Use of the in situ and free internal thoracic artery for myocardial revascularization.
Explore the source record for details and available documents.
Anastomosis, Surgical↗
Biomedical subjects
F D Loop
Publications and source records attributed to F D Loop.
Choice of internal mammary artery or saphenous vein graft for myocardial revascularization.
The saphenous vein has been the traditional conduit for elective myocardial revascularization. Although readily available and adaptable to many configurations around the heart, it is prone to intimal hyperplasia and vein graft atherosclerosis, which diminish long-term patency and relief of symptoms. The internal mammary artery graft represents a marked improvement over the saphenous vein graft in many respects. Data are presented comparing saphenous vein graft patency with that of the internal mammary artery, bilateral internal mammary artery, free internal mammary artery, and sequential internal mammary artery grafts.
Coronary Disease↗
Free (aorta-coronary) internal mammary artery graft. Late results.
Free internal mammary artery grafts were placed in 156 patients (1971 to 1985). Preoperative clinical and angiographic variables were similar to those of other series of isolated coronary bypass grafts. Of 244 total internal mammary artery grafts, 166 were in the aorta-coronary position and were performed mainly because of unsuitable saphenous veins or to gain additional graft length. One patient (0.6%) died during hospitalization. Perioperative complications included respiratory dysfunction in 16 (10.3%), reoperation for bleeding in 13 (8.0%), stroke in four (2.6%), myocardial infarction in three (1.9%), and wound complications in two (1.3%). Morbidity occurred significantly more often in the 1971 to 1975 period. Subsequently, eight (7%) had reoperation (6 to 158 months; mean 99 months). After a 98 month mean follow-up, the 10 year actuarial survival rate (including all causes of death) was 73.3%. Of 40 free grafts restudied within 18 months of operation, 31 (77%) were patent. The higher rate of early closure is attributed to technical problems early in our experience, especially construction of the aortic anastomosis. However, 32 of 35 (91%) free grafts studied after more than 18 months (mean 94 months) were open. Fifty of 58 (86%) free internal mammary artery grafts placed to the anterior descending coronary artery, seven of nine (78%) to the circumflex, and six of eight (75.0%) to the right coronary artery were patent. Sequential catheterization showed that of 24 free grafts open at 9 months, 24 remained patent at 80 months; when six of these were restudied at 93 months (third catheterization) and two (fourth catheterization) at 125 months, all were patent. These late studies of free internal mammary artery grafts showed no evidence of graft atherosclerosis. Free internal mammary artery grafts, like in situ internal mammary artery grafts, appear to have relative immunity from atherosclerosis. These findings expand the versatility of internal mammary artery grafting and justify wider use of free internal mammary artery grafts.
Adult↗
Early results of emergency surgery after coronary angioplasty.
During the period of our study 81 patients undergoing elective coronary artery angioplasty at our institution required emergency revascularization surgery within the ensuing 24 hr. The mean age of the 59 men and 22 women was 57 years (32 to 74 years). The principal indications for the emergency surgery were acute occlusion (n = 36), dissection (n = 28), unstable angina (n = 10), ventricular arrhythmias (n = 4), and unsuccessful balloon dilatation (n = 3). There were two early deaths and in 35 patients the presence of three criteria for myocardial infarction was noted postoperatively. Including these patients, 52 patients surviving their hospital course suffered 75 major complications. Emergency surgery after failed percutaneous transluminal coronary angioplasty can be performed with low mortality, but it carries a high incidence of major postoperative complications.
Adult↗
Reoperation after previous grafting with the internal mammary artery: technique and early results.
Among 1,006 patients undergoing coronary bypass reoperation from 1968 through 1982, 100 had a patent internal mammary artery graft. There were 88 men and 12 women with a mean age of 53.4 years and a mean interval between first and second operations of 56.6 months. Reasons for reoperation were vein graft closure in 26% of the patients, progressive disease in previously ungrafted arteries in 48%, and combined indications in 26%. One operative death occurred. There was no significant difference in morbidity when compared with a reference group of 906 reoperations in patients without IMA grafting. Complete revascularization was achieved in 64% of the patients; the mean number of grafts per patient was 1.6. Seven patients had a perioperative myocardial infarction, and eight mammary artery pedicles were damaged during reoperation.
Coronary Disease↗
Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts.
