Young adults with coronary atherosclerosis: 10 year results of surgical myocardial revascularization

Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

Coronary Artery Disease in Patients Aged 35 or less - A Different Beast?

Aim:

To assess the extent and severity of coronary artery disease (CAD) in 200 consecutive patients aged 35 years or less undergoing diagnostic coronary angiography.

Patients and Methods:

Findings in these 200 patients (≤ 35 years of age) were analyzed to find the extent and severity of CAD. The mean age was 31.69 (±3.76) years. Majority were males (94%) and from the Arab ethnicity (70.5%).

Result:

Smoking (71%) and history of premature CAD (27%) were the most frequent risk factors (RF). History of previous ST elevation myocardial infarction (MI) was present in 68%. Anterior wall MI was the most frequent location (63.3%). The majority (54.3%) had moderate or large size MI. Ejection fraction (EF) less than 50% was noted in 30.3%. Left main or triple vessel CAD was seen in 15%. One- and two-vessel CAD was seen in 32.5% and 19% patients, respectively. Coronary angiogram was completely normal in 23.5%. The majority (54.5%) were treated conservatively and the rest (45.5%) needed percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The mean number of stents used was 1.3 ± 0.67 and the mean length of stents used was 20.3 ± 12.6 mm.

Conclusion:

The extent and severity of CAD was very significant in this subgroup of very young (≤35 years) Asian patients. Smoking was the main risk factor and half of the patients needed either PCI or CABG.

Comparison of differences in outcome after percutaneous coronary intervention in men versus women <40 years of age

We evaluated the outcomes of 177 consecutive patients (43 women, 134 men) <40 years of age with premature atherosclerosis who underwent percutaneous coronary intervention. Women were younger, had more diabetes mellitus (37% vs 10%; p <0.001), but less hyperlipidemia (58% vs 75%; p <0.001) compared with men. In-hospital vascular complications and 1-year mortality rate or Q-wave myocardial infarction (7.9% vs 0.08%, p <0.01) were higher in women. By multivariable regression analysis, female gender was the only independent predictor of vascular complications (odds ratio, 14.1; 95% confidence intervals, 1.59 to 125, p = 0.01) and of 1-year mortality rate or nonfatal myocardial infarction (odds ratio, 12.5; 95% confidence interval, 1.14 to 111, p = 0.03). Women with premature coronary disease had a distinctive risk factor profile relative to men, with a predominance of diabetes and hypercholesterolemia, and were at higher risk of developing vascular and ischemic complications after percutaneous coronary intervention, warranting aggressive risk factor modification and vigilance in this population.

Outcomes of percutaneous and surgical revascularization in women

There are gender-related differences both in the natural history of coronary artery disease (CAD) and in the response to revascularization strategies of patients with CAD. This paper reviews the specific pathophysiology of CAD in women as it influences outcome and current interventional and surgical treatment modalities and outcomes for stable and unstable coronary artery syndromes.

Beyond complete myocardial revascularization: is it important and does it matter?

Constructing more than one graft per coronary system (left anterior descending, circumflex, right) has been widely and enthusiastically practiced for many years because it was thought to confer long-term freedom from major adverse coronary events. In reality the medical and surgical literature do not document the importance of maximizing the number of coronary vessels bypassed beyond one per system. Published series exhibit great variation in patient cohort, length of follow-up and lack the whole gamut of clinical endpoints. None of the published series provide an analysis based on subset stratification according to detailed coronary vessel anatomopathologic inventory in relation to revascularization strategy.

Results of bioprosthetic versus mechanical aortic valve replacement performed with concomitant coronary artery bypass grafting

BACKGROUND

Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG).

METHODS

From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease.

RESULTS

Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p < 0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p < 0.005; reoperation, 98% versus 98%, p = NS.

CONCLUSIONS

AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.

Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting

BACKGROUND

Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups.

HYPOTHESIS

The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged < or = 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients.

METHODS

In all, 112 young patients aged < or = 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function.

RESULTS

Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p < 0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p < 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p < 0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p < 0.05).

CONCLUSION

Compared with the older population, patients < or = 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.

