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Surgery, PTCA or medical treatment — which is the best modality of treatment in octogenarian patients with coronary artery disease
22nd World Congress of the International Society for Cardiovascular Surgery 10.11
Surgery, P T C A or Medical Treatment - Which is the Best Modality of T r e a t m e n t in Octogenarian Patients with Coronary Artery Disease G. SAHAR, M. YANKO, E. RAANANI, N. AD and B.A. VIDNE, Petach Tikva, Israel Improved medical care has prolonged life expectancy. The question now arises as to the best option to offer the aged cardiac patient. Between January 1990 and May 1994, 159 octogenarians were catheterized in our institution for coronary artery disease (CAD). 61 pts were referred for surgery, 25 for percutaneous transluminal coronary angiography (PTCA) and 73 remained on medical treatment. The groups were matched for age, sex and associated disease. Cardiac function in the surgical group was lower (LVEF <40%) and the incidence of previous MI higher (52%). Overall mortality was 23.2% in the medical group, 16% in the PTCA group and 11.4% in the surgical group. Operative mortality was 4.5% for the entire period; mortality for emergency and elective cases was 20 and 7.7% respectively. Follow-up results in the medical group demonstrated a 25% incidence of MI, worsening angina and decreasing functional capacity (NYHA 2.9, declining to 3.3). 14% of patients undergoing PTCA required emergency surgery, 31% restenosed in the 6-month postoperative period, and 12.5% developed acute MI. Severe complications in the surgical group included CVA (5.4%), perioperative infarction (4.5%), bleeding (3.2%), severe wound infection (3.2%), renal failure (3.2%) and arrythmias (18%). The use of the internal mammary artery (IMA) in 40% of the patients was not associated with an increased incidence of complications. More than 90% of patients in the surgical group experienced signficant relief of symptoms, better quality of life and an average improvement in their NYHA score from 3.5 to 1.5. We conclude that coronary artery surgery in selected elderly patients can provide improved long-term survival and functional capacity when compared to PTCA or medical treatment.
10.12
Coronary and Carotid Artery Occlusive Disease: Operative Tactics and Results in 174 Operated Patients S. NASTASIC, N. RADO VANO VIC, J. SELESTIANSKY, J. LA VAC, S. NICIN, LJ. PETRO VIC, M. PRERADO VIC, Z. JONJEV and Z. POTIC, Novi Sad, Yugoslavia Between 1982 and 1994, 6647 aortocoronary bypass operations were performed at the University Clinic of Cardiovascular Surgery in Novi Sad, with a 30-day operative mortality of 2.79%. In 174 patients (2.62%), an additional endarterectomy of carotid arteries was also performed because of neurologic symptoms or high grade (> 80%) carotid artery stenosis. The cardiac status of these patients was: bad left ventricle (EF < 30%) in 39 (22.4%), left main stenosis in 31 (17.8%), unstable angina in 73 (42.0 %), endarterectomy of coronary arteries because of diffuse and distal coronary artery occlusive disease in 91 patients (52.3%). Carotid artery status was: unilateral stenosis in 131
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(75.2%), bilateral stenosis in 43 (24.7%), neurologically symptomatic 31 (17.8%), and neurologically asymptomatic 143 patients (82.2%). According to cardiac and carotid artery status, our operative tactics were as follows: two-stage procedure in 83 patients (47.7%), three-stage procedure (bilateral carotid artery) in 29 patients (16.7%) and simultaneous procedure in 62 patients (35.6%). Complications were: neurologic deficit in two patients (1.1%), transitory ischemic attack 3 patients (1.7%), myocardial infarction 6 patients (3.4%), haemorrhage 2 patients (1.1%), gastrointestinal bleeding 3 patients (1.7%), pulmonary complications 2 patients (1.1%), serious rhythm disturbances 2 patients (1.1%). Operative mortality was 8 patients (4.6%), the causes of death being: cardiac 3 patients (1.7%), neurologic 2 patients (1.1%), other 3 patients (1.7%). Despite the fact that the operative risk in these polivascular patients is elevated (4.6%), compared with the patients after aortocoronary bypass or single carotid artery endarterectomy, for these polivascular patients it is still acceptable. The highest risk in our experience is in cases having simultaneous procedures and this kind of operation has been reserved only for the patients with unstable angina.
