Internal mammary artery bypass: effect on longevity and recurrent angina pectoris in 2900 patients

Internal mammary artery bypass (IMA) to the anterior descending coronary artery was performed in 2900 patients from January 1978 to December 1987. The average age of the patients was 64 years. Males accounted for 68% (1972 patients) and 82% (2378 patients) were in New York Heart Association (NYHA) class III. Left ventricular function was impaired in 51%. The average number of additional saphenous vein grafts per patient was 1.8. The operative mortality was 1.6%. Mediastinitis occurred in 29 patients (1%). Reoperation for bleeding was necessary in 32 patients (1.1%). Perioperative myocardial infarction (MI) was seen in 58 patients (2%) and neurological complications occurred in 32 patients (1.1%). Repeat coronary angiography was performed in 703 patients (25%) and demonstrated a patency rate of 96% in IMA grafts and 81% in saphenous vein grafts (SVG). Survival at 9 years was 90% from all causes and 95% when noncardiac deaths were excluded. Recurrence of angina occurred in 522 patients (18%) and reoperation was performed in 15 patients (0.5%). During the same time period, 1783 patients underwent coronary artery bypass utilizing a SVG. Survival at 9 years was 78% from all causes and 83% when noncardiac deaths were excluded. Recurrent angina was present in 546 patients (39%). These data suggest that a patent-IMA to the anterior descending protects against recurrent angina and death from cardiac causes and should be the conduit of choice.     

Internal mammary artery bypass: thirteen years of experience. Influence of angina and survival in 5125 patients.

Internal mammary artery (IMA) bypass to the anterior descending coronary artery (ADA) was performed in 5125 patients from January 1978 to December 1990. The average age of patients was 68 years; males accounted for 68% (3485 patients) and 82% (4203) were NYHA Class III. Left ventricular function was impaired (ejection fraction < 40%) in 68% (3485 patients). The average number of additional saphenous vein graft (SVG) per patient was 2.2. Operative mortality was 1.8%. Mediastinitis occurred in 51 patients (1.0%). Reoperation for bleeding was necessary in 56 patients (1.1%). Perioperative myocardial infarction was seen in 102 patients (2.0%) and neurological complications occurred in 51 patients (1%). Repeat coronary angiography was performed in 1414 patients (28%) and demonstrated a patency rate of 96% in IMA grafts and 75% in SVG grafts (p < 0.001). Survival at 13 years was 80% from all causes and 90% when non-cardiac deaths were excluded. Recurrence of angina occurred in 768 patients (15%) and reoperation or PTCA was performed in 61 (1.2%). During the same time period, 2345 patients underwent coronary artery bypass utilizing solely SVG. Survival at 13 years was 68% from all causes and 78% when non-cardiac deaths were excluded (p < 0.001). Recurrent angina was present in 727 patients (31%) (< 0.001). This data suggests that long-term probability of cumulative survival and occlusion free survival were significantly greater and the probability of recurrent angina and reoperative CABG and death from cardiac causes were significantly less in the IMA patients and should be the conduit of choice in coronary bypass surgery.     

Internal mammary artery to lung parenchyma fistula after aortocoronary bypass grafting

Two unusual cases of internal mammary artery fistulization to lung parenchyma after coronary revascularization are reported. They were incidentally discovered during coronary angiography, and one of them was successfully closed with a percutaneous transvenous coil-spring occluder. The cause is thought to be the direct contact between the dissected mammary artery pedicle and the lung parenchyma.     

Internal mammary artery grafting in patients with smaller body structure

The results of internal mammary artery grafting in 50 patients with a body surface area less than 1.6 m2 were compared with those in 54 patients with a larger body surface area. Age (58.8 +/- 8.2 versus 54.9 +/- 10.3 years old) and prevalence of female gender (28% versus 4%) were significantly different between the group of patients with a small body surface area and the group with a large body surface area, respectively. However, the prevalence of unstable angina, previous myocardial infarction, extent of coronary artery disease, and preoperative ejection fraction was not significantly different between the two groups. The mean number of distal anastomoses was 3.0 and 2.8, and the mean duration of aortic occlusion was 65.6 +/- 23.0 minutes and 59.5 +/- 21.7 minutes in the small and large body surface area groups, respectively (not significant). The mean free flow rate of the internal mammary artery was 65.6 +/- 16.8 ml/min in the small body surface area group and 78.0 +/- 21.6 ml/min in the large body surface area group (p less than 0.05). The diameters of the anterior descending and the circumflex arteries were significantly smaller in the small body surface area group. Two patients (4%) died within 30 days of operation and one patient died later in the small body surface area group, whereas no death was noted in the large body surface area group (not significant). No significant differences were found in the incidence of aortic balloon pumping, perioperative myocardial infarction, and serious postoperative complications between the two groups. Symptomatic relief was equally good in both groups (92% and 96%). The patency rate of the internal mammary artery was 95% (42/44) in the small body surface area group and 100% (48/48) in the large body surface area group within 1 year, mean 2.3 +/- 2.4 months. In conclusion, internal mammary artery grafting can be performed safely and effectively even in patients with small body structure. Though the blood flow of the internal mammary artery and the size of the coronary arteries were smaller in patients with small body structure, excellent patency of the internal mammary artery graft and satisfactory symptomatic relief can be expected.     

