/m2 and 29.7 ⫾ 5.7 kg/m2, respectively, p ⬍ 0.001). Patients in the recent time periods were also more likely to have undergone prior PCI (23% vs. 32% and 36% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) or CABG (19% vs. 21% and 22%, respectively, p ⬍ 0.001) and were more likely to have
Table 1. Characteristics of Patients Undergoing Percutaneous Coronary Intervention
Age (yrs) Male gender (%) Diabetes mellitus (%) Hypertension (%) Body mass index (kg/m2) Prior PCI (%) Prior CABG (%) Unstable angina (%) Ejection fraction ⬍40% Type of PCI Elective Urgent Emergent Calcification in lesion (%) ACC/AHA type C lesion Total number of stents placed Glycoprotein IIb/IIIa used (%)
Group 1 1979 to 1994 (n ⴝ 8,905)
Group 2 1995 to 1999 (n ⴝ 7,605)
Group 3 2000 to 2003 (n ⴝ 6,577)
63.8 ⫾ 11.4 6,453 (72) 1,531 (17) 4,347 (49) 27.8 ⫾ 4.6 2,067 (23) 1,664 (19) 6,460 (73) 408 (5)
65.5 ⫾ 11.9* 5,380 (71) 1,700 (22)* 4,559 (61)* 29.0 ⫾ 5.2* 2,429 (32)* 1,619 (21)* 5,084 (67)* 750 (10)* * 2,966 (39) 3,355 (44) 1,276 (17) 2,918 (41)* 3,169 (46)* 1.2 ⫾ 1.1* 2,593 (34)*
66.9 ⫾ 12.1* 4,260 (70) 1,697 (26)* 4,613 (74)* 29.7 ⫾ 5.7* 2,369 (36)* 1,474 (22)* 3,739 (57)* 753 (11)* * 2,204 (34) 3,142 (48) 1,228 (19) 1,991 (33)* 2,532 (42)* 1.4 ⫾ 1* 3,907 (59)*
7,287 (82) 708 (8) 909 (10) 2,032 (24) 1,074 (32) 0.1 ⫾ .3 0 (0)
2005
*p ⬍ 0.001 versus Group 1. ACC/AHA ⫽ American College of Cardiology/American Heart Association; CABG ⫽ coronary artery bypass graft surgery; PCI ⫽ percutaneous coronary intervention.
2006
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JACC Vol. 46, No. 11, 2005 December 6, 2005:2004–9
Figure 1. Percentage of patients requiring emergency coronary artery bypass grafting (CABG) after percutaneous coronary intervention from 1979 to 2003 (n ⫽ 23,087). *Armitage test for trend.
an ejection fraction ⬍40% (5% vs. 10% and 11%, respectively, p ⬍ 0.001). Patients in Groups 2 and 3 were also more likely to have calcified (24% vs. 41% and 33% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and type C coronary lesions (32% vs. 46% and 42%, respectively, p ⬍ 0.001). Despite a greater percentage of patients presenting with unstable angina (57% vs. 73% and 67%, respectively, p ⬍ 0.001), patients in Group 1 were less likely than those in Groups 2 and 3 to undergo urgent (8% vs. 44% and 48%, respectively, p ⬍ 0.001) or emergent procedures (10% vs. 17% and 19%, respectively, p ⬍ 0.001). There were a significantly greater proportion of stents used
(0.1 ⫾ 0.3 stents/patient vs. 1.2 ⫾ 1.1 and 1.4 ⫾ 1 stents/patient, respectively, p ⬍ 0.001) and glycoprotein IIb/IIIa inhibitors (0% vs. 34% and 59%, respectively, p ⬍ 0.001) in Groups 2 and 3. In-lab death. The incidences of in-lab death were 35 (0.39%) in Group 1, 22 (0.29%) in Group 2, and 15 (0.23%) in Group 3 (p ⫽ 0.06 for trend). Characteristics of patients requiring emergency CABG. Temporal trends in the proportion of patients requiring emergency CABG are shown in Figure 1. A significant decrease in the incidence of emergency CABG from 2.9% to 0.7% to 0.3% (p ⬍ 0.001 Armitage test for trend) was observed across the three groups. As shown in Table 2, patients requiring emergency CABG in the recent time periods had a higher prevalence of hypertension (39% vs. 56% and 65% for Group 1 vs. Groups 2 and 3, respectively, p ⫽ 0.010), prior PCI (19% vs. 3% and 24%, p ⫽ 0.039), and left ventricular dysfunction (5% vs. 13% and 24%, respectively, p ⫽ 0.004). These patients were also more likely than those in Group 1 to have undergone urgent (4% vs. 30% and 38% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and emergent (15% vs. 45% and 38%, respectively, p ⬍ 0.001) procedures and have more complex coronary lesions. During the study period, there was a significant change in reasons for emergency CABG (Table 2). Compared with the patients in Group 1, those in Groups 2 and 3 had a significantly lower incidence of abrupt vessel closure (21%
Table 2. Characteristics of Patients Requiring Emergency Coronary Bypass Surgery After Percutaneous Coronary Intervention
Age (yrs) Male gender (%) Diabetes mellitus (%) Hypertension (%) Body mass index (kg/m2) Prior PCI (%) Prior CABG (%) Unstable angina (%) Ejection fraction ⬍40% (%) Type of PCI Elective Urgent Emergent Calcification in lesion (%) ACC/AHA type C lesion Total number of stents placed Glycoprotein IIb/IIIa used (%) Indication for emergency CABG Abrupt vessel closure Dissection Incomplete revascularization Perforation Unsuccessful dilation Other *p ⬍ 0.05 versus Group 1. Abbreviations as in Table 1.
