Revascularization interventions for ischemic heart disease

Coronary artery bypass grafting and percutaneous transluminal coronary angi oplasty are now well established methods of myocardial revascularization. T he choice of a method of revascularization depends on several clinical and angiographic parameters, Patients who derive the greatest benefit from coro nary artery bypass grafting are those with left main coronary artery diseas e or those with three-vessel disease with left ventricular impairment. Pati ents with single-vessel disease achieve more symptomatic relief with corona ry angioplasty than with medical therapy alone, but with no improvement in long-term mortality. In nondiabetic patients with multiple-vessel disease, angioplasty and bypass grafting likely yield similar results, and the choic e of revascularization technique rests on weighing the more invasive nature of bypass grafting against the need for additional future revascularizatio ns with angioplasty, Diabetic patients with multiple-vessel disease seem to achieve better outcomes with bypass grafting. Minimally invasive bypass su rgery is an evolving technique. It is less invasive in nature but its appli cations are limited, and its advantages over traditional bypass grafting ha ve not yet been shown, Stenting now plays a major role in percutaneous reva scularization and is performed in more than two thirds of all interventiona l procedures. It improves both the short-term and the longterm outcomes of coronary angioplasty. Other novel percutaneous techniques such as direction al or rotational atherectomy, laser angioplasty, or thrombectomy devices ha ve not shown convincing superiority over coronary angioplasty alone. Transm yocardial laser revascularization can be performed surgically or percutaneo usly and may be beneficial in patients with angina refractory to traditiona l revascularization procedures. (C) 2000 Lippincott Williams & Wilkins, Inc .