Surgical myocardial revascularization

In conclusion, surgical myocardial revascularization has utilized diverse methods to increase blood flow to the starving myocardium. These methods initially used the microcirculation as the portal to reach myocytes until angiography showed that the obstructions were macrovascular. This resulted in a 30-year era of direct attack on the coronary blockages by coronary bypass. Surgical conduits unfortunately have longevity considerably less than that of native arteries and are limited in number. Alternative conduits, both biologic and prosthetic, have not yet proved to have the same clinical results as the ITA. More patients are living long enough to have the extensiveness of their disease exhaust conventional therapies. Newer therapy, restricted thus far to untreatables, revisits the microcirculation by making laser channels. These many innovative procedures have benefited hundreds of thousands of patients. They emerged from the probity and innovation of many individual surgeons.

Results of percutaneous coronary angioplasty in patients <40 years of age

This study examined factors influencing the outcome of percutaneous transluminal coronary angioplasty (PTCA) in patients <40 years of age. We followed 86 patients (mean age 37 years) treated from 1982 to 1994. The primary procedural success was 90%. At follow-up of 83 patients (97%) at a mean of 48 +/- 33 months (range 5 to 147), there had been 3 late deaths. Actuarial survival at 5 and 10 years was 95% and 91%, respectively. At review only 5% of patients had class III angina and no patient had class IV angina. Repeat revascularization (PTCA alone in 21 [25%], surgery in 8 [10%], or both in 10 [12%] patients) was performed for restenosis in 29 patients (35%) and for disease progression at other sites in 10 patients (12%). On multivariate analysis, a history of diabetes mellitus (p <0.02) was the only factor associated with death or a subsequent cardiovascular event (myocardial infarction, stroke, or hospital admission with unstable angina). At follow-up, 20 patients (24%) still smoked, 64 (77%) had a total cholesterol level > or = 200 mg/dl, 20 (24%) had a body mass index > or = 30, and 15 (18%) were not taking aspirin. In conclusion, PTCA in adults <40 years of age has excellent early results with a low morbidity and mortality. The medium-term prognosis and control of symptoms was good, although by 5 years, further revascularization was required in almost half of the patients.

Angiographic follow-up of internal thoracic artery for free bypass grafting

BACKGROUND

The use of free internal thoracic artery (ITA) grafts in patients with smaller body surface areas has been questioned because of technical difficulties and inadequate graft flow.

METHODS

To evaluate postoperative changes in the diameter of free ITA grafts, we performed coronary angiography immediately after coronary artery bypass grafting and then again at a mean of 42 +/- 6 months later. In 20 consecutively treated patients, 21 free ITAs were used as bypass conduits. Two ITA grafts that were patent at the time of the first angiography had closed at the second angiography. Postoperative changes in ITA graft diameter were measured in the 19 patent ITA grafts.

RESULTS

At the first angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.28 +/- 0.45 mm, 2.34 +/- 0.39 mm, and 2.12 +/- 0.38 mm, respectively. At the second angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.85 +/- 0.50 mm, 2.89 +/- 0.53 mm, and 2.72 +/- 0.53 mm, respectively. All segments of the ITA grafts had dilated significantly between the first and second angiographic evaluations (p < 0.01). The percentage change in graft diameter was greater when the initial ITA diameter was less than 2.3 mm (32.0% +/- 28.0%) than when it was 2.3 mm or more (18.8% +/- 11.3%) (p < 0.05).

CONCLUSIONS

The postoperative increase in free ITA graft diameter depends on coronary blood flow requirements.

Coronary revascularisation in young adults

OBJECTIVE

To evaluate the long-term outcome of coronary artery bypass surgery (CABG) in patients < 40 years old and to determine factors predictive of adverse outcomes.

METHODS

Retrospective review of data on 220 patients who underwent isolated CABG at Green Lane Hospital, New Zealand from 1970 to 1992.

RESULTS

The actuarial survival after surgery was 91, 74 and 50% at 5, 10 and 15 years, respectively. Recurrence of ischaemic symptoms occurred at a median time of 72 months, and only 20% of patients remained asymptomatic 10 years after CABG. Univariate analysis of potentially adverse surgical factors showed that patients who had prolonged bypass time (> or = 100 min, P < 0.007) had increased late mortality. There were two distinct operative eras with respect to the use of IMA conduits (4% pre 1985, 87% post 1984) The relationship between IMA conduits use and survival was significant on time independent analysis (P < 0.02), but was not using the log-rank test. Preoperative clinical characteristics associated with increased late mortality were impaired left ventricular function (end-systolic volume (ESV) > or = 80 ml, P = 0.008; ejection fraction < 40%, P = 0.0005), and lack of aspirin use either pre- or post-operatively (P < 0.0001). Multivariate analysis indicated that reduced ejection fraction (P = 0.04) and prolonged bypass time (P = 0.05) was associated with an increased risk of late death. Aspirin therapy (P = 0.001) was associated with decreased late mortality. Cumulative events rate of reintervention and mortality was reduced in female patients (P = 0.0009). At review, 45% of patients had total cholesterol > 6.5 mmol/l.

