Document 6638

Myocardial Revascularization: A Combined
Roqr~ePiforre. .\I.D., F.C.C.P.. \l'iIJiunl E. Seville. .!f.D., F.C.C.P .
Ki~rrshrouE. Patel, 1f.D.. Robed D. Lynch, 1f.D.. and
T. K . Ragl~rrr~ath.
The surgical treatment of incapacitating angina pectoris is now pmsiMe through
the use of a combined approach. Direct and indirect myocardial revarularization
b combined with resection of ventricular aneurysms or akinetic ares. During
the part 20 months, 44 patients have been operated upon. The procedures performed were: I ) single internal mammar) arter? implants ( I 2 patients); 2) double
internal mammary arten implants (18 patients); 3) aoriocoronary vein bypass
graR (14 patienb 12 to the right c o r o n q and hvo to the anterior descending
arteries). Twelve OF these patients had a combined internal mammap artery
implantation and three a ventricular aneunsmectom). Two patients who did
not obtain complete relief after indirect m)ocardial revarularizstion had one
year later a carotid sinus nerve stimulator implanted and the) are abk to control
their angina. Vein grafts have the advantage of relieving angina immediately,
and. when pmsible, are the procedure of choice. The hospital mortality has been
9 percent The operative techniques are described.
e treatment of angina pectoris 11.1s been chansT b g rapidl! in tlir fe\v ya;ir.. S e w dnlgs
ha\-e helped to cvntrol anginal pain in .I numher of
patient\. Ho\vever. there are m.111) patients who
continue to \utfer incapacitating angina in spite of a
well-regnli~tedmedical therapy. Coron,iry arteriography hiis dc.monrtrated the loc.~tion ;lnd extent of
the dise'lse. In some cases the obstructing lesions
\Yere loc,ilizc>d in the main coronan drteries. 1Yith
the infortnation pro\ ided by coronary arteriography
it b now possihle to tredt surgically the majority of
patients that are clisahled by zingina pectoris
It is the pnrpo\e of this report to present our
exprcricnce in thr surgical treatment of angina.
Implantation of one or t\vo internal mamman
arteries has I ~ c r [nmlIined
with aortocnronar!- vein
grafts and resection of ventriruldr aneurvsms
or akinetic areas. Two patients who did not obtain
con>plete rrlief attvr indirect niyo~lrdialrnascuI.iriz;~tion. had. on'. !ear 1.1trr. .I carotid sinus ner\e
\timul;~tor implanted ;~ricl the! .ire no\\. able to
control their angin.1.
In thr ~xn<d
Iwto~.rnOct,~lx.rI'A7. .and Jr~l! 1WY. rlnglr n,.inilx>.rr> .rrtc,r\ ~ ~ r l p l . s r ~ l . a l ~ cacwc
~ n r ~ r f c m n c dan 19
pattrnt\ Durlnr! thr \.m,t, ~x.rl,xl 18 p ~ t t n t t s uodcment
cl~,tilrlc trrtrrtrrl tu,alnrn.iT) rrlvr! ~~npl.xntahc,nF,n!rtrm pa~ I V ~ I L ,11ad a n .%ortwc,run.q l ~ 11.1s
xr,xft ( alonv in hvo 1
\ ~ l t f l~lllpldnt.ltll)ll0f t11(.~ n t ~ m d111,LlllllldT)
i ~n 121 .,lid rr<ert>c,n~ , .If \ w i t r l c t t l e r aneor)*zn (I" t h r r r i or
pllc.ntlon ~ l tllc
niltr.aI \.tI\v I <,urI i Tahlcr I and 2 i
Table I-llornr'linl
(October 1967 to July 1 9 6 9 )
'From the Canliupulmonan. S t ~ r ~ i c aResearch
S e c t i o ~Vetrrrm Acltl,lt>!\tr,~t>~,t>
Hnnes, Illlni,~\ and the Deparhnrnl of Surqrr?. Lotola L'nnrruh Strtt'h Schwl of
\~'Y~,C,,I<.. \l.,\\\~"<l.ill,";>,.
Prrwntrd at thc Font Annual Fall Sc~rntlfic.i\*rmhl! (35th
.Annual \Irrtlnu i Atnrrlcan College of Chtit Phjciciam,
Clrtc~ur,.I l l c n ~ , Octc11,cr
29-Sc,\ranl,rr 2, l9G9
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S I ~ I K111
IC. \ I
Veil, yntft ~nl+~rlw,.iltlrst~
lright ~.oron:%ryl
Aortc~rln,s:try IIVI>:IA<
win mait
lriyht rorort:try,
Aort#r.<,n,n:try iright 1 I,yl,:w< vein graft
azal sinylc. inlvnt:tl tnanlmnry
artcry lnq~liint
Aortocon~narvI,rl,nsv vrpir~graft
I I 11, rigla1 itnd 2
c l r w ~ ~ n c l rit~ylv
i ~ ~ y ~intc.nt:tl rnnnlmnry
rrtr-ry i n ~ ~ , l : ~:ind
n t r~ntrictllar
.\ortucaron;~r? I>vl,:ts<v\.r.ln gmft
lriylnl vc~rut~:iry
I I L I I ~ pIiv:~tiot~
vf th?
m11r:,I v:,lv,,
2, Phntrrgraph showing a mnlpleted aortocoronac
win h y p ~ \ sgndt (md-to-siclr).