10.13
Coronary Artery Bypass Surgery in Familial Hypercholesterolemia M. KAWASUJI, N. SAKAKIBARA, H. TAKEMURA, T. TEDORIYA and Y. WA TANABE, Kanazawa, Japan Familial hypercholesterolemia (FH) is an autosomal dominant disorder and is characterized by high plasma levels of lowdensity lipoprotein (LDL), cholesterol and rapidly progressing coronary atherosclerosis. We assessed the long-term results of coronary artery bypass grafting, performed in 72 heterozygous FH patients during the last 14 years. The patients had mean plasma total and LDL cholesterol levels of 325 mg/dl and 235 mg/dl and had severe coronary atherosclerosis. Seventy-one patients successfully underwent coronary bypass operation, with an average of 2.5 grafts, and the coronary stenosis index decreased from 19.8 to 6.8. During the last 8 years, 49 patients received arterial grafts. After surgery, all of the patients received cholesterol-lowering drug therapy with pravastatin, probucol, or cholestyramine. Seven patients who were resistant to drug therapy were treated with plasma LDL apheresis. Cholesterol-lowering therapy reduced plasma LDL cholesterol level by 40%. During the follow-up period (6-169 months; mean, 55), there was one sudden death and three patients died of malignant disease. The actuarial survival rate was 93% at 5 years after operation and 88% at 14 years. Actuarial freedom from recurrent angina was 89% at 5 years after operation and 75% at 10 years, and it was 85% and 91% for patients who received vein grafts only and arterial grafts at 8 years (ns). Four patients underwent reoperation 5-10 years after operation because of vein graft atherosclerosis. In spite of severe coronary atherosclerosis, patients with FH showed good long-term outcome after coronary bypass operation. The present study suggest frequent utilization of arterial grafts, intensive cholesterol-lowering drug therapy, and plasma LDL apheresis in patients with FH.
CARDIOVASCULAR SURGERY SEPTEMBER 1995
Surgery, P T C A or Medical Treatment - Which is the Best Modality of T r e a t m e n t in Octogenarian Patients with Coronary Artery Disease G. SAHAR, M. YANKO, E. RAANANI, N. AD and B.A. VIDNE, Petach Tikva, Israel Improved medical care has prolonged life expectancy. The question now arises as to the best option to offer the aged cardiac patient. Between January 1990 and May 1994, 159 octogenarians were catheterized in our institution for coronary artery disease (CAD). 61 pts were referred for surgery, 25 for percutaneous transluminal coronary angiography (PTCA) and 73 remained on medical treatment. The groups were matched for age, sex and associated disease. Cardiac function in the surgical group was lower (LVEF <40%) and the incidence of previous MI higher (52%). Overall mortality was 23.2% in the medical group, 16% in the PTCA group and 11.4% in the surgical group. Operative mortality was 4.5% for the entire period; mortality for emergency and elective cases was 20 and 7.7% respectively. Follow-up results in the medical group demonstrated a 25% incidence of MI, worsening angina and decreasing functional capacity (NYHA 2.9, declining to 3.3). 14% of patients undergoing PTCA required emergency surgery, 31% restenosed in the 6-month postoperative period, and 12.5% developed acute MI. Severe complications in the surgical group included CVA (5.4%), perioperative infarction (4.5%), bleeding (3.2%), severe wound infection (3.2%), renal failure (3.2%) and arrythmias (18%). The use of the internal mammary artery (IMA) in 40% of the patients was not associated with an increased incidence of complications. More than 90% of patients in the surgical group experienced signficant relief of symptoms, better quality of life and an average improvement in their NYHA score from 3.5 to 1.5. We conclude that coronary artery surgery in selected elderly patients can provide improved long-term survival and functional capacity when compared to PTCA or medical treatment.
