Survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

Objective

Long-term survival after off-pump surgery in patients with low ejection fraction was investigated.

Methods

Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery.

Results

The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients.

Conclusions

OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.

In-hospital mortality and complications after coronary angioplasty, City of Rio de Janeiro, Southeastern Brazil

OBJECTIVE

To estimate in-hospital mortality and prevalence of complications of percutaneous transluminal coronary angioplasty (PTCA) in public hospitals.

METHODS

Data for 2,913 PTCA were obtained from the Brazilian National Health System (SUS) Hospital Authorization Database in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2003. After simple random sampling and data weighting, 529 medical records of patients undergoing PTCA, including all deaths, in four public hospitals (federal and state university, and federal and state reference hospitals) were studied. Comparison tests of mortality according to patient characteristics, comorbidities, complications, types of PTCA procedures, and indications for PTCA were performed using Poisson's regression models.

RESULTS

The overall in-hospital mortality was 1.6% (range: 0.9-6.8%). The age distribution of mortality was as follows: 0.2% in patients younger than 50; 1.6% in those 50-69; and 2.7% in those older than 69. High mortality was seen in primary and rescue PTCAs: 17.4% and 13.1%, respectively; and mortality in elective PTCA was 0.8%. The main complications during PTCA were dissection (5%; mortality: 11.5%) and artery occlusion (2.6%; mortality: 21.8%). Bleeding was seen in 5.9% of the patients (mortality: 5.6%) and 3.0% required blood transfusion (mortality: 12.0%). The complication of acute myocardial infarction was seen in 1.1% of patients (mortality: 38%) and stroke was associated with a mortality of 17.5%.

CONCLUSIONS

The cardiac in-hospital mortality was high when PTCA was performed for a patient with ST elevation acute myocardial infarction. Elective PTCA had mortality and complications levels above the expected in four public hospitals in the main city of Rio de Janeiro.

Short- and long-term outcomes of percutaneous coronary interventions in patients with severe left ventricular dysfunction

AIMS

Poor left ventricular function is considered a high risk condition for performing either percutaneous (PCI) or surgical revascularisation. The aim of this study was to evaluate immediate and long term results of PCI in patients with coronary artery disease (CAD) and severe left ventricular dysfunction (EF < 0.30).

METHODS AND RESULTS

Seventy-eight consecutive patients with CAD and severe left ventricular dysfunction (EF < 30%) were selected. The majority of these patients (87%) had multivessel disease. Coronary angioplasty procedure was mainly motivated by angina associated with clinical manifestation of heart failure (54%). Total number of treated vessels was 181, and a total of 203 stents were implanted (2.6 stent/patient). Procedural success was achieved in 77 patients (97.8%). The total procedural and in-hospital adverse event rate was 7.8%. Mean follow-up period (FU) was 25+/-6 months. Event-free survival rate at the end of FU was 55%; repeat revascularisation was performed in 21 patients (27.6%). Female gender, diabetes, new acute myocardial infarction and number of treated vessels were independent predictors for death and combined mayor adverse cardiac events (MACE) during the follow-up.

CONCLUSIONS

In symptomatic patients with CAD and severe left ventricular dysfunction, PCI can be performed with excellent procedural outcome and acceptable long-term morbidity and mortality.

Percutaneous coronary stenting in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis

AIMS

There is uncertainty on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with left ventricular dysfunction (LVD). We thus performed a systematic review of studies reporting on PCI in LVD.

METHODS AND RESULTS

Pertinent studies were searched in PubMed, and included if reporting on >/=30 patients, with ejection fraction < 50%, and prevalently (>60%) treated with stents. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) at the longest follow-up. Outcomes were pooled with random-effect methods (95% confidence intervals). We retrieved 11 studies including 1,284 patients with ejection fraction <50% (specifically <40% in 1,033 and <30% in 211). All studies but one reported on bare-metal stenting only. In-hospital MACE occurred in 5% (3-6), with death in 2% (1-3), myocardial infarction in 3% (2-4), and repeat revascularisation in 1% (0-2). After a median of 18 months, MACE occurred in 33% (30-36), with death in 11% (9-13), myocardial infarction in 7% (6-9), and repeat revascularisation in 15% (13-18). Meta-regression suggested the beneficial impact of drug-eluting stents on MACE (p=0.030).