CONCLUSION

To avoid the early recurrence of symptoms, the need for reintervention and late mortality, young patients should receive IMA conduits, cardioplegia as myocardial protection, aspirin and therapy to modify/ameliorate their risk factors including dyslipidaemia, diabetes and left ventricular dysfunction.

Coronary artery bypass grafting in patients in their third decade of life

BACKGROUND AND AIM

Coronary artery disease (CAD) and coronary artery bypass grafting (CABG) in young patients are different than their older counterparts. The purpose of this study is to more fully define the issues of CABG in patients in their third decade of life.

METHODS

The medical records from all patients under forty years of age undergoing CABG at Allegheny University Hospital, Hahnemann Division, Philadelphia, PA from July 1990 to June 1995 were examined. Surgical outcome, psychosocial, and sexual issues were examined. Lipid analyses were compared perioperatively.

RESULTS

There were 43 male and 9 female patients. The mean age was 35 years (23 to 39 years). Risk factors included 43 (83%) patients with a history of smoking, 34 (65%) with familial hypercholesterolemia, 25 (48%) with a family history of CAD, 23 (44%) with hypertension, and 11 (21%) with diabetes. The mean preoperative serum cholesterol was 241 mg/dL. There were no hospital mortalities. Morbidities were found in 18 (35%) patients, including 9 (17%) cardiac, 5 (10%) pulmonary, 3 (6%) infectious, and 1 (2%) renal. In follow-up, three cardiac-related mortalities occurred within five years of surgery. Sixteen patients were readmitted to a hospital for cardiac related causes. Thirty-two (62%) patients failed to return to work, twenty-five (48%) failed to engage in regular exercise, and twenty-four resumed smoking. Psychosocial changes were found postoperatively in thirty (58%) patients. Eight (15%) patients admitted to sexual changes following surgery. Postoperative lipid profiles were minimally altered from preoperative values.

CONCLUSIONS

Surgical revascularization is successful in alleviating symptoms with minimal risk. Postoperatively, a number of cardiac related events occurred. A significant number of patients resume smoking, fail to engage in regular exercise, fail to resume work, and fail to take prescribed lipid-lowering agents. Psychosocial and sexual dysfunctions are prominent.

Right gastroepiploic-to-coronary artery bypass. The first decade of use

BACKGROUND

The right gastroepiploic artery was first used by us as a coronary artery bypass graft (CABG) in June 1984 and has become an accepted alternative conduit for myocardial revascularization.

METHODS AND RESULTS

We have now performed this operation in 126 patients (111 of whom were men) aged 32 to 78 years. The right gastroepiploic artery was used as a pedicle graft to the right main coronary artery in 25 patients, to its posterior descending branch in 90, to a left ventricular branch in 2, to branches of the circumflex system in 6, and to the left anterior descending artery in 1. Free (aortocoronary) gastroepiploic grafts were placed to circumflex branches in 2 patients. There were 2 hospital deaths (stroke, arrhythmia), and mean +/- SD postoperative stay was 7.5 +/- 2.0 days. All survivors were symptomatically improved and are functionally in New York Heart Association functional class I or II. There have been 3 late deaths (at 34, 50, and 84 months) in 2 to 120 months of follow-up (mean, 41.4 months). Angiography of bypass grafts and coronary arteries was performed in 44 patients at 7 days to 80 months postoperatively, providing direct evidence of gastroepiploic graft patency in 34 patients and strong indirect evidence in another 6; adequate data could not be obtained in 3 patients for technical reasons, and 1 graft was occluded.

CONCLUSIONS

These short-term, intermediate, and long-term results demonstrate the suitability of the right gastroepiploic artery as a CABG. The use of the right gastroepiploic artery as a graft to coronary arteries on the posterior wall of the heart, in conjunction with one or both internal mammary arteries, has the potential to allow complete myocardial revascularization with viable arterial grafts.

Late outcome after coronary artery bypass graft surgery in patients < 40 years old

BACKGROUND

Randomized trials confirm the long-term efficacy of coronary artery bypass graft surgery (CABG), although there are no randomized data in patients < 40 years old. Because these patients have been reported to have an early recurrence of symptoms, the long-term postoperative outcome was examined.