Group 1 1979 to 1994 (n ⴝ 258)
Group 2 1995 to 1999 (n ⴝ 56)
Group 3 2000 to 2003 (n ⴝ 21)
62.4 ⫾ 10.7 181 (70) 23 (9) 98 (39) 27.0 ⫾ 4.1 48 (19) 25 (10) 187 (72) 14 (5) 210 (81) 10 (4) 38 (15) 54 (22) 15 (29) 0.1 ⫾ 0.4 0 (0)
64.6 ⫾ 10.0 36 (64) 3 (5) 28 (56)* 28.4 ⫾ 3.9 19 (34)* 3 (5) 31 (55)* 7 (13)* * 14 (25) 17 (30) 25 (45) 30 (61)* 24 (56)* 0.9 ⫾ 1.1* 16 (29)*
53.5 ⫾ 14.9 16 (76) 2 (10) 13 (65)* 30.4 ⫾ 4.3* 5 (24)* 0 (0) 13 (62)* 5 (24)* * 5 (24) 8 (38) 8 (38) 11 (65)* 9 (50)* 1.1 ⫾ 1.4* 11 (52)*
55 (21) 88 (34) 26 (10) 1 (0.5) 67 (26) 21 (8)
2 (4)* 12 (22)* 7 (13) 1 (2) 28 (50) 6 (10)
3 (14)* 3 (14)* 4 (19) 2 (9) 7 (33) 2 (9)
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2007
Table 3. Predictors for Emergency Coronary Artery Bypass Grafting During the Pre-Stent Era (1979 to 1994) Pre-procedure shock Acute myocardial infarction Canadian Cardiovascular Society angina class ⱖ3 Angulated segment (⬎45°) Multi-vessel coronary disease
Odds Ratio
95% CI
2.35 1.82 1.81
1.33–4.13 1.31–2.53 1.35–2.42
1.66 1.55
1.27–2.17 1.18–2.04
CI ⫽ confidence interval.
vs. 4% and 14% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and coronary artery dissection (34% vs. 22% and 14%, respectively, p ⬍ 0.001) requiring emergency CABG. Patients requiring emergency CABG in Groups 2 and 3 were also more likely to have coronary artery stents placed (0.1 ⫾ 0.4 stents/patient vs. 0.9 ⫾ 1.1 and 1.1 ⫾ 1.4 stents/patient, respectively, p ⬍ 0.001) and receive glycoprotein IIb/IIIa inhibitors (0% vs. 29% and 52%, respectively, p ⬍ 0.001). Predictors of emergency CABG. During the pre-stent era (1979 to 1994) the strongest predictor for emergency CABG was pre-procedure shock (OR 2.35, 95% confidence interval 1.33 to 4.13). Other significant predictors (Table 3) included acute myocardial infarction, CCS score ⱖ3, lesion in an angulated segment (⬎45°), and multi-vessel coronary disease. During the stent-era (1995 to 2003) the strongest predictor for emergency CABG was an emergent indication for PCI (odds ratio 3.77, 95% confidence interval 2.02 to 7.02). Other significant predictors (Table 4) were multi-vessel coronary artery disease, the presence of peripheral vascular disease, lesion in an angulated segment (⬎45°), and history of tobacco abuse. Mortality rate of emergency CABG. Forty-one patients (31 in Group 1, 8 in Group 2, and 2 in Group 3) who had emergency CABG died during hospitalization. The inhospital mortality rates of patients undergoing emergency bypass surgery are shown in Figure 2 and range from 10% to 14%. There was no significant difference in the mortality rates between the three groups. The most common causes of death (Table 5) were postoperative myocardial infarction (56%) and respiratory failure from pneumonia, acute lung injury, acute respiratory distress syndrome, or pulmonary embolism (19.5%). An unsuccessful PCI attempt was the most common indication for emergency CABG in these patients (53.7%). Table 4. Predictors for Emergency Coronary Artery Bypass Grafting During the Stent Era (1995 to 2003) Emergent PCI Multi-vessel coronary disease Peripheral vascular disease Angulated segment (⬎45°) History of smoking
Odds Ratio
95% CI
3.77 2.40 2.28 1.90 1.88
2.02–7.02 1.44–4.0 1.24–4.17 1.19–3.03 1.07–3.28
CI ⫽ confidence interval; PCI ⫽ percutaneous coronary intervention.
Figure 2. In-hospital mortality rates of patients requiring emergency coronary artery bypass grafting after percutaneous coronary intervention from 1979 to 2003 (n ⫽ 335).
One-year outcomes. In Groups 1, 2, and 3, respectively, 227, 48, and 19 patients who had emergency CABG survived to hospital discharge. The 1-year survival rates were similar in these patients (94.3%, 97.9%, and 87.7%).