CONCLUSIONS

Currently available data support the adoption of percutaneous revascularisation in carefully selected patients with LVD. While event attrition remains substantial at long-term follow-up, drug-eluting stents hold the promise of significantly improving event-free and overall survival.

Effects of heart failure and diabetes mellitus on long-term mortality after coronary revascularization (from the BARI Trial)

This study evaluated the effect of heart failure (HF) and ejection fraction (EF) at baseline on long-term cardiac mortality in patients undergoing coronary revascularization and investigated the effect of diabetes mellitus (DM) on mortality. We evaluated long-term outcomes of patients without HF, HF and a preserved EF, and HF and a decreased EF who underwent revascularization with percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery after enrollment in the Bypass Angioplasty Revascularization Investigation (BARI) trial. Ten years after initial revascularization, cumulative rates of freedom from cardiac death were 90% in patients without HF, 75% in patients with HF and a preserved EF, and 59% in patients with HF and a decreased EF (p <0.001, 3-way comparison). In diabetic patients with HF and a preserved EF, there was a significant increase in cardiac mortality compared with patients without HF (p <0.001); however, this relation was not seen in patients without DM. In conclusion, patients with HF and a preserved EF have increased mortality over 10 years compared with those without HF. Only in patients with DM did HF with preserved EF confer additional risk.

The impact of ejection fraction on outcomes after percutaneous coronary intervention in patients with congestive heart failure: an analysis of the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry and Dynamic Registry

BACKGROUND

Patients with congestive heart failure (CHF) have higher rates of adverse outcomes after percutaneous coronary intervention (PCI). A comprehensive analysis of outcomes in patients with CHF in the current era has not been done. We studied the outcomes of patients with CHF who underwent PCI in the National Heart, Lung, and Blood Institute-sponsored Percutaneous Transluminal Coronary Angioplasty (PTCA) and Dynamic registries.

METHODS

We evaluated demographic and angiographic characteristics and the clinical outcomes of patients with CHF in the Dynamic Registry and the PTCA Registry, excluding patients with acute myocardial infarction. In the Dynamic Registry, patients with CHF (n = 503) were compared with patients without CHF (n = 4194), and patients with CHF with a preserved ejection fraction (EF) (n = 134) were compared with patients with CHF who have a reduced EF (n = 199). The patients with CHF in the 1997 through 2001 Dynamic Registry (n = 236) were then similarly compared with patients with CHF in the earlier PTCA Registry (n = 117).

RESULTS

In the Dynamic Registry, compared with patients without CHF, patients with CHF had a higher-risk clinical and angiographic profile, and a higher mortality rate both inhospital (2.6% vs 0.4%, P < or = .001) and at 1 year (13.1% vs 3.0%, P < .001). Patients with reduced EF had higher inhospital mortality rates and a trend toward higher mortality at 1 year. The patients with CHF in the Dynamic Registry compared with those in the PTCA Registry had a higher risk profile yet had significantly higher procedural success rates and improved clinical outcomes.

CONCLUSIONS

Although CHF remains a strong predictor of adverse outcomes after PCI, significant improvement seen in the past decade is likely related to improved procedural techniques and improved medical therapy.