METHODS AND RESULTS

The long-term outcome of patients (n = 221) < 40 years old undergoing CABG at Green Lane Hospital, New Zealand, from 1970 to 1992 was determined. The 30-day mortality rate was 1.8% for initial and 9.5% for redo CABG. The median times to angina or myocardial infarction (recurrent ischemic event), further intervention, and death were 6.0, 9.6, and 14.2 years, respectively. Factors associated with increased late mortality on univariate analysis included end-systolic volume (ESV) > or = 80 mL (P = .004; 10-year mortality 19% versus 39% ESV > or = 80 mL), no internal mammary conduit (P = .01), no lipid-modifying therapy (P = .005), and no postoperative aspirin use (P = .0002); the latter was also associated with increased recurrent ischemic events (P = .04) or increased reintervention (P = .02). On stepwise logistic regression analysis, factors associated with increased late mortality were increasing ESV (P = .004), no internal mammary artery conduit (P = .009), diabetes (P = .04), and no postoperative aspirin (P = .02); the latter was also associated with increased recurrent ischemic events (P = .02). Hypercholesterolemia (> or = 6.5 mmol/L) was present in 65% of patients at presentation and 45% at follow-up.

CONCLUSIONS

To attempt to prevent recurrent ischemia or late death, patients < 40 years old who require CABG should receive internal mammary conduits, aspirin, lipid-modifying therapy, therapy to inhibit ventricular dilatation, and strict diabetes management.

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less

OBJECTIVE

To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less.

DESIGN

Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians.

SETTING

A tertiary referral cardiac centre.

PATIENTS

57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient.

RESULTS

The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival.

CONCLUSIONS

In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.

Comparison of thrombolytic therapy for acute myocardial infarction in patients aged < 35 and > 55 years

There are differences in the risk factor profile and coronary anatomy of young patients who develop coronary artery disease compared with those of older ones. There is an absence of data in published reports regarding the response to thrombolytic therapy and the outcome of acute myocardial infarction in young patients. Sixty-two patients aged < 35 years (group 1) were compared with 58 aged > 55 years (group 2) who presented with acute myocardial infarction and were treated with intravenous streptokinase. Group 1 had a significantly higher incidence of smoking (p = 0.0009) and a lower incidence of diabetes mellitus (p = 0.002) than did group 2. Fifty-eight patients in group 1 and 40 in group 2 were studied by angiography at a similar time (5 to 6 days) after admission. Patients in group 1 had a better left ventricular ejection fraction (55 +/- 13% vs 49 +/- 13%; p = 0.03), but similar patency rates of the infarct vessel (74 vs 73%) compared with those of group 2. Group 1 also had a higher incidence of insignificant disease (22.5 vs 2.5%; p = 0.008) and a lower incidence of 3-vessel disease (10 vs 37.5%; p = 0.004). This suggests that there are differences in the risk factor profiles and coronary anatomy of young patients compared with those of older ones. Despite similar benefits from thrombolytic therapy in the form of a patient infarct vessel, there may be differences in the long-term outcome among these patients.

Myocardial revascularization. Coronary angioplasty and bypass surgery indications

Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) have been performed increasingly over the last 20 and 10 years, respectively. The growth in PTCA is both complementary and threatening to CABG. The controversy between cardiologists and cardiac surgeons over the role of each procedure will no doubt continue as new devices are developed for coronary interventions. This article reviews the controversy and provides information to internists so that they will be fully prepared to advise patients about their treatment options.

Coronary artery bypass surgery in young patients

Coronary atherosclerosis is being increasingly observed in young patients. However results of surgery in such patients have so far been disappointing both in terms of operative mortality, symptomatic relief and long-term survival. Reasons given for this include the increased prevalence of risk factors in young patients and a higher incidence of graft occlusion. In the treatment of Asian patients, a further negative factor is the belief that coronary artery disease is more often diffuse and the vessels smaller. Between January 1987 and May 1991, a total of 66 patients under the age of 45 years at the time of surgery had coronary artery bypass grafting performed. The demographic, clinical, angiographic and operative data were analysed. Eighty-nine per cent of the patients were male and their racial distribution was 63% Chinese, 8% Malays, 26% Indians and 3% Others. Their mean age was 40.8 years. The presence of risk factors was high: 45.6% had hypertension; 34.8% were smokers; 21.2% had diabetes mellitus; and 12.1% had hyperlipidaemia. The main indication in these patients was either angina or a previous myocardial infarction (53%). There were no patients with perioperative infarction diagnosed by the presence of new Q wave. There was no hospital death. The stay of the patients ranged from 6 to 28 days with a mean of 10 days. Follow-up ranged from 3 to 54 months. There were no late deaths. It was concluded that there is a high incidence of risk factors among young patients with coronary artery disease, which follows the pattern of many other studies. The operative risk in these patients is low and morbidity is minimal.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome following coronary balloon angioplasty in young adults aged 35 years or less