DISCUSSION The current study demonstrates that despite the increase in high-risk patients undergoing PCI, there has been a significant and sustained decrease in the incidence of emergency CABG. There has also been a change in the indication for emergency CABG, with fewer abrupt vessel closures and coronary artery dissections. These changes are likely due to improvements in interventional technology and medical therapy. The in-hospital mortality rate for those requiring emergency CABG, however, is unchanged and remains high. Characteristics of patients undergoing PCI. Our results show that older and sicker patients are undergoing PCI. Patients in the more recent time periods were more likely to have hypertension, diabetes, and left ventricular dysfunction. Angiographically, these patients also had higher risk coronary disease with greater calcification and more severe ACC/AHA lesion scores. Similar findings were noted in a prior study involving patients from the National, Heart, Lung, and Blood Institute Registry (4). A possible explanation for the increase in high-risk patients is that the Table 5. Cause of Death and Indication for Bypass Surgery in 41 Patients With In-Hospital Death After Emergency Surgery Cause of death Postoperative myocardial infarction Cardiac arrhythmia Respiratory failure Heart failure Cerebrovascular accident Ventricular rupture Indication for CABG Unsuccessful dilation Dissection Incomplete revascularization Abrupt vessel closure
23 (56) 8 (19.5) 5 (12.1) 3 (7.3) 1 (2.4) 1 (2.4) 22 (53.7) 5 (12.2) 5 (12.2) 3 (7.1)
Values are n (%). Respiratory failure includes pneumonia, acute lung injury, acute respiratory distress syndrome, and pulmonary embolism.
2008
Yang et al. Emergency CABG for PCI
widespread use of coronary artery stenting has resulted in an improvement in PCI outcomes. These improvements may have allowed more high-risk patients to undergo PCI. Although more high-risk patients are undergoing PCI, the in-lab death rate has remained the same. This finding, along with the decrease in emergency PCI rates, suggests that improvements in PCI have resulted in fewer complications, but if a major complication occurs, the mortality rate remains unchanged by the newer technologies. Incidence of emergency CABG. Despite the increase in high-risk patients undergoing PCI, we found a 10-fold reduction in the incidence of emergency CABG, from 2.9% to 0.3%. These data are similar to the rates reported by Seshadri et al. (6) from the Cleveland Clinic, who reported a rate of 0.61%. Our results are also consistent with those from six trials comparing coronary artery stenting to angioplasty. This analysis demonstrated that 0.31% of patients in the most recent time period undergoing primary PCI required emergency CABG (11). The decline in the incidence of emergency CABG is most likely due to the development of coronary artery stents and glycoprotein IIb/IIIa inhibitors (12,13). The patients requiring emergency CABG in the currentstent era were also older and sicker than the patients in the pre-stent era. This may be a reflection of the increase in high-risk patients undergoing PCI. Indications for emergency CABG. There was a significant change in the indications for emergency CABG after PCI, with a decrease in the incidence of abrupt vessel closure and coronary artery dissection resulting in the need for emergency CABG. Both of these changes are most likely due to the increased use of coronary artery stents and glycoprotein IIb/ IIIa inhibitors, which reduce the risk of abrupt vessel closure and can be used to treat coronary artery dissections (14). There has also been a change in the predictors of emergency CABG. In the pre-stent era, the presence of pre-procedural shock was the strongest predictor. In the stent era, shock is no longer a significant predictor and again may be due to improvements in PCI technology. Outcomes of emergency CABG. Although there has been a change in the characteristics and indications for emergency CABG, the in-hospital and one-year mortality rate for these patients remains the same, underscoring the need to recognize variables associated with higher incidence of emergent CABG, and tailor strategies to avoid or reduce such complication. We observed a mortality rate of 10% to 14%, which is similar to the rate of 15% reported by Seshadri et al. (6). These rates are much higher than those for elective CABG, and a previous study suggests that the high mortality rate may be due to the hemodynamic instability that is present at the time of emergency surgery (15). This instability can lead to a lower probability of receiving an internal mammary graft and a greater requirement for inotropic support and blood products (15,16). The most common causes of death in these patients were postoperative myocardial infarction and cardiac arrhythmias. Emergency
JACC Vol. 46, No. 11, 2005 December 6, 2005:2004–9
CABG has also been associated with longer hospital stays, increased risk of postoperative myocardial infraction, and a greater prevalence of ventricular arrhythmias (16). Study limitations. A limitation of the current study is that it was a retrospective review of outcomes at a single highvolume center. The results may therefore not be applicable to other centers with lower volumes. Conclusions. In conclusion, the results of the current study show that despite the increase in high-risk patients undergoing PCI, there has been a dramatic decrease in the incidence of patients requiring emergency CABG. In addition, there has been a change in the indication for emergency CABG, with a decrease in the incidence of coronary artery dissections and abrupt vessel closure. The mortality rate associated with emergency CABG, however, remains high and unchanged. Reprint requests and correspondence: Dr. Mandeep Singh, Division of Cardiovascular Disease and Internal Medicine, Mayo College of Medicine, 200 First Street SW, Rochester, Minnesota 55905. E-mail: [email protected].
