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Biomedical subjects

B D Rutherford

Publications and source records attributed to B D Rutherford.

At least 19 recordsLinked to original sources
PubMed1996

Results of direct percutaneous transluminal coronary angioplasty in octogenarians.

Direct percutaneous transluminal coronary angioplasty (PTCA) has emerged as effective reperfusion therapy for acute myocardial infarction; however, few data exist on its use in octogenarians. Thrombolytic therapy in this age group has reduced early mortality from approximately 30% to 20%, but is associated with an increased risk of stroke and major hemorrhage. We analyzed the acute and long-term results of direct PTCA performed on patients aged > or = 80 years at our institution between 1980 and 1993. The study group consisted of 55 patients (mean patient age 83.3 +/- 2.3 years). Infarcts were anterior in 27 patients (49%). Cardiogenic shock was present in 6 patients (11%). The mean time to reperfusion was 4.3 +/- 2.8 hours. Direct PTCA was successful in 53 patients (96%). There were no emergent bypass operations. In-hospital death occurred in 9 patients (16%), including 4 of 6 (67%) presenting in cardiogenic shock and 5 of 49 (10%) who were hemodynamically stable on presentation. Repeat PTCA for recurrent ischemia was performed in 6 patients (11%). There were no strokes during hospitalization. Bleeding complications requiring blood transfusion were present in 4 patients (7%). Thirty-day mortality was 16% and 1-year actuarial survival was 67%. Direct PTCA in patients aged > or = 80 years can be performed safely with a high procedural success rate. The clinical outcome with PTCA in this high risk subset of patients compares favorably with that reported previously for both thrombolytic and medical therapy.

Actuarial Analysis↗
PubMed1994

Directional atherectomy of left main stenoses.

Balloon angioplasty (PTCA) of left main (LM) stenoses is limited by frequent clinical restenosis. Directional coronary atherectomy (DCA) may be an effective alternative to PTCA due to its ability to achieve a greater postprocedural luminal diameter when treating bulky, eccentric plaques and aorto-ostial lesions. We analyzed the acute and long-term results following 24 DCA procedures in 22 patients with "protected" LM lesions. Acute success (residual stenosis < or = 40%, no major ischemic complications) was 88% overall, 100% in 13 planned procedures, and 73% in 11 adjunctive DCA procedures that followed suboptimal PTCA. Mean LM stenosis was reduced from 86% to 13% (P < 0.01). There were no procedural complications directly attributed to DCA. At a mean of 24 +/- 3 months, the clinical restenosis rate was 16%, survival was 100%, and event-free survival (freedom from death, MI, or repeat lesion-related interventions) was 89%. We conclude that DCA in protected LM lesions (1) can achieved excellent angiographic results with low procedural complication rates, (2) may succeed where PTCA yields suboptimal results, and (3) may provide late clinical outcomes superior to those of balloon angioplasty.

Angioplasty, Balloon, Coronary↗
PubMed1994

Initial and long-term outcome of 83 patients after balloon angioplasty of totally occluded bypass grafts.

OBJECTIVES: This study was designed to evaluate the safety and short- and long-term results of coronary angioplasty of totally occluded bypass grafts in patients with clinical conditions other than acute myocardial infarction. BACKGROUND: Total occlusion of bypass grafts after coronary artery surgery often causes recurrent ischemia. The safety and results of percutaneous transluminal coronary angioplasty in occluded bypass grafts are controversial. METHODS: All patients with dilation of a totally occluded bypass graft attempted between 1981 and 1991 were retrospectively identified from a data base. Patients treated in the setting of an acute myocardial infarction were excluded. Eighty-three patients met these criteria and constitute the study group. Hospital records, office charts and procedural reports were reviewed in all patients to supplement details available in the data base. RESULTS: The time from bypass surgery to attempted coronary angioplasty ranged from 1 to 226 months (mean time 88 months). The mean (+/- SD) duration of graft occlusion was 31 +/- 46 days (range 1 to 180). In 27 attempts the bypass graft was the only site dilated, and in 56 attempts (68%) one to six other sites (n = 101) were dilated. Angiographic success (< or = 40% residual lumen stenosis) was achieved in 61 grafts (73%) and 98 of the additional sites (97%) (p < 0.001). Major complications included one procedural death and two Q wave infarctions. Follow-up for a mean of 32 months demonstrated a 1- and 3-year actuarial survival rate of 94% and 80%, respectively. At 3 years, only 34% of patients were free of repeat angioplasty or surgery. CONCLUSIONS: Angioplasty of totally occluded bypass grafts can be successful in the majority of selected patients, although major complications can occur. Strategies for sustained patency are needed to improve the long-term results.