Comparison of in-hospital and one-year outcomes in patients with left ventricular ejection fractions <or=40%, 41% to 49%, and >or=50% having percutaneous coronary revascularization

Outcome studies of percutaneous coronary intervention (PCI) with conventional balloon angioplasty have established increased in-hospital and 1-year mortality in patients with left ventricular (LV) dysfunction compared with others. It is unclear whether recent PCI practice innovations, including stents and adjunctive pharmacotherapy, have made PCI safer and more effective in patients with LV dysfunction. We evaluated the influence of LV ejection fraction (EF) indexes on in-hospital and 1-year outcomes in 1,458 patients within the National Heart, Lung, and Blood Institute-sponsored Dynamic Registry. Patients (n = 300) with acute myocardial infarction were excluded. The remaining 1,158 patients were subdivided into 3 categories: group 1, EF <or=40% (n = 166); group 2, EF 41% to 49% (n = 126); and group 3, EF >or=50% (n = 866). We determined the frequency of individual and composite adverse events (death/myocardial infarction [MI]/coronary artery bypass grafting) at discharge and 1 year. In the Dynamic Registry patients, mean EF in the 3 groups was 32%, 45%, and 62% and in-hospital mortality was 3.0%, 1.6%, and 0.1%, respectively (p <0.001). The composite end point of death/MI was also significant, but other in-hospital adverse events did not differ between groups. The respective mortality rates were 11.0%, 4.5%, and 1.9% (p <0.001) after 1 year. The composite end points of death/MI and death/MI/coronary artery bypass grafting also occurred more frequently in group 1 patients. Thus, significant LV dysfunction was still associated with increased in-hospital and 1-year mortality in patients having contemporary PCI.

Clinical outcome of coronary angioplasty in patients with ischaemic cardiomyopathy

OBJECTIVE

To assess the clinical outcome of successful percutaneous transluminal coronary angioplasty (PTCA) in patients with poor ventricular function.

METHODS

Analysis of angiographic, echocardiographic and clinical records of patients with severe LV dysfunction who underwent PTCA from January 1, 1995 to December 31, 1997 was undertaken. Forty-one patients aged 63+/-10 years, 36 men, all with significant coronary artery disease and impaired LV function (fractional shortening, FS<or=20%) were identified. Patients' data before and after angioplasty were analyzed.

RESULTS

Post PTCA: angiographic success was 95.2%. Major complications occurred in 19.5% and hospital mortality was 2.7%. At 6 months after PTCA:LV fractional shortening (FS) increased from 15.9+/-3.4% to 19.6+/-6.6%, P=0.02 and consequently cardiac output from 4.28+/-0.98 to 5.34+/-1.77 l/min, P<0.01. Change in at least one class of angina and cardiac functional status was observed in 46% of patients, P<0.001, and this was maintained to the end of the year. After 12 months follow-up: restenosis occurred in 10.8%; mortality was 5.4%; event-free and actuarial survivals were 62.3% and 91.9%, respectively.

CONCLUSIONS

In patients with severe LV dysfunction, continued symptomatic improvement can be achieved with successful coronary angioplasty. This is associated with significant recovery of LV systolic function and cardiac output. In order to minimize procedure-related complications, careful patient selection should be considered.

Procedural results of coronary angioplasty but not late mortality have improved in patients with depressed left ventricular function

BACKGROUND

Published experience with coronary angioplasty in patients with severely depressed left ventricular (LV) ejection fraction indicates that procedural complications are more frequent in such patients than in those with normal or near normal LV function. Although the immediate outcomes of transcatheter revascularization in unselected populations have improved substantially since the procedures upon which these reports were based were performed, outcomes with this subset of patients has not been recently reviewed.

HYPOTHESIS

This study was undertaken to document the results of the application of current transcatheter technology to this patient subset.

METHODS

We analyzed data from 194 consecutive patients with a visually estimated LV ejection fraction < 30%, who underwent coronary angioplasty in this institution between January 1, 1995, and April 30, 1996, and compared their outcomes with those of 1,390 patients with normal LV function treated concurrently.

