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Objectives: We sought to define the risks facing octogenarians undergoing contemporary percutaneous coronary interventions (PCIs)., Background: The procedural risks of PCI for octogenarians have not been well established., Methods: We compared the clinical characteristics and in-hospital outcomes of 7,472 octogenarians (mean age 83 years) with those of 102,236 younger patients (mean age 62 years) who underwent PCI at 22 National Cardiovascular Network (NCN) hospitals from 1994 through 1997., Results: Octogenarians had more comorbidities, more extensive coronary disease and a two- to fourfold increased risk of complications, including death (3.8% vs. 1.1%), Qwave myocardial infarction (1.9% vs. 1.3%), stroke (0.58% vs. 0.23%), renal failure (3.2% vs. 1.0%) and vascular complications (6.7% vs. 3.3%) (p < 0.001 for all comparisons). Independent predictors of procedural mortality in octogenarians included shock (odds ratio [OR] 5.4, 95% confidence interval [CI] 3.3 to 8.8), acute myocardial infarction (OR 3.2, 95% CI 2.3 to 4.4), left ventricular ejection fraction (LVEF) <35% (OR 2.9, 95% CI 2.1 to 3.9), renal insufficiency (OR 2.8, 95% CI 2.0 to 3.8), first PCI (OR 2.3, 95% CI 1.7 to 3.3), age >85 years (OR 2.1, 95% CI 1.5 to 2.7) and diabetes mellitus (OR 1.5, 95% CI 1.1 to 2.0). For elective procedures, octogenarian mortality varied nearly 10-fold, and was strongly influenced by comorbidities (0.79% mortality with no risk factors vs. 7.2% with renal insufficiency or LVEF <35%). Despite similar case-mix, PCI outcomes in octogenarians improved significantly over the four years of observation (OR of 0.61 for death/myocardial infarction/stroke in 1997 vs. 1994; 95% CI 0.45 to 0.85)., Conclusions: Risks to octogenarians undergoing PCI are two- to fourfold higher than those of younger patients, strongly influenced by comorbidities, and have decreased in the stent era.

Background/purpose: Biliary anastomotic strictures (BAS) after left lateral segment liver transplantation (LLST) may cause graft dysfunction, sepsis, and patient mortality. A review of the authors' experience was performed to better characterize the risk factors and corrective management., Methods: The medical records of 9 children who underwent a LLST in whom a BAS developed from 1989 to the present were reviewed retrospectively., Results: Seventy-five of 199 liver transplants (38%) at the authors' institution since 1989 have been LLST. BAS developed in 12% of these cases. BAS were diagnosed less than 12 months after transplantation in 4 children (mean, 7.5 months; range, 5 to 11 months) and greater than 12 months in 5 children (mean, 37 months; range, 14 to 72 months). Early strictures (<12 months) were associated with hepatic artery thrombosis (n = 1), and posttransplant bile leak (n = 1) and ducts from segment II and III exiting separately from the left lateral segment (n = 2). The diagnosis of BAS was heralded by episodes of liver biopsy-proven cholangitis in all patients and confirmed radiographically. Seven children underwent successful biliary exploration and revision of the hepaticojejunostomy. Two of these children ultimately required retransplantation secondary to chronic graft rejection., Conclusions: BAS in LLST are a source of significant morbidity and should be considered in children after LLST who present with cholangitis. Surgical correction is possible in most cases.

Background: There are limited data on the use of percutaneous revascularization techniques for transplant coronary artery disease (CAD)., Methods: Medical records and angiographic results for cardiac transplant patients undergoing percutaneous revascularization at Emory University Hospital were reviewed. Procedural results, results of angiography 4Eth 6 months after intervention, and clinical follow-up were recorded., Results: Nineteen patients underwent 51 interventions. Thirty-eight lesions (75%) were de novo and 13 (25%) were restenotic. All patients had hypertension, 37% had diabetes, 79% had elevated lipid levels, and 53% had at least one episode of moderate to severe allograft rejection (grade 3A or greater). The primary procedural success rate was 100% with no major complications. Six-month restenosis rate (defined as > 50%) was 49%. At 23+/-17 months follow-up, 6 patients were dead or retransplanted (31%). Thirteen patients were alive without retransplantation (9 New York Heart Association class I, 3 class II, 1 class III)., Conclusion: Percutaneous revascularization is safe and has a high initial procedural success rate in patients with transplant CAD. However, the restenosis rate in this population remains higher than reported for atherosclerotic coronary disease and the long-term prognosis remains poor.

Cardiovascular disease is the leading cause of complications and death in the United States, affecting nearly 60 million Americans in 1998 and costing an estimated $274.2 billion. A major contributor to the costs of cardiovascular disease is atrial fibrillation (AF). AF is the most common sustained arrhythmia and affects > 2.2 million people and approximately 5% of all persons over the age of 60. Transesophageal echocardiography (TEE) with short-term anticoagulation has been proposed as a viable strategy to guide patients with AF. Here, we (1) review the current environmental context for a TEE-guided approach, (2) summarize the existing literature on the economic aspects of TEE, and (3) outline an economic framework for an economic analysis of TEE investigation or any major clinical therapy. We conclude that more powerful analytical tools are evolving to analyze the important economic, clinical, and social aspects of a patient's medical encounter.