REFERENCES 1. Stone F, Gregg W, Brodie F, et al. Prospective, multicenter study of the safety and feasibility of primary stenting in acute myocardial infarction: in-hospital and 30-day results of the PAMI Stent Pilot Trial. J Am Coll Cardiol 1998;31:23–30. 2. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997;336:1689 –97. 3. O’Shea JC, Hafley GE, Greenberg S, et al. Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. JAMA 2001; 285:2468 –73. 4. Williams DO, Holubkov R, Yeh W, et al. Percutaneous coronary intervention in the current era compared with 1985–1986: the National Heart, Lung, and Blood Institute Registries. Circulation 2000; 102:2945–51. 5. Singh M, Rihal CS, Berger PB, et al. Improving outcome over time of percutaneous coronary interventions in unstable angina. J Am Coll Cardiol 2000;36:674 – 8. 6. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation 2002;106: 2346 –50. 7. Cowley MJ, Dorros G, Kelsey SF, Van Raden M, Detre KM. Emergency coronary bypass surgery after coronary angioplasty: the National Heart, Lung, and Blood Institute’s Percutaneous Transluminal Coronary Angioplasty Registry experience. Am J Cardiol 1984;53: 22C– 6C. 8. Parsonnet V, Fisch D, Gielchinsky I, et al. Emergency operation after failed angioplasty (published erratum appears in J Thorac Cardiovasc Surg 1989;97:503). J Thorac Cardiovasc Surg 1988;96:198 –203. 9. Craver JM, Weintraub WS, Jones EL, Guyton RA, Hatcher CR, Jr. Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience. Ann Surg 1992;215:425– 33; discussion 433– 4. 10. Ryan TJ, Faxon DP, Gunnar RM, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on assessment of diagnostic and therapeutic cardiovascular procedures (subcommittee on percutaneous transluminal coronary angioplasty). Circulation 1988;78:486 –502.
JACC Vol. 46, No. 11, 2005 December 6, 2005:2004–9 11. Singh M, Ting HH, Berger PB, et al. Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal. J Am Coll Cardiol 2002;39:1881–9. 12. Altmann DB, Racz M, Battleman DS, et al. Reduction in angioplasty complications after the introduction of coronary stents: results from a consecutive series of 2,242 patients. Am Heart J 1996;132:503–7. 13. Blankenship JC, Sigmon KN, Pieper KS, O’Shea C, Tardiff BE, Tcheng JE. Effect of eptifibatide on angiographic complications during percutaneous coronary intervention in the IMPACT(Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis) II Trial. Am J Cardiol 2001;88:969 –73.
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14. Moliterno DJ, Chan AW. Glycoprotein IIb/IIIa inhibition in early intent-to-stent treatment of acute coronary syndromes: EPISTENT, ADMIRAL, CADILLAC, and TARGET. J Am Coll Cardiol 2003;41:19. 15. Lazar HL, Jacobs AK, Aldea GS, Shapira OM, Lancaster D, Shemin RJ. Factors influencing mortality after emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty. Ann Thorac Surg 1997;64:1747–52. 16. Borkon AM, Failing TL, Piehler JM, Killen DA, Hoskins ML, Reed WA. Risk analysis of operative intervention for failed coronary angioplasty. Ann Thorac Surg 1992;54:884 –91.
Vol. 46, No. 11, 2005 ISSN 0735-1097/05/$30.00 doi:10.1016/j.jacc.2005.06.083
Interventional Cardiology
Emergency Coronary Artery Bypass Surgery for Percutaneous Coronary Interventions Changes in the Incidence, Clinical Characteristics, and Indications From 1979 to 2003 Eric H. Yang, MD,* Richard J. Gumina, MD, PHD,* Ryan J. Lennon, MS,† David R. Holmes, JR, MD,* Charanjit S. Rihal, MD,* Mandeep Singh, MD* Rochester, Minnesota The purpose of the current study was to evaluate the changes in incidence, clinical characteristics, and indications for emergency coronary artery bypass grafting (CABG) in patients undergoing percutaneous coronary intervention (PCI) from 1979 to 2003. BACKGROUND Emergency CABG after PCI is associated with significant morbidity and mortality. METHODS Data from 23,087 patients who underwent PCI at Mayo Clinic from 1979 to 2003 were analyzed. Patients were divided into three groups: the “pre-stent” era, 1979 to 1994 (n ⫽ 8,905); the “initial stent era,” 1995 to 1999 (n ⫽ 7,605); and the “current stent era,” 2000 to 2003 (n ⫽ 6,577). RESULTS Although patients undergoing PCI in the recent time periods had more high-risk features, there was a significant decrease in the incidence of emergency CABG from 2.9% to 0.7% to 0.3% across the groups (p ⬍ 0.001). Patients requiring emergency surgery in the recent time periods had a higher prevalence of hypertension, prior revascularization, and left ventricular dysfunction (ejection fraction ⬍40%), as well as more complex coronary lesions. Fewer patients in the current stent era had coronary artery dissections and abrupt vessel closure requiring emergency CABG. The in-hospital mortality rate for emergency CABG patients remains unchanged and ranges from 10% to 14%. CONCLUSIONS The current study demonstrates that despite the increase in high-risk patients undergoing PCI, there has been a marked decrease in the incidence of patients requiring emergency CABG. However, the in-hospital mortality rate for those requiring emergency CABG remains high and unchanged. (J Am Coll Cardiol 2005;46:2004 –9) © 2005 by the American College of Cardiology Foundation OBJECTIVES
Many technologic and pharmacologic advances in percutaneous coronary intervention (PCI) have been made over the past 25 years. Steerable guide wires, coronary artery stents, and new anti-platelet therapies have resulted in an increase in the success rate of PCI procedures (1–3). In addition, high-risk patients who in the past would have undergone surgical revascularization are now undergoing PCI (4,5).