The natural history of symptomatic young patients with coronary artery disease is often far from benign. Follow-up studies of young patients who have undergone coronary bypass graft surgery show frequent recurrence of symptoms and need for reoperation. Prompted by these considerations, we reviewed the records of 23 consecutive patients aged less than or equal to 35 years with symptomatic coronary artery disease, who underwent coronary balloon angioplasty at our center between August, 1984 and November, 1989. Mean patient age was 32 (3) (mean [SD]) years. Acute myocardial infarction was the first symptom of coronary artery disease in 7 (30%) of the 23 patients. At the time of angioplasty, 17 (74%) patients, had functional Class 3 or 4 anginal symptoms. Eight (35%) had multivessel coronary artery disease (stenoses greater than or equal to 70% in two or more major coronary arteries). Overall, a total of 36 critical coronary lesions were identified in 32 vessels of the 23 patients (mean of 1.6 lesions and 1.4 diseased vessels per patient). At angioplasty, dilatation of 31 lesions in 27 vessels was attempted. Multilesion angioplasty was attempted in 7 (30%) patients. Successful dilatation was achieved in 29 of the 31 (94%) lesions, and 25 of the 27 (93%) vessels. Primary clinical success (successful dilatation of all attempted lesions without any complications) was achieved in 21 of 23 (91%) patients. Three of the 21 patients with successful initial angioplasty had repeat angioplasty for restenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty in young adults: initial results and late outcome

The initial and late outcome of coronary angioplasty was studied in 148 patients less than 40 years of age (mean 36.4 +/- 3). Angioplasty was performed on a single vessel in 70% of patients and on multiple vessels in 30%; it was performed on a totally occluded vessel in 20%. Angioplasty was successful in 90.5% of patients, unsuccessful but uncomplicated in 7.4% and complicated by myocardial infarction in 0.7%, emergency bypass surgery in 0.7% and death in 0.7%. At late (mean 3.7 +/- 3 years; range 0.5 to 11.5) follow-up study after successful angioplasty, 94% of patients were alive, 79% were free of angina and 85% had returned to work; late myocardial infarction occurred in 4%. Actuarial survival at 5 years was 95%, and 85% of patients were free from death, infarction or bypass surgery. A second angioplasty was performed in 29 patients (22%) (mean 6.1 +/- 8.4 months) and was successful in 27 (93%), with no deaths. Elective coronary bypass surgery was performed in 8.5% of patients, with perioperative infarction in 9% and no deaths. By univariate analysis, late death was more likely to occur in hypertensive patients (15% versus 2.5%; p less than 0.01) and diabetic patients (21.4% versus 3.6%; p less than 0.01). Cox proportional hazard regression analysis identified hypertension (p = 0.007) and diabetes (p = 0.04) as independent time-related predictors of subsequent death. Thus, early and late results after coronary angioplasty in young adults are favorable, but certain risk factors are important predictors of outcome. Late revascularization procedures (repeat angioplasty or surgery) for restenosis or disease progression are common.

Total arterial revascularization of the heart using both mammary arteries and the right gastroepiploic artery

From April 1988 to April 1989, nine patients (seven men and two women) with coronary three-vessel disease and disabling angina underwent elective myocardial revascularization. None of the patients had available veins because of previous bypass procedures (three) or extensive varicosis (six). On standard cardiopulmonary bypass and cardioplegic arrest the right and the left mammary arteries (RIMA, LIMA) and the right gastroepiploic artery (RGEA) were anastomosed each to a major coronary branch (none of them as free graft) in each patient. All patients survived the operation but one, who died 2 weeks after the operation of a bilateral pneumonia. Autopsy revealed patent anastomoses. One patient had to be reexplored for bleeding. Two patients required temporary inotropic support. There was no perioperative myocardial infarction. All survivors were discharged home in an average of 18.7 days after the operation, are free from angina, and all have negative stress tests (mean follow-up 7.7 months) but one with severe coronary atherosclerosis who experiences slight exertional angina despite good patency of the grafts. Five patients were recatheterized after a mean interval of 5.4 months after operation revealing in all cases patent anastomoses. Total revascularization of the heart with arterial grafts is feasible, safe, and it could become the method of choice if patency persists in the long run.

