Ann Thorac Surg 1995;59:1396
© 1995 The Society of Thoracic Surgeons
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See also page 1391.
DR ROBERT A. GUYTON (Atlanta, GA): Doctor Johnson, I enjoyed your paper. I think that we need to make some comparison with the Emory Angioplasty Versus Surgery Trial (EAST) and the other randomized trials and point out that in the EAST and the other randomized trials we were dealing with a very small subgroup of patients with multivessel disease, and that subgroup specifically in the EAST were patients in whom the angioplasty operator thought that every lesion in the heart could be dilated, which eliminated total occlusion, eliminated long stenoses, and so forth. I think what you have attempted to do is to extend that to a broader range of patients with multivessel disease. Your patients had 1.7 angioplasties per patient, even though they had two and a half or three major lesions per patient. Your patients had incomplete revascularization, and therefore the patients did poorly.
Now, one problem with the study is that you have looked at the patients who did poorly from an angioplasty operator's point of view and gone backward. The study obviously would be done better if you looked at all the patients who had angioplasty and went forward. But what I think you have shown is that among the patients who did badly, they did badly more quickly if they had more lesions. The report implies that this was primarily focused on patients with multivessel disease, and that is my first question: would you clarify the multivessel versus single vessel disease status of these patients? Second, do you agree that completeness of revascularization is probably the most important indicator of the potential need for subsequent coronary bypass?
DR JOHNSON: I totally agree, and I appreciate those comments. This is a different approach. As Dr Guyton knows, our institution participated in BARI, and those results are not out yet. In that group, as in the EAST and the German Angioplasty Bypass Surgery Investigation, are represented small selected subgroups of patients with multivessel disease. This is a look at the practice of angioplasty as it existed in the 1980s in our institution, and I realize that presents some study flaws, but otherwise point out that it does demonstrate clearly that the patients with more lesions are presumably less well revascularized and return for operation at a relatively early interval. We document an increased mortality for those patients who subsequently require CABG after successful PTCA.
The question about the number of diseased vessels is one that we did focus on in the report. Cardiologists tend to talk about one-, two-, and three-vessel disease, and we may have been trapped into that. It is not a very discerning way to triage patients to the better method of revascularization.
More helpful in terms of stratifying these patients, in terms of predicting which patients should have initial revascularization with angioplasty, would be to look at the number of lesions that a patient has, and this is true for total number of lesions or lesions greater than or equal to 70%. By doing this, you take patients with ``two-vessel disease'' and split them up a little bit more finely and can perhaps do a better job of treating them. As Dr Guyton suggests, a study such as this should be done in a prospective fashion. Our predictive model, which we report in the article, can be used until something better comes along, but that can only be done in a prospective study.
