Circulation, Vol 87, 21-29, Copyright © 1993 by American Heart Association
DR Holmes Jr, KM Detre, DO Williams, KM Kent, SB King 3d, W Yeh and A Steenkiste
BACKGROUND. Coronary revascularization with bypass has been shown to
improve survival in patients with coronary artery disease and left
ventricular dysfunction. In these patients, use of nonsurgical
revascularization with percutaneous transluminal coronary angioplasty
(PTCA) is increasing, although their long-term outcome has not been well
delineated. The purpose of this investigation was to characterize the
outcome of angioplasty in patients with decreased left ventricular function
and contrast it with the results in patients with normal left ventricular
function. METHODS AND RESULTS. In the 1985-1986 National Heart, Lung, and
Blood Institute's PTCA Registry, of 1,802 patients undergoing PTCA, 244
patients (13.5%) had an ejection fraction of < or = 45% (mean, 39.6 +/-
6.8%). These patients had a higher incidence of prior infarction, a longer
and worse history of manifestations of coronary disease, and more extensive
coronary artery disease than patients with well-preserved function; 88% and
91%, respectively, had successful dilation of at least one lesion
(nonsignificant difference). However, patients with decreased left
ventricular function had a decreased frequency of successful dilation of
all lesions in which PTCA was attempted (76% versus 84%, p < 0.01).
There were no statistically significant differences in in-hospital
complications--death occurred in 0.8% and 0.7%, nonfatal myocardial
infarction occurred in 4.9% and 4.5%, and emergency surgical
revascularization was performed in 4.5% and 3.2%, respectively. Patients
were followed for a mean of 4.1 years; during this time, patients with
decreased left ventricular function had significantly worse survival and
combined event-free survival. Despite this, at 4 years, 87% of the patients
with a mean ejection fraction of 39.6% remained alive, and 77% were alive
and had not experienced infarction or required bypass. CONCLUSIONS. PTCA is
effective in selected patients with depressed left ventricular function.
Initial outcome and risk-benefit ratio are excellent. Successful dilation
of at least one vessel was achieved in 88% of patients with depressed left
ventricular function and in 91% of patients with more normal left
ventricular function. The former group, however, had a decreased incidence
of successful dilation in all lesions in which dilation was attempted (76%
versus 84%, p < 0.01). There was no significant difference in
in-hospital complications between the two groups. During follow-up,
patients with decreased left ventricular function had worse event-free
survival, although 77% were alive without infarction or bypass grafting at
4 years.
ARTICLES
Long-term outcome of patients with depressed left ventricular function undergoing percutaneous transluminal coronary angioplasty. The NHLBI PTCA Registry
Mayo Clinic, Rochester, MN 55905.
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