Serial arteriograms were obtained in 501 patients after coronary bypass grafting. Study I within 5 years of operation (mean interval 15 months) and Study II more than 5 years after (mean interval 88 months, range 60 to 147 months). One hundred patients received both internal mammary artery and saphenous vein grafts: 37, mammary artery grafts only, and 364, vein grafts only. In Study I, 645 (82%) of 786 vein grafts were patent, 42 (5%) stenotic or irregular, and 99 (13%) occluded. Of 140 mammary artery grafts, 136 (97%) were patent, two (2%) stenotic, and two (2%) occluded. Of the 645 vein grafts patent in Study I, 357 (55%) remained patent in Study II, 119 (18%) were stenotic or irregular, and 169 (26%) were occluded. Of 136 mammary artery grafts patent in Study I, 130 (96%) were unchanged, one was stenotic, and five (4%) were occluded in Study II. Early vein graft patency was influenced by the coronary artery grafted and by angina. Progression of vein grafts patent at Study I to stenosis or occlusion at Study II was associated with increasing postoperative interval (p less than 0.00001), interval myocardial infarction (p less than 0.001), angina (p less than 0.001), diabetes (p less than 0.004), hypercholesterolemia (p less than 0.006), and hypertriglyceridemia (p less than 0.02); it was not influenced by the coronary artery grafted. Within 5 years of operation, mammary artery graft patency exceeded vein graft patency. Between 5 and 12 years after operation, the attrition rate of vein grafts greatly exceeded that of mammary artery grafts (p less than 0.0001).
Adult↗
Does mammary artery grafting increase surgical risk?
From 1980 through 1982, 7105 patients underwent primary isolated myocardial revascularization. Of these, 49.2% received only vein grafts and 50.2% received at least one internal mammary artery graft. The incidence of mammary artery grafting increased from 33.5% in 1980 to 67.1% in 1982. The operative mortality rate was 1.4% in the vein group and 0.2% in the mammary artery group (p less than .0001). A multivariate analysis identified six incremental risk factors for operative mortality. After adjusting for these risk factors, the use of vein grafts only was found to be an incremental risk factor (p less than .0001). In a subset of patients without major risk factors, there was no difference in the incidence of perioperative infarction, respiratory insufficiency, wound complication, stroke, use of intra-aortic balloon, reoperation for bleeding, or blood requirements. We conclude that internal mammary artery grafting is safe and is not associated with increased surgical morbidity or mortality.
Adult↗
Myocardial revascularization: evolution of a surgical procedure.
Since its inception, myocardial revascularization has steadily evolved. The patient population is older with more extensive cardiac disease. Surgical mortality is currently 1% with a less than 1% perioperative myocardial infarction rate. The number of grafts done per patient has increased to more than three with 80% of the patients being completely revascularized. Ninety percent of the patients receive at least one internal mammary artery graft. With more complete revascularization and greater use of the internal mammary artery, the prospects for long-term survival and palliation have improved.
Adult↗
The conservation of blood during cardiac surgery.
Explore the source record for details and available documents.
Blood↗
Atherosclerosis of the left main coronary artery: 5 years results of surgical treatment.
Three hundred consecutive patients received coronary arterial bypass grafts as treatment for stenosis of the left main coronary artery. Ostial stenosis was more prevalent among women (P less than 0.001). Operative (hospital) mortality was 4 percent (12 of 300). Among 148 survivors who underwent recatheterization after a mean interval of 16.5 months, the graft patency rate was 88 percent. After a minimal follow-up period of 49 months and a mean interval of 69 months, 75 percent of the survivors were asymptomatic and 94 percent were employed or fully active. The actuarial 5 year survival rate was 88.2 percent. The presence of right coronary artery disease, abnormal preoperative ventricular function and incomplete revascularization adversely affected survival, but the differences did not reach statistical significance. Comparison of this long-term follow-up study with controlled and noncontrolled studies of nonsurgical treatment of obstructions of the left main coronary artery indicates that myocardial revascularization alleviates cardiac symptoms and increases life expectancy in patients with severe atherosclerosis of this artery.
Adult↗
Posterior midventricular rupture after mitral valve replacement.
Posterior midventricular rupture occurred in 3 patients after insertion of a mitral prosthesis. Iatrogenic surgical trauma was not implicated. There were five clinical factors common to each case: a woman with mitral stenosis; a left ventricle of relatively normal size; the use of intermitent cold cardioplegia; the insertion of a porcine heterograft valve; and transient postoperative hypertension. Rupture in such cases may be caused by hyperdynamic left ventricular contraction against the strut of the prosthesis. Causes of ventricular perforation are discussed.