Objectives: To evaluate the long-term outcome of patients randomized to coronary bypass surgery or coronary angioplasty., Background: The Emory Angioplasty versus Surgery Trial (EAST) is a single center randomized comparison of a strategy of initial coronary angioplasty (n = 198) or coronary bypass surgery (n = 194) for patients with multivessel coronary artery disease. The primary end point (death, myocardial infarction or a large ischemic defect at 3 years) was not different, and repeat revascularization was significantly greater in the angioplasty group. Subsequently, the National Heart, Lung and Blood Institute supported a five-year extension of the trial., Methods: After the three year anniversary visit, annual questionnaires, telephone contact and examination of medical records were accomplished until death or the eight year anniversary in 100% of the patients surviving at 3 years., Results: Survival at 8 years is 79.3% in the angioplasty group and 82.7% in the surgical group (p = 0.40). Patients with proximal left anterior descending stenosis and those with diabetes tended to have better late survival with surgical intervention although not reaching statistical significance. After the first 3 years, repeat interventions remained relatively equal for both treatment groups., Conclusions: Long-term survival is not significantly different between angioplasty and surgery, and late (three to eight year) revascularization procedures were infrequent. Patients without treated diabetes had similar survival in both groups.

Background: Stroke is a major complication of coronary operation, with reported rates of postoperative cerebral dysfunction ranging from 0.4% to 13.8%. In this report, the incidence, correlates, outcomes, and costs of stroke in coronary operation were evaluated at Emory University between 1988 and 1996., Methods: Data were entered prospectively into a dedicated computerized database at Emory University and analyzed retrospectively. Univariate and multivariate analyses were utilized where appropriate., Results: Data from 10,860 patients undergoing primary coronary operation between 1988 and 1996 were analyzed. There were 250 patients not entered into the database. Stroke occurred in 244 (2.2%). Univariate predictors of stroke (p<0.05) included age, female gender, hypertension, diabetes, prior stroke, prior transient ischemic attack (TIA), and carotid bruits. Multivariate correlates included age (odds ratio 1.07) previous TIA (odds ratio 2.2), and carotid bruits (odds ratio 1.9), although the area under the Receiver Operating Characteristics (ROC) curve was only 0.69, suggesting limited ability to predict stroke. One and 5 year survival rates were 64% and 44% with stroke, and 94% and 81% without stroke, respectively. Among the stroke group, 23% of the patient population died before hospital discharge. The stroke group had a significantly longer length of hospital stay, as well as higher costs., Conclusions: Stroke is a devastating complication of coronary operation, significantly increasing morbidity, mortality, and cost. Three independent variables were identified for predicting stroke, including age, previous TIA, and carotid bruits. Patients should be carefully screened for cerebrovascular disease to help prevent stroke and its associated morbidity.

Objective: To estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income., Design and Setting: Using 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years., Main Outcome Measures and Results: Previous measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars)., Conclusions: Estimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.

Background/purpose: Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties., Methods: Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively., Results: A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.)., Conclusions: The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.

Objective: To identify factors responsible for the variation in real hospital costs and length of stay for patients with diabetes undergoing coronary angioplasty or coronary bypass surgery., Study Design: Retrospective study of patients with diabetes and coronary artery disease treated at a single hospital., Patients and Methods: The study population included 1809 patients with diabetes and multivessel (2-vessel or 3-vessel) coronary artery disease who underwent an initial coronary angioplasty or coronary bypass surgery between 1988 and 1996. After accounting for the extent and severity of the patient's coronary artery disease, a sequential model was used to assess if diabetic characteristics were independently associated with higher hospital resource utilization during revascularization., Results: Multivariate regression results indicated that for patients with diabetes who underwent coronary angioplasty, a baseline creatinine level of > or = 2.0 mg/dL was associated with significantly higher hospital costs and longer length of stay. For patients with diabetes who underwent a coronary bypass surgery only, a baseline creatinine level of > or = 2.5 mg/dL was associated with higher hospital costs and longer hospital length of stay., Conclusions: After controlling for coronary risk factors, selected diabetes-specific characteristics are associated with higher hospital resource utilization. Risk adjustments in hospital reimbursement may be needed to assure that patients with diabetes who have cardiovascular disease have access to revascularization procedures.

Objective: To determine whether patients with chest pain referred to a cardiologist from a gatekeeper managed care organization differ from those referred from an open-access managed care organization., Study Design: Retrospective study using clinical and claims data from a cardiac network database., Patients and Methods: We reviewed data from 1414 patients with chest pain or angina who were referred to a cardiologist between January 1, 1995, and June 30, 1996. We examined baseline clinical characteristics and subsequent physician practice patterns for these patients, who were referred from either a primary care gatekeeper model (n = 490) or an open-access model (n = 924)., Results: Although twice as many open-access patients were referred to a cardiologist, there were no differences in patient demographics or clinical characteristics at the time of referral. Cardiologists ordered similar diagnostic tests for patients from both types of managed care plans, and gatekeeper patients did not have a higher rate of abnormal tests. Rates of cardiac catheterization, coronary angioplasty, myocardial infarction, and hospitalization were similar in both groups. A significantly higher percentage of gatekeeper patients received a cardiac catheterization on the day of referral (7% versus 1%; P = .05). Open-access patients were significantly more likely to continue to be seen by a cardiologist (44% versus 28%; P < .01). Cardiology professional charges per patient were lower among gatekeeper patients ($972 +/- 1398 versus $1187 +/- 1897; P = .06), and total cardiology professional charges were significantly lower for the gatekeeper group because of the smaller number of patients seen., Conclusions: The type of cardiology services provided to patients with chest pain was not affected by the primary care administrative structure of the managed care organization, but the higher volume of patient referrals from the open-access plan may be an important consideration for cardiology practices participating in capitated contracts. The lower volume of referrals and coordination of care suggest potential cost advantages for the gatekeeper model.

