SIMULTANEOUS CORONARY-ARTERY BYPASS AND CAROTID ENDARTERECTOMY - DETERMINANTS OF OUTCOME

From January of 1988 to May of 1993, simultaneous single-stage coronar y revascularization and carotid endarterectomy was performed in 33 pat ients (mean age, 69 years). Thirty-one patients (94%) were in New York Heart Association class III or IV 15 (46%) had unstable angina, and 7 (21%) were operated on because of evolving myocardial infarction. One or more previous myocardial infarctions were present in 18 patients ( 54%). Nineteen patients (58%) presented with neurologic symptoms, and 22 (67%) had severe bilateral carotid stenosis. Thirty (91%) had tripl e-vessel or left main coronary artery disease, Sequential reconstructi on of the carotid artery followed by coronary artery bypass grafting w as performed in all patients. In 4 cases, additional cardiac procedure s were performed. Operative mortality (6%) was cardiac related. Periop erative morbidity included myocardial infarction in 1 patient (3%) and neurologic deficit in 6 (18%), with permanent functional impairment i n 2 patients (6%). The stroke rate was higher in the bilateral than in the unilateral carotid stenosis group (22.7% vs 9.1%, p=0.047). Previ ously completed stroke influenced the operative outcome (55.6% vs 4.2% , p=0.003). Low ejection fraction (33.5% +/- 7.5% vs 52.8% +/- 3.5%, p =0.03) and left main coronary artery disease (36% vs 5%, p=0.03) also predicted postoperative neurologic complications. During a mean follow -up of 24.6 +/- 3.5 months, 3 patients died. The 5-year life-table sur vival rate was 85%. Eighty-nine percent of long-term survivors were fr ee of cardiovascular disease symptoms. Our results show that the outco me of simultaneous carotid endarterectomy/coronary artery bypass graft ing in this high-risk population depends upon the preoperative absence or presence of completed stroke or bilateral carotid stenosis, upon t he preoperative ejection fraction, and upon the extent of the left mai n coronary artery disease.