We hypothesized that improvements in PCI technology and the inclusion of high-risk patients have resulted in a change in the incidence, clinical characteristics, and indications for emergency CABG in patients undergoing PCI from 1979 to 2003.
See page 2010
Study patients. Patients undergoing PCI at the Mayo Clinic have been followed in a prospective registry since 1979. Patients in this registry have undergone follow up at 6 months, 1 year, and then annually since their PCI. A total of 23,087 patients undergoing PCI from 1979 to 2003 were included in the study. Patients were divided into three groups on the basis of the time period of their PCI. Group 1 consisted of 8,905 patients who underwent PCI from 1979 to 1994 and represents the “pre-stent era.” During this period, the technology for percutaneous transluminal angioplasty was being developed and operator experience was being gained. Group 2 consisted of 7,605 patients undergoing PCI from 1995 to 1999 and is considered the “early-stent era.” This was a transition period where stents and new parentral anti-platelet agents were introduced. Group 3 included 6,577 patients who underwent PCI from
Despite the increase in the number of PCI procedures performed, the need for emergency coronary bypass grafting (CABG) has been decreasing (6). Emergency CABG, however, still occurs and is associated with significant morbidity and mortality (7–9). The impact of improvements in technology and the inclusion of high-risk patients on the need and outcome of emergency CABG following PCI are not well known. From the Divisions of *Cardiovascular Disease and Internal Medicine and †Biostatistics, Mayo College of Medicine, Rochester, Minnesota. Manuscript received April 11, 2005; revised manuscript received June 10, 2005, accepted June 20, 2005.
METHODS
Yang et al. Emergency CABG for PCI
JACC Vol. 46, No. 11, 2005 December 6, 2005:2004–9
Abbreviations and Acronyms ACC/AHA ⫽ American College of Cardiology/American Heart Association CABG ⫽ coronary artery bypass grafting CCS ⫽ Canadian Cardiovascular Society PCI ⫽ percutaneous coronary intervention
2000 to 2003 and represents the “current-stent era.” In this recent time period, there was more frequent use of baremetal stents, parentral glycoprotein IIb/IIIa inhibitors, and dual oral anti-platelet therapy. Definitions. Emergency CABG was defined as cardiac surgery performed within hours of PCI to avoid unnecessary morbidity or death. This surgery takes precedence over elective cases. Indications for emergency CABG included abrupt vessel closure, extensive coronary artery dissection, incomplete revascularization, coronary perforation, unsuccessful dilation, and other situations resulting in hemodynamic instability and requiring surgical intervention. Unstable angina was defined as new onset of chest pain at rest or progression of stable angina to an increased Canadian Cardiovascular Society (CCS) score. Patients presenting with chest pain within two months of coronary revascularization were also considered to have unstable angina if the last episode of pain occurred within one week of the PCI. The indication for the index PCI was classified as elective, urgent, or emergent. Emergent cases were those that required PCI within hours of presentation in order to avoid significant morbidity and mortality. Urgent cases required PCI before discharge from the hospital and usually occurred within one to three days after presentation with chest pain. All other cases were considered elective. Coronary lesions were classified according to the American
College of Cardiology/American Heart Association (ACC/ AHA) scoring system (10). Statistical analysis. Data are presented as mean ⫾ SD for continuous variables and frequency for discrete variables. Kaplan-Meier methods were used to estimate long-term survival. Group comparisons were made using one-way analysis of variance for continuous data and Pearson’s chi-square test for nominal data. Discrete ordinal data were compared with the Wilcoxon rank-sum test. For pairwise comparisons, a Bonferroni-adjusted significance level of 0.0167 was used so that the total Type 1 error rate from the pairwise comparisons was no more than 0.05. Predictors of emergency CABG were determined by using a backwards selection method with multiple logistic regression. Significant predictors (p ⬍ 0.05) were reported as odds ratios and 95% confidence intervals (CI).