Objective: This study was conducted to assess the impact of GPIIb/IIIa blockade with tirofiban on costs during the initial hospitalization and at 30 days among patients undergoing high-risk coronary angioplasty., Background: GPIIb/IIIa blockers are a new class of compounds that have been shown in clinical studies to prevent complications after high-risk angioplasty., Methods: The RESTORE trial was a multinational, blinded placebo-controlled study of 2,197 patients randomized to tirofiban or placebo following coronary angioplasty. This economic assessment was a prospective substudy of the RESTORE trial, and included 1,920 patients enrolled in the U.S. Costs were estimated for the U.S. cohort based on their utilization of healthcare resources and on costs measured directly in 820 U.S. patients at 30 sites., Results: There was a 36% difference in the rate of the composite event of death, myocardial infarction (MI) and revascularization at two days between tirofiban and placebo (8% vs. 12%, p = 0.002). This difference was attributed to a reduction in nonfatal MI, repeat angioplasty, coronary surgery and stent placement. These clinical benefits followed a similar trend at 30 days, with a 16% reduction in the composite event (p = 0.10). In-hospital cost, including professional and study drug costs, was $12,145 +/- 5,882 with placebo versus $12,230 +/- 5,527 with tirofiban (p = 0.75). The 30-day cost was $12,402 +/- 6,147 with placebo versus $12,446 +/- 5,814 with tirofiban (p = 0.87)., Conclusions: Tirofiban has been shown to decrease in-hospital and possibly 30-day events after high-risk angioplasty. The beneficial clinical effects of tirofiban in high-risk patients can be achieved at no increased cost.

The dramatic transformations taking place in the healthcare environment have created a new paradigm for healthcare and pose far-reaching changes for cardiovascular care. This 2-part paper reviews these changes and discusses the major implications for cardiovascular specialists, based on literature reviews and summaries of legislative initiatives. The new healthcare paradigm focuses on a continuum of care, wellness maintenance and promotion, accountability for the healthcare of defined populations, and provider differentiation based on ability to add 'value' to the patient's healthcare outcome. This paradigm will become 'standard operating procedure' in the cardiovascular market. As a result, major areas of change in the cardiovascular environment include: continuing growth of managed care arrangements, expanding physician and other payment reforms, growing influence of state and private payer initiatives, expanding role of 'centers of excellence,' continuing surplus of physicians, growth in pharmaceuticals and new technologies, and extension of evidence-based guidelines. Practice guidelines, in particular, will become an integral part of medical practice and will represent the standards against which medical practice will be measured. Given the prominent position of cardiovascular disease in healthcare, cardiovascular specialists will remain in the forefront of these developments.

Coronary catheterization laboratories (CCLs) are the cornerstones of the delivery system for many cardiovascular procedures performed in the United States. However, few comprehensive data exist benchmarking physician activities in CCLs. This study benchmarks cost and time data on 82,548 consecutive patient encounters in 53 CCLs for the 18-month period of January 1997 through June 1998. The data are compiled from the OEP program, a relational database developed by Boston Scientific/Scimed (Maple Grove, Minnesota) for use in CCLs. CCL productivity (total time and procedure time) and cost (variable costs and device costs) benchmarks are created for: 1) left heart catheterization; 2) right and left heart catheterization; 3) percutaneous transluminal coronary balloon angioplasty (PTCA); 4) atherectomy; and 5) coronary stents. Results show the variable costs (those costs that vary in direct proportion to changes in CCL activities) for the five procedures are: $308, left heart catheterization; $395, right and left heart catheterization; $841, PTCA; $2,768, atherectomy; and $3,186, coronary stent. These variable costs are lower than the typical average costs reported for these procedures because they do not include hospital, laboratory, and physician costs, only the procedure-specific activity-related costs most directly controlled and/or influenced by CCL physicians or administrators. The total time for the left heart catheterization averaged 64 minutes and 84 minutes for the right and left heart catheterization, respectively, and procedural times averaged 25 and 32 minutes, respectively. For the major interventional procedures N PTCA, atherectomy, and coronary stents, total times averages were 102, 135, and 117 minutes, respectively. Procedural times for these procedures averaged between 60 and 65 percent of the total time. The major implications of these findings are discussed and limitations noted.

This paper, the second in a series of 2, reviews major developments and trends in the current healthcare arena that will affect cardiovascular disease (CVD) treatment over the next 10 years. The paper also discusses the implications and future outlook for cardiovascular services in a managed care environment.

Background: There has been increasing interest in improving the outcome of coronary surgery while also seeking to minimize cost. It was the purpose of the present study to determine changes in the outcome and cost of CABG between 1988 and 1996., Methods and Results: The outcome and costs for 12,266 patients undergoing CABG were evaluated. Clinical data were gathered from the Emory Cardiovascular Database, and financial data were obtained from the UB92 formulation of the hospital bill. Charges were reduced to cost through the use of departmental cost-to-charge ratios. Costs were inflated to 1996 costs by using the medical care inflation rate. The patients became sicker, especially with increased incidences of hypertension, diabetes, and prior myocardial infarctions and a decrease in ejection fraction over the study period. Mortality rates tended to decrease from 4.7% to 2.7% (P = 0.07). After accounting for increasing indexes of severity of disease over the period, there was a significant decrease in death (OR, 0.90/y; P = 0.0001). Q-wave myocardial infarction rate fell from 4.1% to 1.3% (P < 0.0001). Mean hospital cost decreased from $22,689 to $15,987. Length of stay after surgery decreased from 9.2 to 5.9 days. After accounting for other variables, cost decreased by $1118 per year, and annual length of stay decreased by 0.55 day., Conclusions: The outcome of CABG continues to improve with declines in mortality rate and Q-wave myocardial infarction. This was accomplished while decreasing costs and length of stay. Whether these favorable trends will continue remains to be seen.

