Carey J A, Davies S W, Balcon R, Layton C, Magee P, Rothman M T, Timmis A D, Wright J E, Walesby R K
Department of Cardiac Surgery and Cardiology, London Chest Hospital.
Br Heart J. 1994 Nov;72(5):428-35. doi: 10.1136/hrt.72.5.428.
To evaluate trends in referrals for emergency operations after percutaneous transluminal coronary angioplasty (PTCA) complications; to analyse morbidity and mortality and assess the influence of PTCA backup on elective surgery.
A retrospective analysis of patients requiring emergency surgical revascularisation within 24 hours of percutaneous transluminal coronary angioplasty.
Between January 1980 and December 1990, 75 patients requiring emergency surgery within 24 hours of percutaneous transluminal coronary angioplasty.
A tertiary referral centre and postgraduate teaching hospital.
57 patients (76%) were men, the mean age was 55 (range 29-73) years, and 30 (40%) had had a previous myocardial infarction. Before PTCA, 68 (91%) had severe angina, 59 (79%) had multivessel disease, and six (8%) had a left ventricular ejection fraction of less than 40%. A mean of 2.1 grafts (range one to five) were performed; the internal mammary artery was used in only one patient. The operative mortality was 9% and inhospital mortality was 17%. There was a need for cardiac massage until bypass was established in 19 patients (25%): this was the most important outcome determinant (P = 0.0051) and was more common in those patients with multivessel disease (P = 0.0449) and in women (P = 0.0388). In 10 of the 19 cases a vacant operating theatre was unavailable, the operation being performed in the catheter laboratory or anaesthetic room. These 19 patients had an operative mortality of 32% and inhospital mortality of 47%, compared with 2% and 7% respectively for the 56 patients who awaited the next available operating theatre. Complications included myocardial infarction, 19 patients (25%); arrhythmias, 10 patients (3%); and gross neurological event, two patients (3%). The mean intensive care unit stay was 2.6 days (range 1 to 33 days) and the mean duration of hospital admission was 13 days (range 5-40 days).
Patients undergoing emergency surgery after PTCA complications have a substantially increased inhospital mortality and morbidity. PTCA in this unit continues to require surgical cover. Delays in operating on stable patients in centres which operate a "next available theatre" backup policy may not differ from some units performing PTCA with offsite cover for PTCA complications. Particularly in the presence of multivessel disease, however, PTCA complications may be associated with the need for "crash" bypass and such patients are unlikely to survive hospital transfer. The proportion of patients requiring "crash" bypass has increased during the period reviewed because of the extent of disease in the emergency surgical group increased. These results indicate that surgery should not be denied to these patients.
评估经皮腔内冠状动脉成形术（PTCA）并发症后急诊手术转诊的趋势；分析发病率和死亡率，并评估PTCA备用方案对择期手术的影响。
对经皮腔内冠状动脉成形术24小时内需要急诊手术血运重建的患者进行回顾性分析。
1980年1月至1990年12月期间，75例在经皮腔内冠状动脉成形术24小时内需要急诊手术的患者。
一家三级转诊中心和研究生教学医院。
57例（76%）为男性，平均年龄55岁（范围29 - 73岁），30例（40%）曾有过心肌梗死。PTCA前，68例（91%）有严重心绞痛，59例（79%）有多支血管病变，6例（8%）左心室射血分数低于40%。平均进行2.1支血管搭桥（范围1至5支）；仅1例患者使用了乳内动脉。手术死亡率为9%，住院死亡率为17%。19例患者（25%）在建立旁路之前需要心脏按压：这是最重要的预后决定因素（P = 0.0051），在多支血管病变患者（P = 0.0449）和女性患者（P = 0.0388）中更常见。19例患者中有10例没有空的手术室，手术在导管实验室或麻醉室进行。这19例患者的手术死亡率为32%，住院死亡率为47%，而等待下一个可用手术室的56例患者的手术死亡率和住院死亡率分别为2%和7%。并发症包括心肌梗死，19例患者（25%）；心律失常，10例患者（3%）；以及严重神经事件，2例患者（3%）。重症监护病房平均住院时间为2.6天（范围1至33天），平均住院时间为13天（范围5 - 40天）。
PTCA并发症后接受急诊手术的患者住院死亡率和发病率显著增加。本单位的PTCA仍需手术保障。在实行“下一个可用手术室”备用方案的中心，稳定患者手术延迟情况可能与一些有PTCA并发症异地保障的单位无异。然而，特别是在有多支血管病变的情况下，PTCA并发症可能需要“紧急”旁路手术，这类患者不太可能在转院过程中存活。在所审查期间，由于急诊手术组疾病范围扩大，需要“紧急”旁路手术的患者比例有所增加。这些结果表明不应拒绝为这些患者进行手术。