RESULTS

Angiographic success in the two groups was similar. The hospital mortality of the patients with low ejection fraction was higher (2.6 vs. 0.6%, p = 0.02) than in concurrently treated patients with normal LV function. Other procedural complications were no more frequent than in such patients. Late mortality in patients with low ejection fraction was 16%, a similar value to that in older reports.

CONCLUSION

Compared with older reports, current hospital outcomes of coronary angioplasty are improved in patients with severely depressed LV function. Unfortunately, late outcomes are not demonstrably better.

Cardiogenic shock: thrombolysis or angioplasty?

Cardiogenic shock (CGS) occurs in 3 to 20% of patients presenting with acute myocardial infarction (MI), and it generally involves dysfunction of at least 40% of the total myocardial mass. Prior to the advent of balloon angioplasty and thrombolysis, in-hospital mortality was greater than 75%. This mortality rate has been consistent in reported series despite the advent of cardiac intensive care units, vasopressor, inotropic, and vasodilator therapy. Intra-aortic balloon counterpulsation therapy provides hemodynamic improvement, and it may provide some mortality benefit when used in conjunction with appropriate revascularization. Survival studies have shown that patency of the infarct-related artery is a strong predictor of survival. No randomized trials have been completed to examine which reperfusion therapy best treats this emergent situation. Subgroup analysis of large scale, multicenter trials, although underpowered, has shown no improvement in mortality with use of thrombolytic agents, leading many to advise use of mechanical intervention. In patients who present with acute MI with contraindications to thrombolysis, primary angioplasty is the treatment of choice. At selected centers, primary angioplasty is comparable to or better than thrombolytic therapy for patients presenting with acute MI, with or without CGS. Studies examining angioplasty in patients with CGS have shown high procedural success rates (75%) and reduced in-hospital mortality (44%), particularly in those patients with successful revascularization. Emergency bypass surgery may improve survival, but it is costly, unavailable to many, and often leads to excessive delays in therapy. If available, we believe that primary angioplasty is the treatment of choice for patients with CGS.

Percutaneous cardiopulmonary bypass-supported coronary angioplasty in patients with unstable angina pectoris or myocardial infarction and a left ventricular ejection fraction < or = 25%

The objective of this study was to determine the acute and long-term results of percutaneous cardiopulmonary bypass-supported angioplasty in treating high-risk patients with unstable presentations and severely depressed left ventricular (LV) function (ejection fraction [EF] < or = 25%). One hundred seven consecutive patients with a mean LVEF of 19 +/- 3% were studied. Seventy-four patients (69%) had unstable angina, 60 (56%) had New York Heart Association class III or IV symptoms, 74 (69%) had recent (< 15 days) documented acute myocardial infarction, 103 (96%) had 3-vessel disease, and 58 (54%) had only 1 remaining patent artery. A total of 50 patients (47%) were deemed unsuitable for bypass surgery. Of 196 severe narrowings attempted in 166 coronary arteries, 193 (98%) were successfully dilated in 105 patients (98%), and there was no procedure-related mortality, Q-wave myocardial infarction, or urgent requirement for coronary bypass surgery. There were 5 in-hospital deaths (4.7%) and the remaining 102 patients have been followed for 24.5 +/- 1.3 (mean +/- SE) months. Twenty-three patients (21%) died between 1 and 23 months after the procedure. One- and 2-year survival free of cardiac death was 83% and 77%, respectively. Of the 79 surviving patients, 65 have survived event free of myocardial infarction and revascularization; event-free survival for 1 and 2 years was 76% and 69.5%, respectively. In the 64 patients in whom LV function was measured before and after the procedure, global EF increased from 20.6% to 29.3% (p < 0.001). Patients who remained event free had a greater improvement in LVEF than those who had a cardiac event during follow-up (p < 0.05). Thus, this study demonstrates the safety and efficacy of percutaneous cardiopulmonary bypass-supported angioplasty in the immediate treatment of high-risk unstable patients with multivessel coronary artery disease and severely depressed LV function.