Objective: The aim of this study was to determine the long-term survival and control of angina in patients with coronary artery disease and sequentially decreased ejection fractions (EF) after first-time coronary artery bypass grafting., Methods: Between 1981 and 1995, 156 (1.3%) patients with an EF less than 0.25 (group 1), 588 (5%) patients with an EF of 0.25 to 0.34 (group 2), 2,438 (20.6%) patients with an EF of 0.35 to 0.49 (group 3), and 8,648 (73.1%) patients with an EF equal to or greater than 0.50 (group 4) underwent coronary artery bypass grafting. The EFs were determined by uniplanar or biplanar left ventriculography. For each group, the clinical and angiographic characteristics and the operative and outcome data were compared. Survival curves were derived and compared for each group. Correlates of angina, and of early (30-day) and long-term mortality, for all groups were analyzed., Results: For all groups the mean age was approximately 60+/-10 years. Group 1 had the highest percentage of patients who were men (88%), had congestive heart failure (34%), had hypertension (53%), and had left main coronary artery disease (24%). Groups 1 through 3, compared with group 4, had a lower percentage of complete revascularization (p < 0.0001), a lower percentage of internal mammary artery grafts (p < 0.0001), and a greater use of intraaortic balloon pump (p < 0.0001), but had similar cross-clamp and cardiopulmonary bypass times, number of grafts, incidences of myocardial infarction, and stroke. Hospital mortality for groups 1, 2, 3, and 4 was 3.8% (n = 6), 3.4% (n = 20), 3% (n = 72), and 1.6% (n = 134), respectively. Groups 1 through 3, compared with group 4, had similar incidences of angina during follow-up (31% to 40% versus 33%, respectively; p < 0.06). Survival was greatest for group 4 compared with groups 1 through 3 at 1, 5, and 10 years (p < 0.0001). Patients in group 1 had 1-, 5-, and 7-year survivals of 90%, 64%, and 49%. Multivariate correlates of early mortality were advanced age, female sex, decreased EF, hypertension, diabetes, and emergency operation. Multivariate correlates of long-term mortality included severity of preoperative angina class, congestive heart failure, number of diseased vessels, and incomplete revascularization. The strongest correlates of angina at follow-up were younger age, female sex, previous myocardial infarction, lower ejection fraction, and incomplete revascularization. The absence of an internal mammary artery graft did not predict the occurrence of angina or influence long-term survival., Conclusions: In the long term there is a higher mortality in patients with sequentially decreased left ventricular function undergoing coronary artery bypass grafting, although more than 60% of patients with an EF less than 0.25 were alive and had good control of angina at 5 years despite having a higher percentage of risk factors, poorer functional status, and more complex coronary disease. Failure of symptom control and survival beyond 5 years appeared to be influenced by preexisting medical conditions and factors that affect the ability to completely revascularize the myocardium. These results suggest that in selected patients with ischemia and poor left ventricular function, coronary artery bypass grafting may preserve remaining viable myocardium, provide relief of symptoms, and offer survival greater than 60% at more than 5 years.

We report a case of a teratoid Wilms tumor arising within a supernumerary ectopic ureteropelvic structure in a 7-year-old boy. The tumor was near the right kidney but was completely separate from it. On the contralateral side, the child had a duplication of the ureteral system. Pathologic examination revealed the mass to be completely enveloped by a fibromuscular sac lined by urothelium. The tumor had a botryoid, polypoid architecture and, in addition to areas of classic Wilms tumor, had extensive squamous, mucinous, and columnar elements. Teratoid Wilms tumors are rare and, to the best of our knowledge, have not previously been described as arising either in anomalous urinary structures or at 7 years of age.

This study evaluates the effect of length of stay and baseline health status on health status and readmission rates 3 months after coronary artery bypass graft surgery. Baseline health status showed a trend toward worse scores for patients who were readmitted. Readmitted patients had longer lengths of stay, and worse 3-month health status scores, and women and patients with heart failure had higher readmission rates. It may be possible to identify patients at risk for readmission using clinical variables, length of stay, and health status. If a predictive model can be developed, then interventions can be developed and tested to decrease the rate of unplanned readmissions.

A substudy of the Lovastatin Restenosis Trial in patients with elevated cholesterol (>200 mg/dl) showed no evidence of an effect of aggressive lipid lowering on restenosis, confirming the results of the main trial.

Purpose: The aim of this review was to determine the incidence of gastrointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earlier diagnosis., Methods: A retrospective chart review of all children who presented with gastrointestinal perforation after liver transplantation at our institution between January 1, 1987 and August 1, 1996 was performed., Results: One hundred fifty-seven orthotopic liver transplants were performed in 128 children. Fifty-eight reexplorations, excluding those for retransplantation, were performed in 38 children. Ten perforations occurred in six children (incidence, 6.4%). Two children required multiple reexplorations because of several episodes of perforation. The sites of perforation were duodenum (n=1), jejunum (n=8), and ileum (n=1). A single-layer closure was used to repair five perforations, two-layer closures in four, and resection with primary anastomosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months old. Four children had undergone prior laparotomy. All children had choledochoenteric anastomoses, but only one had a perforation associated with it. One child sustained bowel injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their perforation, and none had been dosed with pulse steroids for rejection. All of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the rest of the children. Abdominal radiographs demonstrated pneumoperitoneum in only one child. All children had positive culture findings from their abdominal drains. Cytomegalovirus developed in one child. Although the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and significant alterations in temperature and leukocyte counts suggest its presence. Pneumoperitoneum is rarely present., Conclusion: A high index of suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this potentially devastating complication of liver transplant.