Interactive effects of age and other risk factors on long-term survival after coronary artery surgery

The effect of age at the time of coronary artery bypass graft surgery on postoperative survival was studied in 2,507 patients with significant coronary artery disease. Patients were subdivided into five groups based on age at the time of surgery: 20 to 39, 40 to 49, 50 to 59, 60 to 69 and greater than or equal to 70 years. The observed death rate was compared with that expected for subjects from the general U.S. population matched for age, gender, race and calendar year. For patients less than or equal to 59 years of age, the ratio of observed to expected death rates was significantly greater than unity (observed/expected = 4.9 for ages 20 to 39, 1.9 for ages 40 to 49 and 1.3 for ages 50 to 59 years, p less than 0.01). The prevalence of risk factors, including diabetes mellitus, hypertension, hypercholesterolemia and cigarette smoking, was evaluated in the different age subgroups. When patients were subdivided on the basis of history of cigarette smoking, the decreased relative survival rate of younger (less than 60 years old) patients existed only in those who smoked (observed/expected = 6.0 for ages 20 to 39, 2.2 for ages 40 to 49 and 1.4 for ages 50 to 59 years). In nonsmokers, observed/expected ratios for every age group were not significantly different from unity. Thus, the reduced relative survival rate of younger patients after coronary artery bypass graft surgery may be attributed to the interactive harmful effects of cigarette smoking.

Myocardial revascularization with three native in situ arteries. Gastroepiploic and bilateral internal mammary artery grafting

Three native arteries were used for coronary artery bypass grafting in six patients in whom complete revascularization was not feasible because of varices or previous venous stripping. The right gastroepiploic and both internal mammary arteries were placed as pedicled conduits, and four patients additionally received a total of six vein grafts available from the greater or lesser saphenous system. Surgical complications were minimal and complete relief from angina was obtained in all patients, even in maximal stress testing. All 24 grafts were angiographically checked: 23 (96%) were patent and one gastroepiploic artery was occluded. All patients had at least three patent grafts. These native arteries are excellent conduits when suitable veins are not available. They should also be used on individual indications to replace occluded grafts.

Short-term outcome and long-term follow-up following coronary angioplasty in the young patient: an 8-year experience

From 8000 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures performed between 1980 and 1988, 89 separate PTCA procedures (1.1%) were performed in 71 patients less than or equal to 35 years of age. Multivessel disease was present in 41 patients (58%). Eleven procedures (12.4%) were done for acute myocardial infarction. Of 253 lesions attempted, 242 (95.6%) were successfully dilated. Complications consisted of just a single urgent bypass operation (1.1%). At mean follow-up of 32 months, 50 patients (72.5%) were asymptomatic. Late events consisted of one death (1.4%), four nonfatal infarctions (5.8%), and seven bypass surgeries (10.1%). Seventeen patients (24.6%) required 25 repeat PTCAs; restenosis was present in 12 of these patients while progression of native disease was noted in nine patients. In the young patient with coronary artery disease, PTCA can be performed safely, with a high success rate and few complications. Though the 3-year survival is excellent, a significant proportion of these patients develop nonfatal infarction or require repeat PTCA or bypass surgery, often for progression of native disease in addition to restenosis.

Factors influencing long-term (10-year to 15-year) survival after a successful coronary artery bypass operation

The long-term survival of 6,181 consecutive patients who underwent a coronary bypass operation from 1972 to 1986 was evaluated in relation to certain risk factors: age at the time of operation, sex, preoperative left ventricular function, presence of diffuse coronary artery disease, and previous coronary bypass operation. Advanced age markedly reduced the 10-year and 15-year survival. When compared with the general population, however, the survival of patients in the older age groups (over 60 years) exceeded that of the general population at 10 and 15 years. In patients under 55 years of age, the 10-year and 15-year survival is less than that of the general population. Male and female patients of comparable ages had virtually identical 10-year and 15-year survival rates. Severe left ventricular dysfunction, previous coronary bypass operation, and diffuse coronary artery disease requiring coronary artery endarterectomy all adversely affected the long-term survival rates. Within all age groups studied there was a significant benefit in survival with either one or more mammary artery bypass grafts. The data presented provide an important historical control group that can be used in evaluating the long-term results after successful coronary bypass operations.