A m~di;m*tc..n.t<~h,nly
is thr idcal incision ior a mmbined
appn,iwh. Thr intrrn;d mammary ertrrir. (one or hro I are
rliswctcrl arr.c,nl~ngtu the trchniqee clrsrrihpd by Fax-aloro.'
The impl;rnt;atiott of the intrnlal nvulnmary urtrrirs (single or
doal,lr) i\ ~xrforn~cxl
$!ring a long. \ t ~ p r r L i a lhmnel, under
as many I,r;~nrht~r,of thr invr~l\.c~l pnsible:' Area<
of fibn~siran. ;lrcti<lcrl. In thr antrric~rtvall the implant is
prfonntrl. I I I ~ I ,titncs,
under the itnterior dmwnding artery
( F i g I I.
\\'lam ;I cr~znlaint~l
nppmnrh is to In. used thr p d i r l r of
t ~ ) . i\ Ivft i l t t a d l ~ t~
l the epieavtric
thr ~ntcntaln ~ a ~ t ~ t n iitrtrry
artery itnd is ituplrntt~l after thr clirrct crlronary artery
surgery has I m n cc~mplrkd.whilr the patirnt i\ still under
partial cnnlic,ptnl~tnaryI q p ~ s s .
Ac~rtcxoronary rein hypass graft, (Fig 2 ) are lx.rhnned
unrlrr crnrli~~p~uln~~~uv~ry
1,ypa.r. 'rile left ventricle i\ drco~npressed by a \.mt insrrtcvl thn>tzph the right saprrior pulnlonary vein. Prrf~lriumof the distal cownary artery (Fig 3 ) has
Fa:rm 1. .4rtc~norramot thr intcwxal artery hoe year pnst~~prntion
. filling of tht. cntirr rntt.rit,r dewending artery
tmd part nf thr\.
CHEST, VOL. 58, NO. 4. OCTOBER 1970
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lxvn ttrsl in 1no.t cares." This method not only p m w b
iachnniu during the time of anarh,nmmis, but it arts as a stmt.
~ rrlhlrp. and assuring a d i d
filcilitating the P ~ ~ C P I I IofC ~the
luntm. Flowr h a w ;nwagt~f IIY) ml/min with a prfusinn
prrr\arr IwWrrn LIXI and 120 rnnl Hg. Resectinn of a
\.~ntrinnlaraneunmt is perfc,nned ttndrr total carrliopahon.mry hvpasr. Pltdgvts of Tcflc~nfelt are very uuhll in reinforcing the edger of the \.tmtricltlar u.all. Care ir taken ta
?vactustr any sir trupplrl in thr vmhintlar cavity. \'mting of
the vrrrnrltnp acwtil b a gocrl safety major. Resection of a
w t r i c a l a r aneurysm or akinrtic area is always prfi,nned
once the aortmxlronary bypass has been cutnplrtrd.
The overall hospital mortality was 9 percent
(Table 1). There was no mortality with single
implants and only one fatality with double implants.
This patient died on the third postoperative day of
an acute myocardial infarcqion, complicated with
ventricular fibrillation. In the group of 14 patients
that had an aortocoronary bypass graft performed,
combined with indirect myorardial revascularization and/or resection of a ventricular aneurysm.
there \%-erethree hospital deaths ( TaBle 2 ) . One patient died o n the 12th postoper;ltivr day of respiratory complications. The patient who had a plication
Facuxr; 3. Photograph sha\ving the plastic vanntala tlcml to
p r h l s r the distal cornnary artery. during aortaxoronnr). rein
b p a s r ana5tom0rir.
of the mitral valve combined with hypass graft to
the right coronary artery died of recurrent mitral
insufficiency and recurrent ventricular fibrillation.
One patient died of a massive myocardial infarction
after endarterectomy of the right coronary artery
and aortomronary bypass graft.
All patients with an aortomronary bypass graft
have h e n completely relieved of pain (Fig l a and
l b ) . Five grafts have been restudied from one to
four months after operation and found to be patent.
Four of these patients, who had an intemal mammary artery implanted, had arteriography performed at the same time. .4t 2% months, small
communications behveen the implanted artery and
the coronary artery \\.ere present. .4t four months
the collateral anastomoses were larger and more
abundant, opacifying the coronary artery branches.
Collateral anastomoses are fully developed at the
Sa (upper). Cine cwmnary artrriocram of a 43-yearold man eight mamth* after an itrattr anten,lateral myocardial
infarction, showing nnrnplrtc cuvlln\ion c,f the anterior descending artcry, 5h I lower 1. Scvrre olntrurtion of the right
cnmnary artery. He alsu had a \mall \.entricolar aneurysm at
the apex. He was treattd hy the rr~n>hinedapproach (Fig
2 and 3 ) .