Objectives: This study sought to compare the outcome of percutaneous transluminal coronary angioplasty (PTCA) (n = 834) and coronary artery bypass graft surgery (CABG) (n = 1805) in diabetic patients with multivessel coronary disease from an observational database., Background: There is concern about selection of revascularization in diabetic patients with multivessel coronary artery disease., Methods: Data were collected prospectively and entered into a computerized database. Follow-up was by letter or telephone or additional events resulting in readmission., Results: After CABG there were more in-hospital deaths (0.36% vs. 4.99%, p < 0.0001) and a trend toward more Q wave myocardial infarctions than after PTCA. Five- and 10-year survival rates were 78% and 45% after PTCA and 76% and 48% after CABG, respectively (p = 0.47). At 5 and 10 years, insulin-requiring patients had lower survival rates of 72% and 31% after PTCA and 70% and 48% after CABG, respectively (p = 0.54). Multivariate correlates of long-term mortality were older age, low left ventricular ejection fraction, heart failure and hypertension. In the total group, insulin requirement was a correlate of long-term mortality. For the total group, choice of therapy had a multivariate hazard ratio close to 1. In the insulin-requiring subgroup, the multivariate hazard ratio was 1.35 (95% confidence interval 1.01 to 1.79) for PTCA versus CABG. Corrected for baseline differences, 5- and 10-year survival rates were 68% and 36% after PTCA and 75% and 47% after CABG, respectively, in the insulin-requiring subgroup. Nonfatal events were more common after PTCA, especially additional revascularization., Conclusions: This study reveals a high incidence of events in diabetic patients and raises further questions about angioplasty in insulin-requiring diabetic patients with multivessel disease.

Background: Previous studies have demonstrated increased risk in patients undergoing coronary artery bypass surgery (CABG), but the effect of this increasing risk on outcomes has not been well documented. The purposes of this study were (1) to evaluate patients who had CABG from 1993 to 1995 (group III) and compare them with patients from 1981 through 1987 (group I) and 1988 through 1992 (group II) to determine if the trend toward higher-risk patients continued and (2) to evaluate what effect risk had on in-hospital outcomes., Methods and Results: Data were collected prospectively on patients undergoing CABG. Patients from the three time periods were compared by use of univariate and multivariate statistics. Risk models for mortality were developed by use of logistic regression. Significant changes were noted in the three time periods, with risk increasing over time. Increased risk was associated with increased mortality in group II, but mortality declined in group III despite the continued increase in patient risk. Group II had an increase in complications, with little change in group III. The actual mortality rate was lower than predicted in group III., Conclusions: Patients undergoing CABG are increasingly high risk. In-hospital mortality rates declined during the period from 1993 through 1995 and were lower than predicted despite the increase in risk. This decreased mortality rate may reflect greater experience in providing care to high-risk patients and improved myocardial protection and surgical and anesthetic techniques. Although continued analysis of patient risk and benefit is needed, researchers must be cognizant of the rapid changes in technology and knowledge and should correlate changes in the process of care with outcomes.

Percutaneous treatment of saphenous vein graft (SVG) stenosis has been established as an alternative to repeat coronary artery bypass grafting. Intracoronary Palmaz-Schatz stent (PSS) and directional coronary atherectomy (DCA) have been suggested to provide better short- and long-term results than balloon angioplasty. Records of 840 patients with 931 SVG lesions treated with PSS (121 patients, 132 lesions), DCA (103 patients, 107 lesions), and balloon angioplasty (616 patients, 692 lesions) were reviewed. Inhospital and long-term outcome were compared among treated groups. The groups had similar clinical and angiographic baseline characteristics except for higher previously dilated grafts in the stent group and graft location among devices. Stent placement was angiographically successful in 99%, DCA in 95%, and balloon angioplasty in 93% of the lesions (p = 0.03). Quantitative angiography revealed a larger lumen diameter after procedure after PSS (3.2 mm) and DCA (3.1 mm) compared with 2.4 mm after balloon angioplasty (p = 0.0001). Angiographic complications (abrupt closure, severe dissections, or distal embolization) were evident in eight (6.1%) lesions after PSS placement, in 17 (15.9%) after DCA, and in 61 (8.8%) after balloon angioplasty. Serious in-hospital clinical complications (death, emergency coronary artery bypass grafting, or Q-wave myocardial infarction) were similar among devices. Survival rates were similar among the groups (p = 0.15). Repeat revascularization at follow-up was reported in 58 (60.4%) of patients after PSS, in 48 (51.1%) after DCA, and in 280 (49.4%) after balloon angioplasty. Correlates of additional revascularization at follow-up were older grafts, calcific lesions, previously dilated grafts, longer lesions, and patients with lower ejection fractions (odds ratio 1.06, 1.34, 1.43, 1.04, and 1.01, respectively). Correlates of mortality rate at follow-up were older patients, patients with lower ejection fractions, and distal embolization (odds ratio 1.04, 1.04, and 1.92, respectively). These data suggest that in patents with SVG stenosis the initial success and morbidity rates are similar when comparing PSS and DCA with balloon angioplasty. Although a larger lumen is obtained with PSS and DCA, patients who underwent balloon angioplasty had similar rates of cardiac events and requirements for additional procedures at follow-up.