Apolipoprotein B in human aortic biopsies in relation to serum lipids and lipoproteins

A total of 46 patients, aged 39-71 years (mean 57.7), were studied. Forty-eight percent of the patients were hyperlipidemic and 63% had earlier suffered a myocardial infarction. Biopsies from aorta were obtained during coronary bypass surgery. Apo B was extracted from the intima by incubation of the tissue in buffer, followed by collagenase digestion. Intimal apo B was quantified in an immunoradiometric assay. There were significant correlations between total or collagenase-extractable apo B and serum cholesterol (rs = 0.39, P less than 0.01), serum triglycerides (rs = 0.33, P less than 0.05), LDL cholesterol (rs = 0.33, P less than 0.05) and serum apo B (rs = 0.37, P less than 0.05). The correlations were strongest for the collagenase-extractable apo B, while no correlations were observed for the buffer-extractable intimal apo B. No significant correlations were found between intimal apo B and serum HDL, apo A-I, smoking habits, history of hypertension or sustained myocardial infarction. Follow-up data were available for 42 of the patients, with a mean follow-up period of 35.1 months. The patients were classified according to symptoms of angina pectoris at the time of follow-up. There were significantly lower levels of serum apo A-I in the patients with poorer clinical prognosis. In a linear multiple stepwise regression analysis, apo A-I and serum LDL were significantly and independently related to clinical prognosis (R2 = 0.31).

Coronary artery bypass surgery in patients less than 40 years of age

Coronary bypass patients less than 40 years of age were identified and compared with a control group previously studied at our hospital. In patients less than 40 years, the average age was 35 years. Men comprised 90.1 percent of group 1, and 83.4 percent of group 2. Operative mortality was 2.89 percent for group 1 and 2.1 percent for group 2. Patients less than 40 years were more likely to have positive family history (46.3 percent vs 21.94 percent), elevated cholesterol levels (25.62 vs 11.36 percent), and be smokers (59.09 vs 39.9 percent). Group 1 patients were less likely to have diabetes (4.54 vs 13.37 percent) or hypertension (18.18 vs 31.43 percent). The percentage of late deaths was much higher for younger patients. Postoperative angina and the need for reoperation was higher in group 1.

Retrograde flow in the internal mammary artery

Thirty-two patients undergoing coronary artery bypass grafting were studied to evaluate retrograde flow in the internal mammary artery (IMA). The left IMA pedicle was prepared in routine fashion from the level of the first rib superiorly to just distal to the IMA bifurcation. Following cannulation for cardiopulmonary bypass but before institution of extracorporeal circulation, the IMA was divided 5 mm proximal to its bifurcation and allowed to bleed freely. The flow from each end was then measured by allowing the segment to bleed for 30 seconds. The mean antegrade flow was 73 +/- 34 ml/min, and the retrograde flow was 25 +/- 17.2 ml/min. The difference between the flows was significant (p less than 0.05). Based on these data we do not recommend the retrograde IMA technique as a primary form of revascularization of the myocardium. In selected circumstances it may be used if adequate retrograde flow is demonstrated before constructing the anastomosis.

Coronary artery disease and coronary bypass grafting in young men: experience with 138 subjects 39 years of age and younger

One hundred thirty-eight men aged less than or equal to 39 years had coronary bypass grafting during a 13 year period. Angina was the presenting symptom in 77% and of these patients, one-third had unstable angina. More than half of the patients had experienced at least one myocardial infarct. There was a high incidence of coronary risk factors, especially smoking. Nineteen patients (13.8%) had left main coronary artery stenosis (it was isolated in two); 13.8, 24.6 and 60.2% had single, double and triple vessel disease, respectively. Left ventriculograms showed serious functional impairment in 42%. A total of 461 coronary bypass grafts, 3.34 per patient, were placed; almost all were vein grafts. There were no operative deaths. Transmural myocardial infarction occurred in 4.3% of patients. All bypass grafts were opacified angiographically early after operation, 95% at 1 year, 56% at 5 years and 26% at 10 years after operation. Some patients also had coronary angiograms, dictated by clinical events, between 1 and 5 and between 5 and 10 years postoperatively. Patency rates for bypass grafts were comparable with those previously reported and were acceptable, although they decreased with time. However, increasing evidence of atherosclerosis of bypass grafts was seen beyond 1 year, particularly beyond 5 years. Of 23 subjects with a coronary bypass reoperation, 2 died and 44% had perioperative transmural myocardial infarction. During follow-up, 13.8% of the patients died, survival being 95, 84 and 76% at 5, 10 and 12 years, respectively. It is considered that the patients were advantageously treated with coronary bypass grafting especially in the short-term. However, bypass graft patency steadily decreased with the passage of time and graft atherosclerosis became an increasingly important problem.