F1cc.n~4a (sppr). Cine coronary arteriogram
old man rhowinc severe ohstntctirm at the oricin and middle
bypasr rein graft
end of one yrar. Injection of the intemal mammary
artery in one patient with a single implant. opacified
the entire anterior descending and part of the
circumflex arteries (Fig 1 ). This patient had a
severe obstruction of the main left coronaq artery
and \\ns totally incapacitated. He did not obtain
complete relief of pain until six months postimplantation had elapsed.
Only &?percent of the patients with single or
double implants obtained significant relief of their
angina. T\vo patients who cnntinued to have pain
were restudied one year after implantation. One had
a single implant for severe obstruction of the
anterior descending artery. The arteriography revealed a Datent arterv. giving
- - e "blush" to the
myocardium but no anastomoses were demon~trated The
imnlant. The
.... other
-..... nne
-. . had
~-~ a double
-anterior implant sho\r.ed anastomosis \viti the anterior descending artery. The postcrior implant was
CHEST. VOL. 58, NO. 4. OCTOBER 1970
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patent and g a \ e a myocardial "blush," b u t no
anastomoses were present. Both patients had a
carotid sinus nerve stunulator iinplanted and have
been able to control their pain and increase their
exercise tolerance.
T h e surgical treatment of patients y i t h angina
unresponsive to a \\.ell-regulated medical regimen is
now possible in the majority of cases by using a
combined approach ( F i g 5a and 5 b ) . Direct and
indirect myoc;irdial revascularization is combined
with the resection of ventricular aneurysms or
akinetic areas.
Indirect myocardial revascularization by implantation of one4 or h \ o l internal mammary arteries
has been successful in many patients. Ho~vrver,
there is a delay of three to six months before a
significant amount of blood is supplied by the
implanted artrries.2 The saphenous vein grafts used
to replace' or bypass an obstructed segment of the
coronary artery has done axray with that waiting
period, by establishing immediate myocardial revascularization. Blood flow is reestablished and relief of
angina is obtained as soon as the operation is
Bypass vein grafts are being applied to smaller,
more distal arteries as techniques are unproved.
Kevertheless. in some cases, the lesions are multiple
and extend to the periphery. For these patients the
combination of one or h r o internal mamma? artery
implants with a bypass vein graft is the procedure
of choice. Resection of venbicular aneurysms or
akinetic areas should be combined with indirect and
direct coronary artery surgery.
T h e key to success for vein bypass grafts is a good
distal runoff. Since atherosclerosis is a progressive
disease, some of these bypasses may fail as the
dhease progresses. This is one more reason for
combining direct and indirect myocardial revascularization in properly selected cases. It would be
premature to discard indirect my-ocardial revasculanzation a t the present time. Long-term follow u p
of the vein bypass grafts is needed, no matter how
good and e ~ c i t u i gthe early results may be.
Those patients \>rho did not obtain complete relief
of their angina after myocardial revascularization
are very disappointed and discouraged. T h e use of a
carotid sinus nerve stimulator" may b e useful in
controlling their residual angina.
I Fa\aloro RG: Bilateral internal mammary artery implants:
operative tehniqoe. J Thorac Cardlovasc Surg 553457,
1 P~farreR, WiLcon S\I, LaRossa DD, et al: Jlyocardial
revascularization. Arterial and venour implants. J Thorac
Cardiovasc Surg 55:309, 1968
3 Pifarre R, Neville R'E, Patel KE, et al: Direct coronary
artery surgery with distal coronary artery perfusion. J
Thorac Cardiovarc Surg, in press
4 Vlneberg A: Development of an anastomosis behveen the
coronary vessels and a transplanted internal mammary
artery. Canad \led .4ssoc ]55:117, 1946
5 Fa\alora RG: Saphenous vein autograftr replacement of
severe segmental monary artery occlusion: operative
techmque. Ann Thorac Surg 5 334, 1968
3 Brauntvald E, Eprteln SE, Ghck G , et al. Relief of angina
pectons by electrical stimulation of the carotid s ~ n u s
nerves, Kew Eng J \led 277.1878.1967
Reprint requestr: Dr. Pifarre, P.O. Box 22, Veterans Administration Hospital, Hines, Illinois 60141.
The Essence of Joy
The only real enjoyment in life is memory. However
enjoyable this or that activity may have been or have
seemed to he at the time of actian-the eatas? of sensation, the ecctasy of touch and taste and smell, of sight
and sound-unless the memo- of it be good we must, for
our own peace. eschew such action. Peace, that is the
word of power. Peace In St. Thomas's fruitful words is
the tranquility of order. It is only order that the mind
can find rest. And as, upon inquiry, it seems so plainly
that the beauty without which there is no good memor).,
is the splendor of order and therefore of being itself (for
CHEST, VOL. 58, NO. 4. OCTOBER 1970
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being is the antithesis of chaos) does it not immed~ately
become clear that, if only to save sanity, order must he
safeguarded and, to that end, the exuberance and selfcentered enthusiasm of the individual be curbed and
restrained. A religious astringent must be found to give
rhyme and reason to the manifold random exuberances
of men and women.
Gill, E.: Life with the Fathers, in
Connolly, F.X. (editor) : Literature;
The Channel of Culttire, Harmurt,
Brace, Kew York, 1948