Background: Although an inverse relation between physician caseload and complications has been conclusively demonstrated for several surgical procedures, such data are lacking for percutaneous coronary intervention, and the ACC/AHA guidelines requiring > or = 75 cases per year for operator "competency" are considered by some physicians to be arbitrary., Methods and Results: From quality-controlled databases at five high-volume centers, models predictive of death and the composite outcome of death, Q-wave infarction, or emergency bypass surgery were developed from 12,985 consecutively treated patients during 1993 through 1994. Models had moderate to high discriminative capacity (area under ROC curves, 0.65 to 0.85), were well calibrated, and were not overfitted by standard tests. These models were used for risk adjustment, and the relations between both yearly caseload and years of interventional experience and the two adverse outcome measures were explored for all 38 physicians with > or = 30 cases per year. The average physician performed a mean +/- SD of 163 +/- 24 cases per year and had been practicing angioplasty for 8 +/- 5 years. Risk-adjusted measures of both death and the composite adverse outcome were inversely related to the number of cases each operator performed annually but bore no relation to total years of experience. Both adverse outcomes were more closely related to the logarithm of caseload (for death, r = .37, P = .01; for death, Q-wave infarction, or bypass surgery, r = .58, P < .001) than to linear caseload., Conclusions: In this analysis, high-volume operators had a lower incidence of major complications than did lower-volume operators, but the difference was not consistent for all operators. If these data are validated, their implications for hospital, physician, and payer policy will require exploration.

An effective therapy for a costly illness has economic consequences. There may also be differences between provider costs and payer costs and initial versus long-term costs; costs may also vary with the reimbursement scheme. Consider the case of an effective therapy to prevent restenosis after coronary angioplasty. Assume that the initial provider cost of angioplasty is $12,000 and that restenosis within 6 months results in repeat angioplasty in 20% of cases, with a follow-up cost of $2,400, or $14,400 total. Assume that a therapy costs $1,000 per angioplasty and decreases restenosis by 50%, resulting in repeat angioplasty in 10% of cases. This will result in an initial cost of $13,000 and a follow-up cost of $1,300, or $14,300 total. The total societal costs will be -$100, a slight savings. Thus, the $1,100 cost of therapy is offset by reduced costs associated with restenosis, and the societal costs are almost neutral. Assume that under fee for service providers charge costs plus 10% and that without the new therapy either a package price or a capitated system is revenue neutral. Changes in costs resulting from therapy to prevent restenosis are as follows (plus sign indicates cost or loss; minus sign indicates savings or profit): [table: see text] Under fee for service, the payer takes the risks, and the economic consequences to providers are minimal. The situation is reversed under capitation. For whoever takes the risk, there is an initial loss to pay for the therapy, but a long-term gain due to less restenosis. Under package pricing, the providers lose because of the cost of therapy and fewer procedures, while the payers gain. A new therapy, even if it is revenue neutral to society overall, may have considerable economic consequences, which vary with time and with the different perspectives of providers and payers.

Background: The immediate and long-term outcomes of reoperative coronary artery bypass surgery (CABG) (n = 1561) and catheter-based coronary intervention (angioplasty) (n = 2613) were compared in patients from Emory University Hospitals who had previous CABG., Methods and Results: The surgical and angioplasty procedures and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Followup was by letter, telephone, or additional events resulting in readmission. In the angioplasty group, 2.9% required in-hospital CABG. Hospital mortality was 1.2% after angioplasty versus 6.8% after repeat CABG (P < .0001). Recurrent angina was noted frequently at about 4 years and was more common after angioplasty. One-, 5-, and 10-year mortalities were 11%, 24%, and 49% after CABG versus 6%, 22%, and 38% after angioplasty. Survival corrected for baseline differences did not vary with the choice of procedure. There were more additional procedures after angioplasty. Patients undergoing angioplasty may be divided into those with procedures only in native coronary arteries (n = 1545), only in vein grafts (n = 869), and a mixture (n = 199), with respective 10 year survivals of 66%, 56%, and 65% (P < .0001)., Conclusions: These patients have a high incidence of events both in-hospital and in the long term. Although initial mortality was higher after CABG, after baseline differences were accounted for, there was no difference in the long term. Patients more frequently have additional procedures after angioplasty. Choice of therapy should consider clinical and angiographic suitability and patient preference.

The prognosis of patients with left ventricular (LV) aneurysm diagnosed by thallium single-photon emission computed tomography (Tl-SPECT) or technetium-99m sestamibi SPECT (MIBI) has not previously been defined. Of 9,505 Tl or MIBI patients, 139 with apical infarct and probable LV aneurysm on tomographic images were identified. Patients were grouped by the presence of divergent versus parallel LV walls. Divergent walls show increasing separation of the walls as they approach the apex on vertical or horizontal long-axis slices. The degree of the deformation at the apex (divergent vs parallel walls), extent of impaired myocardium (total number of pixels in the defect/total number of pixels in the myocardium x 100%), percentage of reversibility, and segmental and total severity of standard deviations of perfusion defects were calculated. Seventy-six patients underwent contrast ventriculography. Patients with divergent walls (n = 57) were older (p = 0.05), had lower ejection fractions (p = 0.012), higher lung uptake (only Tl patients (p = 0.06), and more frequent ST elevation on the resting electrocardiogram (p = 0.009) than patients with nondivergent (parallel) walls. For both groups, the percent impaired myocardium was comparably high (44 +/- 9% vs 46 +/- 10%). Analysis of asynergic segments in 76 patients who underwent contrast ventriculography showed more akinetic, paradoxical, or aneurysmal segments in the apical region of the left ventricle in the group with SPECT divergent walls. Cox model analysis showed divergence as the significant correlate of death. At 5 years, survival for the group with divergent walls was 52% compared with 75% for those with nondivergent walls (p = 0.008). Despite significant apical LV impairment in both groups, mortality was almost twice as high in the group with divergent walls compared with patients with parallel walls. Thus, patients with LV aneurysm diagnosed by radionuclide SPECT perfusion imaging have a higher mortality when displaying a divergent wall pattern than patients with lesser deformity.

