Myocardial Revascularization: A Combined Approach* 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. .\I.D. 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 p.ist 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 ~l with aortocnronar!- vein h\.vdss 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 tntrm.tl 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,>l,ll,r-<l \ ~ l t f l~lllpldnt.ltll)ll0f t11(.~ n t ~ m d111,LlllllldT) l 'Lrf?T) 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 f niltr.aI \.tI\v I <,urI i Tahlcr I and 2 i Table I-llornr'linl R~mrularizotion (October 1967 to July 1 9 6 9 ) - ---- - 'From the Canliupulmonan. S t ~ r ~ i c aResearch l S e c t i o ~Vetrrrm Acltl,lt>!\tr,~t>~,t> H~>%pstal, 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 Downloaded From: http://publications.chestnet.org/ on 06/09/2014 S I ~ I K111 IC. \ I l~,,,,l,~c [ I)trc,<,tc,on~rr:xr?-Ilrcri\ .r,>t:,1 --- -- . MYOCARDIAL REVASCULARIZATION 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 nllt(lri~r 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 snu!~ry*rnvrltnrr~y .\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,, I 0 I U FIGL-RE 2, Phntrrgraph showing a mnlpleted aortocoronac win h y p ~ \ sgndt (md-to-siclr). 3 I I 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 .~rtt.ry.as 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 Sntt. . filling of tht. cntirr rntt.rit,r dewending artery tmd part nf thr r.in.11~~~11~~\. CHEST, VOL. 58, NO. 4. OCTOBER 1970 Downloaded From: http://publications.chestnet.org/ on 06/09/2014 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 FIGURE 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 a 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 Downloaded From: http://publications.chestnet.org/ on 06/09/2014 341 MYOCARDIAL REVASCULARIZATION 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 completed. 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, 1968. 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 Downloaded From: http://publications.chestnet.org/ on 06/09/2014 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