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The Journal of Thoracic and Cardiovascular Surgery, Vol 105, 864-879, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
BS Allen, GD Buckberg, FM Fontan, MM Kirsh, G Popoff, F Beyersdorf, JN Fabiani and C Acar
Although percutaneous transluminal coronary angioplasty is successful in
more than 90% of patients after acute coronary occlusion, overall mortality
remains approximately 10% with higher subgroup mortality (i.e., occlusion
of the left anterior descending coronary artery, multivessel disease, age
older than 70 years, cardiogenic shock) and early recovery of regional wall
motion is marginal. This multicenter report shows that controlled surgical
reperfusion in patients with acute coronary occlusion reduces overall and
subgroup mortality and restores substantial early contractility. In a
survey from six institutions, 156 consecutive patients with acute coronary
occlusion documented by angiography underwent surgical revascularization
with controlled reperfusion using amino acid-enriched blood cardioplegic
solution on total vented bypass. Ventricular wall motion was studied by
echocardiography or multiple gated acquisition scan on postoperative days 5
to 7 and scored independently (0 = normal, 1 = mild hypokinesia, 2 = severe
hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared with
results in 1203 patients with acute coronary occlusion treated by
angioplasty in five reported medical series. Surgically treated patients
were revascularized at longer ischemic intervals (6.3 versus 3.9 hours, p
< 0.05) and had a greater incidence of left anterior descending
occlusion (61% versus 43%, p < 0.05), multivessel disease (42% versus
22%, p < 0.05), and cardiogenic shock (41% versus 10%, p < 0.05),
with 12 patients undergoing cardiopulmonary resuscitation en route to the
operating room. Surgical results were superior in all categories, with
overall mortality reduced from 8.7% after angioplasty to 3.9% after
coronary bypass (p < 0.05). All surgical deaths occurred in patients
with preoperative cardiogenic shock. Regional wall motion recovered
significantly (score < 2) in 131 of 150 (87%) surgically treated
patients with an average score of 0.9 +/- 0.8 (normal to mild hypokinesia)
despite longer ischemic times.
ARTICLES
Superiority of controlled surgical reperfusion versus percutaneous transluminal coronary angioplasty in acute coronary occlusion
University of California, Los Angeles School of Medicine, Department of Surgery.
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