10.12
Coronary and Carotid Artery Occlusive Disease: Operative Tactics and Results in 174 Operated Patients S. NASTASIC, N. RADO VANO VIC, J. SELESTIANSKY, J. LA VAC, S. NICIN, LJ. PETRO VIC, M. PRERADO VIC, Z. JONJEV and Z. POTIC, Novi Sad, Yugoslavia Between 1982 and 1994, 6647 aortocoronary bypass operations were performed at the University Clinic of Cardiovascular Surgery in Novi Sad, with a 30-day operative mortality of 2.79%. In 174 patients (2.62%), an additional endarterectomy of carotid arteries was also performed because of neurologic symptoms or high grade (> 80%) carotid artery stenosis. The cardiac status of these patients was: bad left ventricle (EF < 30%) in 39 (22.4%), left main stenosis in 31 (17.8%), unstable angina in 73 (42.0 %), endarterectomy of coronary arteries because of diffuse and distal coronary artery occlusive disease in 91 patients (52.3%). Carotid artery status was: unilateral stenosis in 131
52
(75.2%), bilateral stenosis in 43 (24.7%), neurologically symptomatic 31 (17.8%), and neurologically asymptomatic 143 patients (82.2%). According to cardiac and carotid artery status, our operative tactics were as follows: two-stage procedure in 83 patients (47.7%), three-stage procedure (bilateral carotid artery) in 29 patients (16.7%) and simultaneous procedure in 62 patients (35.6%). Complications were: neurologic deficit in two patients (1.1%), transitory ischemic attack 3 patients (1.7%), myocardial infarction 6 patients (3.4%), haemorrhage 2 patients (1.1%), gastrointestinal bleeding 3 patients (1.7%), pulmonary complications 2 patients (1.1%), serious rhythm disturbances 2 patients (1.1%). Operative mortality was 8 patients (4.6%), the causes of death being: cardiac 3 patients (1.7%), neurologic 2 patients (1.1%), other 3 patients (1.7%). Despite the fact that the operative risk in these polivascular patients is elevated (4.6%), compared with the patients after aortocoronary bypass or single carotid artery endarterectomy, for these polivascular patients it is still acceptable. The highest risk in our experience is in cases having simultaneous procedures and this kind of operation has been reserved only for the patients with unstable angina.
10.13
Coronary Artery Bypass Surgery in Familial Hypercholesterolemia M. KAWASUJI, N. SAKAKIBARA, H. TAKEMURA, T. TEDORIYA and Y. WA TANABE, Kanazawa, Japan Familial hypercholesterolemia (FH) is an autosomal dominant disorder and is characterized by high plasma levels of lowdensity lipoprotein (LDL), cholesterol and rapidly progressing coronary atherosclerosis. We assessed the long-term results of coronary artery bypass grafting, performed in 72 heterozygous FH patients during the last 14 years. The patients had mean plasma total and LDL cholesterol levels of 325 mg/dl and 235 mg/dl and had severe coronary atherosclerosis. Seventy-one patients successfully underwent coronary bypass operation, with an average of 2.5 grafts, and the coronary stenosis index decreased from 19.8 to 6.8. During the last 8 years, 49 patients received arterial grafts. After surgery, all of the patients received cholesterol-lowering drug therapy with pravastatin, probucol, or cholestyramine. Seven patients who were resistant to drug therapy were treated with plasma LDL apheresis. Cholesterol-lowering therapy reduced plasma LDL cholesterol level by 40%. During the follow-up period (6-169 months; mean, 55), there was one sudden death and three patients died of malignant disease. The actuarial survival rate was 93% at 5 years after operation and 88% at 14 years. Actuarial freedom from recurrent angina was 89% at 5 years after operation and 75% at 10 years, and it was 85% and 91% for patients who received vein grafts only and arterial grafts at 8 years (ns). Four patients underwent reoperation 5-10 years after operation because of vein graft atherosclerosis. In spite of severe coronary atherosclerosis, patients with FH showed good long-term outcome after coronary bypass operation. The present study suggest frequent utilization of arterial grafts, intensive cholesterol-lowering drug therapy, and plasma LDL apheresis in patients with FH.
CARDIOVASCULAR SURGERY SEPTEMBER 1995