A PROFILE OF CANDIDATES FOR REPEAT MYOCARDIAL REVASCULARIZATION - IMPLICATIONS FOR SELECTION OF TREATMENT

Objectives: It is not known whether the results of randomized trials c omparing coronary artery bypass grafting to percutaneous transluminal coronary angioplasty for initial revascularization apply to repeat rev ascularization in patients with prior bypass grafts. We studied the di fferences between the patients with prior bypass grafts referred for s urgery or angioplasty to identify the clinical and angiographic charac teristics that correlated best with either choice and to find clues th at might aid in selecting one treatment over the other. Methods: Betwe en 1992 and 1904, 870 patients underwent first isolated reoperation an d 793 patients underwent first balloon angioplasty after a previous op eration. A jeopardy score (0 to 8 points) was derived for each patient on the basis of the relative size of the ischemic territory. Clinical and angiographic data were analyzed for association with the revascul arization strategy, Results: The following characteristics were more p revalent in the reoperation group: male sex, diabetes, hypertension, v alvular disease, normocholesterolemia, and severe left ventricular sys tolic dysfunction; fewer functioning venous and arterial grafts; and a higher jeopardy score (p < 0.01 for all) than in the angioplasty grou p. A higher jeopardy score, diabetes, and a lower number of functionin g arterial or venous grafts were strong, independent predictors of ref erral for reoperation (p < 0.01 for all). In-hospital death and Q-wave infarction (p < 0.01 for both) were more frequent in the reoperation group. Conclusions: Reoperation was the revascularization procedure of choice when larger regions of myocardium were in jeopardy, Angioplast y was more frequently chosen in the presence of a patent arterial graf t to the left anterior descending coronary artery or multiple function ing bypass grafts. Reoperation was associated with a higher risk of in -hospital complications than angioplasty.