RESULTS Characteristics of patients undergoing PCI. The baseline characteristics of the 23,087 patients who underwent PCI from 1979 to 2003 are shown in Table 1. Compared to Group 1, patients in Groups 2 and 3 were older (63.8 ⫾ 11.4 years vs. 65.5 ⫾ 11.9 years and 66.9 ⫾ 12.1 years for Group 1 versus Groups 2 and 3, respectively, p ⬍ 0.001), and more likely to have diabetes (17% vs. 22% and 26%, respectively, p ⬍ 0.001), hypertension (49% vs. 61% and 74%, respectively, p ⬍ 0.001), and a greater body mass index (27.8 ⫾ 4.6 kg/m2 vs. 29.0 ⫾ 5.2 kg/m2 and 29.7 ⫾ 5.7 kg/m2, respectively, p ⬍ 0.001). Patients in the recent time periods were also more likely to have undergone prior PCI (23% vs. 32% and 36% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) or CABG (19% vs. 21% and 22%, respectively, p ⬍ 0.001) and were more likely to have
Table 1. Characteristics of Patients Undergoing Percutaneous Coronary Intervention
Age (yrs) Male gender (%) Diabetes mellitus (%) Hypertension (%) Body mass index (kg/m2) Prior PCI (%) Prior CABG (%) Unstable angina (%) Ejection fraction ⬍40% Type of PCI Elective Urgent Emergent Calcification in lesion (%) ACC/AHA type C lesion Total number of stents placed Glycoprotein IIb/IIIa used (%)
Group 1 1979 to 1994 (n ⴝ 8,905)
Group 2 1995 to 1999 (n ⴝ 7,605)
Group 3 2000 to 2003 (n ⴝ 6,577)
63.8 ⫾ 11.4 6,453 (72) 1,531 (17) 4,347 (49) 27.8 ⫾ 4.6 2,067 (23) 1,664 (19) 6,460 (73) 408 (5)
65.5 ⫾ 11.9* 5,380 (71) 1,700 (22)* 4,559 (61)* 29.0 ⫾ 5.2* 2,429 (32)* 1,619 (21)* 5,084 (67)* 750 (10)* * 2,966 (39) 3,355 (44) 1,276 (17) 2,918 (41)* 3,169 (46)* 1.2 ⫾ 1.1* 2,593 (34)*
66.9 ⫾ 12.1* 4,260 (70) 1,697 (26)* 4,613 (74)* 29.7 ⫾ 5.7* 2,369 (36)* 1,474 (22)* 3,739 (57)* 753 (11)* * 2,204 (34) 3,142 (48) 1,228 (19) 1,991 (33)* 2,532 (42)* 1.4 ⫾ 1* 3,907 (59)*
7,287 (82) 708 (8) 909 (10) 2,032 (24) 1,074 (32) 0.1 ⫾ .3 0 (0)
2005
*p ⬍ 0.001 versus Group 1. ACC/AHA ⫽ American College of Cardiology/American Heart Association; CABG ⫽ coronary artery bypass graft surgery; PCI ⫽ percutaneous coronary intervention.
2006
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Figure 1. Percentage of patients requiring emergency coronary artery bypass grafting (CABG) after percutaneous coronary intervention from 1979 to 2003 (n ⫽ 23,087). *Armitage test for trend.
an ejection fraction ⬍40% (5% vs. 10% and 11%, respectively, p ⬍ 0.001). Patients in Groups 2 and 3 were also more likely to have calcified (24% vs. 41% and 33% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and type C coronary lesions (32% vs. 46% and 42%, respectively, p ⬍ 0.001). Despite a greater percentage of patients presenting with unstable angina (57% vs. 73% and 67%, respectively, p ⬍ 0.001), patients in Group 1 were less likely than those in Groups 2 and 3 to undergo urgent (8% vs. 44% and 48%, respectively, p ⬍ 0.001) or emergent procedures (10% vs. 17% and 19%, respectively, p ⬍ 0.001). There were a significantly greater proportion of stents used
(0.1 ⫾ 0.3 stents/patient vs. 1.2 ⫾ 1.1 and 1.4 ⫾ 1 stents/patient, respectively, p ⬍ 0.001) and glycoprotein IIb/IIIa inhibitors (0% vs. 34% and 59%, respectively, p ⬍ 0.001) in Groups 2 and 3. In-lab death. The incidences of in-lab death were 35 (0.39%) in Group 1, 22 (0.29%) in Group 2, and 15 (0.23%) in Group 3 (p ⫽ 0.06 for trend). Characteristics of patients requiring emergency CABG. Temporal trends in the proportion of patients requiring emergency CABG are shown in Figure 1. A significant decrease in the incidence of emergency CABG from 2.9% to 0.7% to 0.3% (p ⬍ 0.001 Armitage test for trend) was observed across the three groups. As shown in Table 2, patients requiring emergency CABG in the recent time periods had a higher prevalence of hypertension (39% vs. 56% and 65% for Group 1 vs. Groups 2 and 3, respectively, p ⫽ 0.010), prior PCI (19% vs. 3% and 24%, p ⫽ 0.039), and left ventricular dysfunction (5% vs. 13% and 24%, respectively, p ⫽ 0.004). These patients were also more likely than those in Group 1 to have undergone urgent (4% vs. 30% and 38% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and emergent (15% vs. 45% and 38%, respectively, p ⬍ 0.001) procedures and have more complex coronary lesions. During the study period, there was a significant change in reasons for emergency CABG (Table 2). Compared with the patients in Group 1, those in Groups 2 and 3 had a significantly lower incidence of abrupt vessel closure (21%
Table 2. Characteristics of Patients Requiring Emergency Coronary Bypass Surgery After Percutaneous Coronary Intervention
Age (yrs) Male gender (%) Diabetes mellitus (%) Hypertension (%) Body mass index (kg/m2) Prior PCI (%) Prior CABG (%) Unstable angina (%) Ejection fraction ⬍40% (%) Type of PCI Elective Urgent Emergent Calcification in lesion (%) ACC/AHA type C lesion Total number of stents placed Glycoprotein IIb/IIIa used (%) Indication for emergency CABG Abrupt vessel closure Dissection Incomplete revascularization Perforation Unsuccessful dilation Other *p ⬍ 0.05 versus Group 1. Abbreviations as in Table 1.