The division of a single hepatic allograft to create two reduced-size grafts has been reported with decreased graft survival (50%) resulting in decreased enthusiasm for this approach. The authors reviewed their experience with 12 recipients of this procedure to evaluate the outcome of the children electively undergoing transplant with the "leftover liver." A retrospective review of six pairs of children receiving part of one hepatic allograft included donor anatomy, recipient operation, and allograft and patient outcomes. Recipient pairs were selected according to blood type compatibility, medical priority, and size restrictions of the larger right lobe and the smaller left lateral segment. Patient and graft survival were compared with elective and urgent patients undergoing whole or reduced-size transplants. Six donors weighed 71.8 +/- 17.4 kg and were 22.6 +/- 11.0 years of age. Recipients of the right lobe were 11.8 +/- 4.2 years of age and weighed 41.9 +/- 14 kg. Recipients of the left lateral segment were 1.81 +/- 1.1 years of age and weighed 9.85 +/- 1.82 kg. Six patients were initially offered the donor allograft because of their hospitalization, critical illness or waiting time. Six additional patients electively underwent transplantation with the leftover liver. Donor organs were screened for normal arterial anatomy. Division of the allograft was performed on the back table in the falciform groove. Generally the left lateral segment graft received the major portion of the hepatic artery and the right lobe the major portion of the portal vein. Five of six (83%) elective patients, two receiving the right lobe and three receiving the left lateral segment had prompt recovery and left the hospital without surgical complication. One recipient of a right lobe transplant died from primary allograft nonfunction. These results are not different from the outcomes of all elective patients who underwent transplantation with whole or reduced-sized transplants in the same program. The authors conclude that split liver transplantation benefits the stable patient who electively receives the liver leftover after reducing the size of a large donor liver for a critically ill child.

Currently, the recommended strategy for Palmaz-Schatz intracoronary stent implantation is to use two balloons: an undersized balloon for predilation to facilitate a channel for the stent and a high pressure balloon for postdilation to obtain good apposition of the struts into the vessel wall. We reported our experience using the perfusion balloon as the initial balloon to dilate intracoronary lesions and demonstrated a reduction in the total number of balloons used per angioplasty procedure. The objective of this study was to examine whether a single balloon could effectively be used for stent implantation. The study population included 95 patients who underwent elective intracoronary stent placement to 100 lesions using 110 Palmaz-Schatz stents by nine individual operators. Lesions were predilated with an ACS RX LIFESTREAM balloon at a low pressure of 4-6 atm (mean 5.7 +/- 2.6). After stent deployment, the same balloon was used at a high pressure (mean 16.2 +/- 1.2). Mean balloon size, which was chosen as the stent size, was 3.4 +/- 0.4 mm. Comparison of this strategy with the recommended strategy of 68 consecutive elective stent deployments at a single center during the same time was performed. Stent implantation using a single balloon strategy was angiographically successful in 99 of 100 (99.0%) lesions. The single balloon strategy was associated with a balloon burst rate of 9.1%. The number of balloons used per stent deployment was 1.2 vs. 2.4 using the recommended strategy (P < 0.0001). There was no evidence of stent thrombosis, any MI, or target lesion revascularization during the procedure and hospitalization. One in-hospital death as a result of nonhemorrhagic stroke was documented in the treated group. We concluded that using a single high pressure perfusion balloon for pre and postdilation in patients undergoing elective stent placement is safe and reduces the number of balloons used per procedure.

Purpose: Fibrosing colonopathy is a newly described entity seen in children with cystic fibrosis. The radiological hallmarks are foreshortening of the right colon with varying degrees of stricture formation. High-dose enzyme therapy has been implicated as the cause of this process. The purpose of this study is to review the author's experience with evaluation and treatment of these patients., Methods: There are currently 380 patients being treated at our CF center. Fifty-five of these patients have been treated with high-dose enzyme therapy (> 5,000 units of lipase/kg). The medical records of these patients, who are at risk for developing fibrosing colonopathy, were reviewed for the presence of recurrent abdominal complaints, and the work-up and treatment of these symptoms., Results: Chronic complaints of abdominal pain, distension, change in bowel habits, or failure to thrive were present in 24 of the 55 patients treated with high-dose enzymes. So far, 18 of these 24 patients have been evaluated by contrast enema. Thirteen of eighteen have been found to have fibrosing colonopathy characterized by foreshortening and strictures of the colon. Additional findings included focal strictures of the right colon (7 of 13), long segment strictures (5 of 13), and total colonic involvement (1 of 13). Nine patients with the most severe symptoms have undergone colon resection, including five segmental right colectomies, three extended colectomies (ileo-sigmoid anastomosis), and one subtotal colectomy with end-ileostomy. Pathological evaluation has shown submucosal fibrosis, destruction of the muscularis mucosa, and eosinophilia. No postoperative complications or deaths occurred. All nine postoperative patients have noted marked symptomatic improvement. Contrast enema follow-up results are available for six patients, and have documented no recurrent strictures to date. Three of four nonoperative patients have less severe symptoms and are currently being treated conservatively. The other family has refused surgery and the patient is being treated symptomatically., Conclusion: High-dose lipase replacement has been implicated as the etiology for FC and was present in all of our patients. Our cystic fibrosis center now routinely limits lipase to 2,500 U/kg per dose. We recommend the use of the contrast enemas to evaluate at-risk patients who have chronic abdominal complaints or who present with recurrent bowel obstruction. Colon resection should be performed in those with clinically and radiographically significant strictures with the expectation of a good outcome.

We report a case of pleomorphic liposarcoma arising in the root of the mesentery of an adolescent girl. Pleomorphic liposarcoma is an extremely rare tumor in the pediatric age group, and few well-documented cases are found in the literature. To the best of our knowledge, none have been described in the abdomen. The histologic and ultra-structural features of this tumor are described, and the literature concerning pediatric pleomorphic liposarcoma is reviewed.