Myocardial infarction in young patients: an analysis by age subsets

We examined, in age subsets, 2643 patients with acute myocardial infarction. Clinical features and 1 year morbidity and mortality were compared in 203 young patients (less than 45 years), 1671 patients 46 to 70 years old, and 769 elderly patients (greater than 70 years). Ninety-two percent of young patients were men, and a family history of premature coronary artery disease was more common in young patients (41% compared with 28% of middle-aged and 12% of elderly patients). More young patients were currently smoking cigarettes (82% compared with 56% of middle-aged and 24% of elderly patients), and only 8% of young patients had never smoked. Previous myocardial infarction and history of angina pectoris or congestive heart failure were less common (p less than .001) in the young patients than in middle-aged and elderly patients. In-hospital mortality was only 2.5% for young patients, compared with 9.0% in middle-aged and 21.4% in elderly patients (both p less than .001). Postdischarge 1 year mortality was also strikingly low in young patients, at 2.6% compared with 10.3% in middle-aged and 24.4% in elderly patients. The incidence of reinfarction during the 1 year of follow-up was similar in all subsets. The statistical significance of 65 variables as predictors of 1 year mortality and reinfarction was tested and the following found to be significant (p less than .05): hospital discharge on antiarrhythmic drugs, digoxin, or diuretics; history of previous myocardial infarction or congestive heart failure; chest x-ray findings of heart failure; low ejection fraction; and atrial fibrillation. Thus, young patients entering the hospital have an excellent 1 year prognosis, but those with prior infarction in whom there are selected abnormal findings at hospital discharge comprise a subgroup that may benefit from early aggressive management.

Long-term survival of more than 2,000 patients after coronary artery bypass grafting

Among 2,004 patients who underwent their first coronary artery bypass graft operation between January 1970 and December 1980 without concomitant valve replacement or aneurysmectomy, life-table survival was 89% at 5 years and 80% at 8 years after surgery. In a multivariate Cox model analysis, the independent correlates of long-term survival were emergent operation with cardiogenic shock (multivariate mortality rate ratio [RR] = 14.0), use of a postoperative intraaortic balloon pump (RR = 3.9), ejection fraction less than 50% (RR = 2.4), preoperative history of congestive heart failure (RR = 2.2), cardiopulmonary bypass time (RR = 1.4 for each 30-minute increment), uncorrected mitral regurgitation (RR = 1.5 for each increment of angiographic gradation), left main coronary artery narrowing (RR = 1.7) and diabetes (RR = 1.6). After controlling for these factors, age, sex and the percentage of narrowings that were bypassed were not independent correlates of long-term survival.

Determinants of 10-year survival after primary myocardial revascularization

The first 1000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to elucidate the determinants of long-term survival. Five-year survival was 93.2%, and 10-year survival was 79.3%. Five-year survivals were 96.1%, 94.2%, 92.1%, and 90.8%, respectively, for single, double, triple, and left main disease. Ten-year survivals for the same subsets were 88.6%, 83.0%, 74.9%, and 70.9%. Five-year survivals were 95.3%, 92.4%, 88.0%, and 81.3% for patients with normal, mild, moderate, and severe impairment of the left ventricle. Ten-year survivals for the same subsets were 84.1%, 76.5%, 65.8% and 53.6%. Patients receiving internal mammary artery grafts had 95.6% and 85.8% 5- and 10-year survivals that were superior to 92.0% and 76.2% in patients with only vein grafts. Patients completely revascularized had 95.0% and 82.5% 5- and 10-year survivals, while incompletely revascularized patients had lower (90.5% and 75.2%) 5- and 10-year survivals. Advancing age was the most important factor influencing late survival. Other risk factors in descending order of significance were impaired left ventricular function, no mammary artery graft, smoking, abnormal EKG, three vessel or left main disease, left ventricular end diastolic pressure (LVEDP) greater than 24, hypertension, 1971 to 1974 surgical era, cholesterol greater than 300, incomplete revascularization, and two vessel disease.