Group 1 1979 to 1994 (n ⴝ 258)
Group 2 1995 to 1999 (n ⴝ 56)
Group 3 2000 to 2003 (n ⴝ 21)
62.4 ⫾ 10.7 181 (70) 23 (9) 98 (39) 27.0 ⫾ 4.1 48 (19) 25 (10) 187 (72) 14 (5) 210 (81) 10 (4) 38 (15) 54 (22) 15 (29) 0.1 ⫾ 0.4 0 (0)
64.6 ⫾ 10.0 36 (64) 3 (5) 28 (56)* 28.4 ⫾ 3.9 19 (34)* 3 (5) 31 (55)* 7 (13)* * 14 (25) 17 (30) 25 (45) 30 (61)* 24 (56)* 0.9 ⫾ 1.1* 16 (29)*
53.5 ⫾ 14.9 16 (76) 2 (10) 13 (65)* 30.4 ⫾ 4.3* 5 (24)* 0 (0) 13 (62)* 5 (24)* * 5 (24) 8 (38) 8 (38) 11 (65)* 9 (50)* 1.1 ⫾ 1.4* 11 (52)*
55 (21) 88 (34) 26 (10) 1 (0.5) 67 (26) 21 (8)
2 (4)* 12 (22)* 7 (13) 1 (2) 28 (50) 6 (10)
3 (14)* 3 (14)* 4 (19) 2 (9) 7 (33) 2 (9)
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2007
Table 3. Predictors for Emergency Coronary Artery Bypass Grafting During the Pre-Stent Era (1979 to 1994) Pre-procedure shock Acute myocardial infarction Canadian Cardiovascular Society angina class ⱖ3 Angulated segment (⬎45°) Multi-vessel coronary disease
Odds Ratio
95% CI
2.35 1.82 1.81
1.33–4.13 1.31–2.53 1.35–2.42
1.66 1.55
1.27–2.17 1.18–2.04
CI ⫽ confidence interval.
vs. 4% and 14% for Group 1 vs. Groups 2 and 3, respectively, p ⬍ 0.001) and coronary artery dissection (34% vs. 22% and 14%, respectively, p ⬍ 0.001) requiring emergency CABG. Patients requiring emergency CABG in Groups 2 and 3 were also more likely to have coronary artery stents placed (0.1 ⫾ 0.4 stents/patient vs. 0.9 ⫾ 1.1 and 1.1 ⫾ 1.4 stents/patient, respectively, p ⬍ 0.001) and receive glycoprotein IIb/IIIa inhibitors (0% vs. 29% and 52%, respectively, p ⬍ 0.001). Predictors of emergency CABG. During the pre-stent era (1979 to 1994) the strongest predictor for emergency CABG was pre-procedure shock (OR 2.35, 95% confidence interval 1.33 to 4.13). Other significant predictors (Table 3) included acute myocardial infarction, CCS score ⱖ3, lesion in an angulated segment (⬎45°), and multi-vessel coronary disease. During the stent-era (1995 to 2003) the strongest predictor for emergency CABG was an emergent indication for PCI (odds ratio 3.77, 95% confidence interval 2.02 to 7.02). Other significant predictors (Table 4) were multi-vessel coronary artery disease, the presence of peripheral vascular disease, lesion in an angulated segment (⬎45°), and history of tobacco abuse. Mortality rate of emergency CABG. Forty-one patients (31 in Group 1, 8 in Group 2, and 2 in Group 3) who had emergency CABG died during hospitalization. The inhospital mortality rates of patients undergoing emergency bypass surgery are shown in Figure 2 and range from 10% to 14%. There was no significant difference in the mortality rates between the three groups. The most common causes of death (Table 5) were postoperative myocardial infarction (56%) and respiratory failure from pneumonia, acute lung injury, acute respiratory distress syndrome, or pulmonary embolism (19.5%). An unsuccessful PCI attempt was the most common indication for emergency CABG in these patients (53.7%). Table 4. Predictors for Emergency Coronary Artery Bypass Grafting During the Stent Era (1995 to 2003) Emergent PCI Multi-vessel coronary disease Peripheral vascular disease Angulated segment (⬎45°) History of smoking
Odds Ratio
95% CI
3.77 2.40 2.28 1.90 1.88
2.02–7.02 1.44–4.0 1.24–4.17 1.19–3.03 1.07–3.28
CI ⫽ confidence interval; PCI ⫽ percutaneous coronary intervention.
Figure 2. In-hospital mortality rates of patients requiring emergency coronary artery bypass grafting after percutaneous coronary intervention from 1979 to 2003 (n ⫽ 335).