Bioprosthesis↗
Autotransfusion following cardiac operations: a randomized, prospective study.
To evaluate the safety and effectiveness of the collection and retransfusion of postoperatively shed mediastinal blood as part of a multifaceted approach to blood conservation following cardiac operation, 113 patients were randomized into either an autotransfusion group (54 patients) or a control group (59 patients). Intraoperative and postoperative hemodilution was practiced in all patients. The clinical safety of this technique was confirmed by the lack of septic, hematological, pulmonary, renal, or hepatic complications. However, in this setting where blood conservation is already aggressively practiced, the ability of the technique to further reduce the use of banked blood following cardiac surgical procedures was not demonstrated.
Adult↗
Blood conservation during myocardial revascularization.
A prospective study of blood utilization in 50 consecutive patients undergoing elective coronary artery bypass was undertaken. Blood was removed from all patients during induction of anesthesia and reinfused after bypass (mean, 675 ml). Intraoperatively, all discard suction was routed through a regionally heparinized collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was retained for transfusion. After operation, shed mediastinal blood was collected in a sterile, filtered collection system and transfused. Normovolemic anemia was accepted in hemodynamically stable patients. The mean amount of patients' blood salvaged by the intraoperative system was 259 ml (range, 0 to 724 ml) and by the postoperative system, 194 ml (range, 0 to 564 ml). Ninety-four percent (47/50) of the patients received no bank blood or blood products during their hospital stay. No patients received bank blood intraoperatively or during the first 24 hours following operation. There were no complications attributable to blood salvage techniques.
Adult↗
An 11 year evolution of coronary arterial surgery (1968-1978).
All patients who underwent isolated myocardial revascularization procedures from 1967-70 (n = 741) were compared with the first 1,000 patients who received similar elective operations each year from 1971 through 1978. Data from these eight years were processed through a computerized cardiovascular information registry. Median age increased from 50 to 56 years, multiple-vessel disease increased from 44 to 89%, and left ventricular asynergy from 41 to 54%. The number of grafts per patient increased from 1.5 to 2.5 and yet morbidity declined in every category except neurologic deficit. Operative mortality was 1.1% from 1967 through 1978 and 0.9% from 1971 through 1978. Graft patency was determined for 475 patients from 1967-70, 553 patients from 1971, 519 from 1972, and 540 from 1973. Patency rates after a mean catheterization interval of 21 months were 77, 77, 84, and 87% respectively. Higher graft patency coincides with introduction of the internal mammary artery graft. Five year follow-up was completed for the 1967-1970 series and 1971, 1972, and 1973 cohorts. Actuarial five year survival was 89.6, 91.6, 93.2, and 91.7%. Five year survival comparisons between 1967-1970 patients and 1971-1973 patients in single-, double-, and triplevessel disease categories show significant extended longevity in the later experience. Abnormal ventricular function and incomplete revascularization adversely influenced longevity (p < 0.05) in all years surveyed. In those series the percentage of asymptomatic patients at five years was 66, 65, 69, and 67%. Lower risk and higher five year survival are attributed to greater technical experience, changing technology, and improved management rather than to selection of lower risk cases.
Aged↗
Asymptomatic coronary artery disease managed by myocardial revascularization: results at 5 years.
A consecutive series of 17 patients surgically treated for asymptomatic coronary artery disease was surveyed for survival, clinical status, and graft patency after a mean follow-up of 75 months. Documented myocardial infarction (MI), 14 transmural and 3 subendocardial, was the major indication for catheterization. All patients were asymptomatic for at least 4 months prior to surgery. Six patients had greater than 70% obstruction in one vessel, seven in two vessels, and four in three vessels. The indication for revascularization was critical stenoses in vessels supplying large areas of viable myocardium. All patients received left internal mammary artery (LIMA) grafts to the left anterior descending coronary artery; seven patients also received saphenous vein grafts (SVG) to other vessels. There was no operative or late mortality. In 12 patients, postoperative angiography (mean interval, 12 1/2 months) showed 11/12 LIMA and all SVG patent. One incompletely revascularized patient with an occluded LIMA is symptomatic. All others are fully active without symptoms or interval MI after a minimum follow-up of 5 1/2 years. The safety and long-term results of myocardial revascularization warrant its consideration for selected asymptomatic postinfarction patients.
Adult↗
A surgeon's view of randomized prospective studies.
Explore the source record for details and available documents.
Control Groups↗
Role of left ventricular assist devices in clinical heart transplantation.
Explore the source record for details and available documents.
Heart Transplantation↗