Aged↗
PubMed1993

Primary angioplasty for acute myocardial infarction in 1,000 consecutive patients. Results in an unselected population and high-risk subgroups.

Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has remained an exclusive and consistent method of infarct intervention at our institution over the past 13 years. A total of 1,000 consecutive patients were prospectively enrolled in our primary angioplasty database. Of patients presenting to our group with an acute myocardial infarction, 96% of those eligible received immediate angioplasty. Cardiogenic shock was noted in 79 patients (7.9%). The mean time from pain onset to reperfusion was 5.4 +/- 4.0 hours. Infarct-vessel recanalization was accomplished in 94% of patients. Recanalization rates were similar among the 3 native epicardial coronary systems but were lower in bypass grafts (86%; p < 0.0001). Overall in-hospital mortality was 7.8%; mortality with cardiogenic shock was 44%. Global ejection fraction increased from 49.7% preangioplasty to 57.4% at the time of dismissal. The amount of myocardial salvage was highly dependent on the size of the initial infarction (the largest infarctions benefiting the most). Patients reperfused in < 2 hours experienced a very low mortality (4%) and impressive myocardial salvage. Complications included stroke in 0.5%, significant bleeding in 2.8%, and early reocclusion of the infarct vessel in 13%. Primary angioplasty is broadly applicable to patients presenting with acute myocardial infarction and results in a very high rate of infarct vessel recanalization, with a mortality rate of 7.8%. This strategy may be uniquely effective in patients presenting with cardiogenic shock, large infarctions, contraindications to thrombolytic therapy, and prior bypass surgery.

Age Factors↗
PubMed1993

Failed direct coronary angioplasty for acute myocardial infarction: in-hospital outcome and predictors of death.

OBJECTIVES: The purpose of this study was to compare the mechanisms, predictors and outcome of patients with failed direct coronary angioplasty of the infarct-related artery with those in patients with successful direct angioplasty. BACKGROUND: Direct coronary angioplasty of the infarct-related artery, without antecedent thrombolytic therapy, is an effective treatment for patients with acute myocardial infarction. Concern has been expressed over high mortality rates in patients with failed direct infarct angioplasty. METHODS: All patients treated by angioplasty were prospectively entered into a computer data base. The characteristics and outcome of all patients with failed direct angioplasty were reviewed and compared with those of patients with successful direct angioplasty. RESULTS: Direct angioplasty was successful in 705 (94%) of 750 patients and unsuccessful in 45 (6%). Patients in the failure group were more likely to be in cardiogenic shock (22% vs. 7%, p < 0.003), to have had a previous myocardial infarction (44% vs. 28%, p < 0.03) and to have three-vessel coronary artery disease (44% vs. 23%, p < 0.003). Age, gender, ejection fraction, previous bypass surgery and diabetes mellitus were similar in both groups. Only the presence of multivessel coronary artery disease (p < 0.004) and cardiogenic shock (p < 0.025) were independent predictors of failed direct angioplasty. In-hospital death (31% vs. 4.8%, p < 0.001) and the need for emergency coronary artery bypass surgery (27% vs. 0.5%, p < 0.0001) were more frequent in patients with unsuccessful than in patients with successful direct angioplasty. Patients with failed direct angioplasty and in-hospital death usually had multiple high risk characteristics, including cardiogenic shock (50%), previous myocardial infarction (43%) and multivessel coronary artery disease (93%). CONCLUSIONS: Direct coronary angioplasty is an effective method for establishing reperfusion in acute myocardial infarction. Procedural failure is infrequent, usually occurring in patients with high risk baseline characteristics.

Adult↗
PubMed1992

Myocardial salvage with direct coronary angioplasty for acute infarction.