One-year outcomes. In Groups 1, 2, and 3, respectively, 227, 48, and 19 patients who had emergency CABG survived to hospital discharge. The 1-year survival rates were similar in these patients (94.3%, 97.9%, and 87.7%).
DISCUSSION The current study demonstrates that despite the increase in high-risk patients undergoing PCI, there has been a significant and sustained decrease in the incidence of emergency CABG. There has also been a change in the indication for emergency CABG, with fewer abrupt vessel closures and coronary artery dissections. These changes are likely due to improvements in interventional technology and medical therapy. The in-hospital mortality rate for those requiring emergency CABG, however, is unchanged and remains high. Characteristics of patients undergoing PCI. Our results show that older and sicker patients are undergoing PCI. Patients in the more recent time periods were more likely to have hypertension, diabetes, and left ventricular dysfunction. Angiographically, these patients also had higher risk coronary disease with greater calcification and more severe ACC/AHA lesion scores. Similar findings were noted in a prior study involving patients from the National, Heart, Lung, and Blood Institute Registry (4). A possible explanation for the increase in high-risk patients is that the Table 5. Cause of Death and Indication for Bypass Surgery in 41 Patients With In-Hospital Death After Emergency Surgery Cause of death Postoperative myocardial infarction Cardiac arrhythmia Respiratory failure Heart failure Cerebrovascular accident Ventricular rupture Indication for CABG Unsuccessful dilation Dissection Incomplete revascularization Abrupt vessel closure
23 (56) 8 (19.5) 5 (12.1) 3 (7.3) 1 (2.4) 1 (2.4) 22 (53.7) 5 (12.2) 5 (12.2) 3 (7.1)
Values are n (%). Respiratory failure includes pneumonia, acute lung injury, acute respiratory distress syndrome, and pulmonary embolism.
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widespread use of coronary artery stenting has resulted in an improvement in PCI outcomes. These improvements may have allowed more high-risk patients to undergo PCI. Although more high-risk patients are undergoing PCI, the in-lab death rate has remained the same. This finding, along with the decrease in emergency PCI rates, suggests that improvements in PCI have resulted in fewer complications, but if a major complication occurs, the mortality rate remains unchanged by the newer technologies. Incidence of emergency CABG. Despite the increase in high-risk patients undergoing PCI, we found a 10-fold reduction in the incidence of emergency CABG, from 2.9% to 0.3%. These data are similar to the rates reported by Seshadri et al. (6) from the Cleveland Clinic, who reported a rate of 0.61%. Our results are also consistent with those from six trials comparing coronary artery stenting to angioplasty. This analysis demonstrated that 0.31% of patients in the most recent time period undergoing primary PCI required emergency CABG (11). The decline in the incidence of emergency CABG is most likely due to the development of coronary artery stents and glycoprotein IIb/IIIa inhibitors (12,13). The patients requiring emergency CABG in the currentstent era were also older and sicker than the patients in the pre-stent era. This may be a reflection of the increase in high-risk patients undergoing PCI. Indications for emergency CABG. There was a significant change in the indications for emergency CABG after PCI, with a decrease in the incidence of abrupt vessel closure and coronary artery dissection resulting in the need for emergency CABG. Both of these changes are most likely due to the increased use of coronary artery stents and glycoprotein IIb/ IIIa inhibitors, which reduce the risk of abrupt vessel closure and can be used to treat coronary artery dissections (14). There has also been a change in the predictors of emergency CABG. In the pre-stent era, the presence of pre-procedural shock was the strongest predictor. In the stent era, shock is no longer a significant predictor and again may be due to improvements in PCI technology. Outcomes of emergency CABG. Although there has been a change in the characteristics and indications for emergency CABG, the in-hospital and one-year mortality rate for these patients remains the same, underscoring the need to recognize variables associated with higher incidence of emergent CABG, and tailor strategies to avoid or reduce such complication. We observed a mortality rate of 10% to 14%, which is similar to the rate of 15% reported by Seshadri et al. (6). These rates are much higher than those for elective CABG, and a previous study suggests that the high mortality rate may be due to the hemodynamic instability that is present at the time of emergency surgery (15). This instability can lead to a lower probability of receiving an internal mammary graft and a greater requirement for inotropic support and blood products (15,16). The most common causes of death in these patients were postoperative myocardial infarction and cardiac arrhythmias. Emergency
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CABG has also been associated with longer hospital stays, increased risk of postoperative myocardial infraction, and a greater prevalence of ventricular arrhythmias (16). Study limitations. A limitation of the current study is that it was a retrospective review of outcomes at a single highvolume center. The results may therefore not be applicable to other centers with lower volumes. Conclusions. In conclusion, the results of the current study show that despite the increase in high-risk patients undergoing PCI, there has been a dramatic decrease in the incidence of patients requiring emergency CABG. In addition, there has been a change in the indication for emergency CABG, with a decrease in the incidence of coronary artery dissections and abrupt vessel closure. The mortality rate associated with emergency CABG, however, remains high and unchanged. Reprint requests and correspondence: Dr. Mandeep Singh, Division of Cardiovascular Disease and Internal Medicine, Mayo College of Medicine, 200 First Street SW, Rochester, Minnesota 55905. E-mail: [email protected].
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