Part of psychiatry's recruitment problem is a result of defections among students who were planning careers in psychiatry when they entered medical school. The authors present data from a 20-year (1974-1993) experience at the University of Maryland that shows that students who expressed a preference for psychiatry as a career in the freshman year were four times more likely to enter psychiatric residency training after graduation if they participated in the Combined Accelerated Program in Psychiatry (CAPP), a 4-year psychiatric elective program, than if they pursued the regular undergraduate psychiatric program. More than 20% of the CAPP students who preferred nonpsychiatric careers as freshmen were "converted" to psychiatry and later entered psychiatric residency programs. Recent changes in the ideology and economics of our profession have neither lessened the popularity of the CAPP nor diminished its apparent ability to shelter students preferring psychiatry from the stigmatizing experiences of medical school.

Background: Increasingly, patients are returning for a second, third, and even fourth coronary artery bypass graft (CABG) procedure., Methods: This report reviews the in-hospital and long-term outcomes for 102 patients undergoing a third or fourth CABG at Emory University from December 1977 to April 1994., Results: The mean interval from the first to second CABG was 5.2 +/- 3.5 years and from the second to the third CABG 6.8 +/- 4.1 years. The mean age was 6 +/- 9 years, 91% were male, 33% had hypertension, 16% diabetes, 86% class III or IV angina (Canadian Cardiovascular Society), 4.4% congestive failure (New York Heart Association), and 73% three-vessel disease. The in hospital mortality rate was 9.8%, with a perioperative myocardial infarction rate of 8.8% and a stroke rate of 1.9%., Conclusions: These perioperative mortality and myocardial infarction rates are several times higher than those reported for initial revascularizations or first-time redo CABG operations. However, the 5- and 10-year survival rates of 79% and 59%, respectively, and a myocardial infarction-free survival of 62% at 5 years, the benefits of a third-time CABG procedure are apparent for this high-risk group of patients.

Costs have become increasingly important in medicine in recent years as demand for services has outstripped readily available resources. Clinical microeconomics offers an approach to understanding cost and outcomes in an environment of economic scarcity. In this article the types of costs and methods for determining cost are presented. In addition, methods for assessing outcome and outcome in relation to cost are developed. Restenosis after coronary angioplasty is a prime example of a clinical problem requiring economic evaluation. This is because it results in little serious morbidity except for recurrent chest pain, but it has serious economic consequences which occur some time after the original angioplasty. This makes the economic assessment of restenosis complicated. The application of health care microeconomic principles to brachytherapy for restenosis in the coronary arteries is presented.

Several studies suggest that normothermic ("warm") bypass techniques may improve myocardial outcomes for patients undergoing cardiac operations. Normothermic temperatures during cardiopulmonary bypass may, however, decrease the brain's tolerance to the ischemic insults that accompany all cardiac procedures. To assess the effect of bypass temperature management strategy on central nervous system outcomes in patients undergoing coronary revascularization, 138 patients were randomly assigned to two treatment groups: (1) hypothermia (n = 70), patients cooled to a temperature less than 28 degrees C during cardiopulmonary bypass, or (2) normothermia (n = 68), patients actively warmed to a temperature of at least 35 degrees C. Patients underwent detailed neurologic examination before the operation, on postoperative days 1 to 3 and 7 to 10, and at approximately 1 month after operation. In addition, a battery of five neuropsychologic tests was administered before operation, on postoperative days 7 to 10, and at the 4- to 6-week follow-up visit. Patients in the normothermic treatment group were older (65 +/- 10 vs 61 +/- 11 years in the hypothermic group), had statistically less likelihood of preexisting cerebrovascular disease, and had higher bypass blood glucose values (276 +/- 100 mg/% vs. 152 +/- 66 mg/% in the hypothermic group). All other patient characteristics and intraoperative variables were similar in the two treatment groups. Seven of 68 patients in the normothermic group were found to have a central neurologic deficit, compared with none of the patients cooled to 28 degrees C (p = 0.006). Performance on at least one neuropsychologic test deteriorated in the immediate postoperative period in more than one half of all patients in both treatment groups but returned to preoperative levels approximately 1 month after the operation in most (85%). This pattern was not related to bypass temperature management strategy. We conclude that active warming during cardiopulmonary bypass to maintain systemic temperatures > or = 35 degrees C increases the risk of perioperative neurologic deficit in patients undergoing elective coronary revascularization.

Completeness of revascularization after coronary artery bypass operation has been shown to improve short- and medium-term outcome. The purpose of this study was to assess the independent contribution of completeness of revascularization to long-term outcome. A total of 2057 patients with multivessel disease with complete revascularization and 803 with incomplete revascularization, mean age 57 +/- 9 years, was studied. The patient groups were similar except for more prior myocardial infarctions, worse left ventricular function, and more three-vessel disease in the incomplete revascularization group. Complications of perioperative infarction and stroke were not different between those having complete versus incomplete revascularization. The hospital death rate for patients having complete revascularization during the period of study was 0.7% versus 1.5% for those having incomplete revascularization (p = 0.06). Length of hospital stay for the two groups of patients also was not different. At late follow-up (mean 11.7 years for complete and 10.8 years for incomplete) patients who had incomplete revascularization had a significantly higher prevalence of recurrent angina. Multivariate analysis demonstrated the strongest predictors of incomplete revascularization to be number of vessels diseased and left ventricular function (ejection fraction). The multivariate correlates of survival were older age, left ventricular dysfunction, and completeness of revascularization. Completeness of revascularization correlated with improved overall patient survival, as well as survival in patients with normal left ventricular function. Furthermore, the curves continued to separate over time, such that the difference was greater at 8 years than at 4 years, although by 12 years the curves started to converge.