To assess the changes in myocardial function following direct coronary angioplasty, we evaluated 323 consecutive patients undergoing coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction. Left ventricular function was evaluated using contrast ventriculography immediately preangioplasty and at the time of predismissal follow-up angiography (a mean of 7 days after infarction). The global ejection fraction increased from 52.6% to 58.9% (p less than 0.0005). Multivariate correlates of improved global left ventricular function included baseline ejection fraction less than or equal to 45%, and a patent infarct vessel at the time of predischarge follow-up angiography. Systolic function in the infarct zone improved by a mean of 30%. Logistic regression analysis identified sustained infarct vessel patency and anterior myocardial infarction as multivariate correlates of improved regional function in the infarct zone. In patients presenting with baseline ejection fractions less than or equal to 40%, the mean ejection fraction increased from 28% to 42%. Long-term survival was compromised in patients with global ejection fractions of less than or equal to 40% at the time of dismissal. Thus significant improvement in left ventricular function can be expected in the majority of patients undergoing direct infarct angioplasty. The myocardial salvage appears to be most significant in patients suffering large infarctions, and in those with sustained infarct vessel patency.

Aged↗
PubMed1991

Safety and efficacy of percutaneous transluminal coronary angioplasty in patients with left ventricular dysfunction.

The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.

Adolescent↗
PubMed1991

Results of multivessel percutaneous transluminal coronary angioplasty in persons aged 65 years and older.

Between 1981 and 1990, 1,373 patients, aged greater than or equal to 65 years (mean 71.2 +/- 4.9), underwent 1,640 multivessel percutaneous transluminal coronary angioplasty (PTCA) procedures. Of these, 224 patients (13.6%) had a left ventricular ejection fraction less than or equal to 40%, 412 (25.1%) had prior coronary artery bypass grafting (CABG) and 48 (2.9%) had left main artery dilatation. Of the 1,640 PTCA procedures, 697 were in patients with 2-vessel disease and 943 were in patients with 3-vessel disease. A mean 3.5 lesions were dilated per patient, with an overall angiographic success rate of 96%. Complete revascularization was achieved in 857 (52%). A total of 52 patients (3.2%) had a major in-hospital complication: 27 patients (1.6%) died, 24 (1.4%) had a Q-wave myocardial infarction, and 14 (0.8%) underwent emergent CABG. Stepwise logistic regression analysis identified ejection fraction less than or equal to 40% (p less than or equal to 0.001), 3-vessel disease (p less than or equal to 0.01), female gender (p less than or equal to 0.02), and PTCA between 1981 and 1985 (p less than or equal to 0.05) as independent predictors of mortality. Of the 1,373 patients, 1,023 have been followed for greater than or equal to 1 year (mean follow-up 32.5 +/- 21.3 months). There were 156 (15.2%) late deaths, 81 (7.9%) recurrent myocardial infarctions, and 162 (15.8%) coronary artery bypass operations. Actuarial survival, computed from the time of hospital discharge, was 92% at 1 year, 86% at 3 years and 78% at 5 years. Repeat PTCA was required in 371 patients (36.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Timing and mechanism of in-hospital and late death after primary coronary angioplasty during acute myocardial infarction.

The effect of early myocardial reperfusion on patterns of death after acute myocardial infarction (AMI) is unknown. Thus, the mechanism and timing of in-hospital and late deaths among a group of 614 patients treated with coronary angioplasty without antecedent thrombolytic therapy for AMI were determined. Death occurred in 49 patients (8%) before hospital discharge. Four patients died in the catheterization laboratory. Death was due to cardiogenic shock in 22 patients, acute vessel reclosure in 5 patients, was sudden in 8 patients and followed elective coronary artery bypass surgery in 8 patients. Cardiac rupture was observed in only 2 patients after failed infarct angioplasty, and did not occur among the 574 patients with successful infarct reperfusion. Intracranial hemorrhage did not occur. Multivariate predictors of in-hospital death included failed infarct angioplasty, cardiogenic shock, 3-vessel coronary artery disease and age greater than or equal to 70 years. During a follow-up period of 32 +/- 21 months (range 1 to 87), 55 patients died. The cause of death was cardiac in 36 patients, including an arrhythmic death in 23 patients and was due to circulatory failure in 13 others. One patient died of reinfarction due to late reclosure of the infarct artery. Actuarial survival curves demonstrated overall survival after hospital discharge of 95 and 87% at 1 and 4 years, respectively. Freedom from cardiac death at 1 and 4 years was 96 and 92%. Multivariate predictors of late death included 3-vessel disease, a baseline ejection fraction of less than or equal to 40%, age greater than 70 years and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Early postoperative balloon coronary angioplasty for failed coronary artery bypass grafting.

In a small number of patients, coronary artery bypass grafting (CABG) fails to relieve anginal symptoms. The usefulness of coronary angioplasty for the treatment of early (less than or equal to 90 days) recurrent ischemia after CABG was examined. Forty-five patients were treated from 2 to 90 days after CABG, including 8 patients studied emergently for prolonged ischemic symptoms. One-, 2- and 3-vessel native disease was found in 4, 10 and 31 patients, respectively. At the time of postoperative angiography, the major anatomic mechanism of recurrent ischemia was complete vein graft occlusion in 12 patients (27%), internal mammary artery occlusion in 3 (7%), vein graft stenoses in 13 (29%), internal mammary artery stenoses in 10 (22%), unbypassed disease in 4 (8%) and disease distal to the graft insertion site in 3 (7%). Angioplasty was successful at 91 of 98 sites (93%), including 95% of 41 lesions in native arteries, 89% of 46 lesions in vein grafts and 100% of 11 internal mammary artery lesions attempted. Complete revascularization was achieved in 84% of patients. There were 2 in-hospital deaths and 2 myocardial infarctions. Two additional patients underwent repeat CABG before discharge after uncomplicated but unsuccessful angioplasty. At late follow-up of the 43 survivors (mean 44 months), there were 4 deaths, 2 of which were noncardiac. Repeat CABG was required in only 3 patients and repeat angioplasty was performed in 10. Angina was absent or minimal in 35 patients; 17 patients were employed full time. Thus, percutaneous transluminal coronary angioplasty can relieve myocardial ischemia after unsuccessful CABG in the majority of patients.

Adult↗
PubMed1990

Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age and older.

Direct percutaneous transluminal coronary angioplasty (PTCA) was performed as the primary means of establishing reperfusion during acute myocardial infarction in 105 elderly patients (mean age +/- standard deviation 75 +/- 4 years) at a mean of 5.5 +/- 4.0 hours from symptom onset. Fifty-two patients (50%) had anterior infarctions, 70 (67%) had significant narrowing in greater than 1 vessel, and 12 (11%) were in cardiogenic shock. Primary success was achieved in 91% of the infarct-related arteries. Four patients with failed PTCA underwent emergency bypass surgery; 10 had early symptomatic reocclusion of the dilated vessel. There was 1 death acutely in the catheterization laboratory. The overall in-hospital mortality was 18%. Three-vessel coronary artery disease and cardiogenic shock on presentation were the strongest predictors of in-hospital death. Global ejection fraction improved from 54 +/- 13 to 61 +/- 15% (p less than 0.001). The 1- and 5-year survival rates, including in-hospital deaths, were 73 and 67%, respectively. It is concluded that direct PTCA is an effective means of salvaging ischemic myocardium during acute myocardial infarction in the elderly patient. It is associated with a high success rate and low complication rate. The short- and long-term survival in this high-risk group of patients are improved compared with survival rates in historical controls.

Aged↗
PubMed1990

Outcome following emergency coronary artery bypass grafting for failed elective balloon coronary angioplasty in patients with prior coronary bypass.

To assess frequency and outcome of emergency coronary artery bypass grafting (CABG) for failed coronary angioplasty in patients with prior CABG, 2,136 elective angioplasty procedures in prior CABG patients were reviewed over a 10-year period. Emergency surgical revascularization was required in 19 patients (0.9%) with prior CABG, compared with 130 of 6,974 patients (1.9%) without prior CABG (p = 0.001). The interval from the most recent CABG to the failed coronary angioplasty was 6.8 years (range 1 to 16). Referral for emergency CABG was made on the basis of an acute closure not responding to repeat dilatation in 12 native coronary arteries and in 7 saphenous vein grafts. Severe hemodynamic instability after acute closure required the placement of an intraaortic balloon pump in 3 patients, including 2 who required cardiopulmonary resuscitation. A total of 34 saphenous vein grafts and 1 internal mammary artery graft were placed emergently. Three patients with high-risk features (3 prior CABG operations in 1 patient, single remaining vessel to heart in 2 patients) could not be weaned from cardiopulmonary bypass. The remaining 16 patients were discharged after a mean hospital stay of 16 days. Four patients developed new Q waves after CABG. At follow-up (mean 52 months, range 3 to 99), 1 patient died late from an acute myocardial infarction. The 15 survivors had no or mild angina and were free of further CABG. Thus, emergency CABG after failed angioplasty in patients with prior CABG is required infrequently. In patients without extreme high-risk features, emergency repeat CABG can be accomplished with good hospital and long-term results.

Aged↗
PubMed1990

Usefulness of angioplasty during acute myocardial infarction in patients with prior coronary artery bypass grafting.

The efficacy and risk of reperfusion strategies for myocardial infarction in patients with prior coronary artery bypass surgery are uncertain. In this study 72 patients with prior bypass grafting underwent direct percutaneous transluminal coronary angioplasty without antecedent thrombolytic therapy. There were 26 anterior and 46 inferior infarctions, including 11 patients (15%) in cardiogenic shock. The baseline ejection fraction was less than 40% in 47 (65%) patients. Angioplasty was successful in 41 of 48 (85%) vein grafts and 24 of 24 (100%) arteries (difference not significant) at 5.1 +/- 4.0 hours from the onset of symptoms (79% treated less than 6 hours). There were no urgent bypass operations, strokes or transfusions. In-hospital survival was 90% (nonshock 95% vs shock 64%, p less than 0.01). Symptomatic acute reclosure occurred in 1 patient. Predischarge coronary arteriography in 34 patients demonstrated continued vessel patency in 32 infarct vessels (94%), although 5 of these vessels were redilated for restenoses. Predischarge paired ventriculography in 26 patients showed an increase in ejection fraction from 44 +/- 16% to 51 +/- 18% (p less than 0.01). One- and 3-year actuarial survival was 89 and 87%. Thus, prior coronary surgery should not preclude reperfusion therapy by direct angioplasty, which can be accomplished with low procedural risk, improvements in ventricular function and excellent in-hospital and late survival.

Aged↗
PubMed1990

Procedural outcome of angioplasty for total coronary artery occlusion: an analysis of 971 lesions in 905 patients.

This study analyzes the results of angioplasty in 905 consecutive patients with 971 total occlusions. The procedures were performed by five cardiologists from January 1980 to January 1989 at one institution. The overall success rate per lesion was 72%. Even the most experienced operator (524 occlusions attempted) has continued to improve on a learning curve, with 83% of his most recent 100 occlusions successfully dilated. Procedural death occurred in seven patients (0.8%), five patients (0.6%) sustained a myocardial infarction and seven patients (0.8%) required urgent coronary bypass surgery. Complications were significantly more likely to occur in the elderly, in women and in patients with triple vessel disease and depressed left ventricular function. Compared with angioplasty in 6,950 patients with nonoccluded stenoses, angioplasty of total occlusions had a lower success rate (72% versus 96%, p = 0.001), although the complication rate was also lower (1.9% versus 3.5%, p = 0.01). Multivariate analysis of 20 clinical and angiographic variables in 100 consecutive patients undergoing angioplasty of 104 total occlusions in 1988 identified only bridging collateral vessels (85% success rate if absent versus 18% if present, p less than 0.001) and a tapered occlusion morphology (88% success rate if present versus 59% if absent, p = 0.01) as independent correlates of procedural outcome. Other variables, including the estimated duration of occlusion, lesion length and location, and extent of disease were unrelated to technical success. With present techniques and sufficient operator experience, 70% to 80% of total occlusions can be successfully recanalized by coronary angioplasty with a complication rate of less than 2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiography↗