Internal mammary artery graft to pulmonary vasculature fistula: a cause of recurrent angina

Recurrent angina pectoris developed in a 59-year-old man 3 years after coronary artery bypass grafting using the left internal mammary artery. Cardiac catheterization showed a fistula between the left internal mammary artery and the pulmonary vasculature. This is an unusual documented case of postoperative internal mammary artery graft to pulmonary vasculature fistula after coronary artery bypass grafting. Division of this fistulous communication resulted in resolution of the patient's angina.     

Internal mammary artery grafting. Clinical results, patency rates, and long-term survival in 833 patients

This report reviews 833 patients who underwent internal mammary artery grafting alone or with vein grafts between 1968 and 1981. Use of the internal mammary artery was indicated in young or middle-aged patients with the following characteristics: a significant lesion of the proximal left anterior descending artery or its diagonal branch alone (70.1%) or combined with diffuse atherosclerosis (19.9%) or a small caliber (3.4%); absent or unsuitable veins for grafting (5.5%); atherosclerosis or an aneurysm of the ascending aorta (0.6%); and failure of previous vein grafts (0.5%). The left anterior descending artery system was grafted by the left internal mammary artery in 53.2%, and the arterial graft was complimented by vein grafts in 2.6%. In 45.2% of the patients, grafts of the left anterior descending artery by the left internal mammary artery were supplemented by vein grafts to the right coronary artery (23.8%), to the circumflex artery (15.2%), or to both (6.2%). The overall operative mortality was 2.2%. It rose to 16.7% with associated cardiac procedures and to 18.5% in patients who were in New York Heart Association Class IV. If these two high-risk categories of patients are excluded, the perioperative death rate in the remaining 750 was only 0.4%. Of the 815 patients who survived the perioperative period (mean 53.1 months follow-up), 63.1% were relieved of angina and 83.4% were in Class I or II of the New York Heart Association, as compared to 27.4% before the operation. At cardiac recatheterization (mean 18.9 months), 87.9% of the internal mammary artery grafts and 63.3% of the vein grafts were patent (p less than 0.05). The cumulative actuarial 10 year survival rate was 88.6% +/- 1.3%.     

Surgical treatment of unstable angina by saphenous vein and internal mammary artery bypass grafting.

During a 3 year period, direct myocardial revascularization was performed on an urgent basis in 48 patients with intermittent resting chest pain which persisted more than 24 hours despite in-hospital medical therapy and was accompanied by electrocardiographic changes representative of ischemia. Sixteen patients had saphenous vein (SV) grafts exclusively, and 32 patients each had one or two internal mammary artery (IMA) grafts with or without additional vein grafts. Follow-up ranges from 5 to 41 months (mean, 22 months). Twelve patients had single grafts to the left anterior descending coronary artery (LAD), 18 had double grafts, 16 had triple grafts, and 2 had quadruple grafts. The LAD required grafting in every patient. There was one operative death (2 per cent) and one late death from noncardiac causes. There were two (4 per cent) early postoperative myocardial infarcts and no late infarcts. Actuarial analysis projects a survival rate of 96 per cent 3 years postoperatively. Eighty-one per cent of the survivors are in Functional Class I, 17 per cent are in Class II, and 2 per cent are in Class III. All patients had postoperative angiography 2 weeks after operation. Eighty-six per cent of the SV grafts and all IMA grafts were open. No significant differences were observed between mean preoperative and postoperative left ventricular end-diastolic pressures or ejection fractions, but these parameters were noted to improve after operation in several patients. The remarkably high early and late survival rates, the low incidence of myocardial infarction, and the excellent functional results after rather long follow-up indicate that emergency coronary revascularization provides an effective therapy for unstable angina. The use of IMA grafts, when feasible, is a safe and possibly preferable approach in these patients.     

Internal mammary artery: methods of use and their effect on survival after coronary bypass surgery

Hazard analysis of total and cardiac mortality after isolated primary coronary artery surgery was performed using univariate and multivariate methods with special emphasis on the importance of the use and method of use of the internal mammary artery (IMA) as a bypass graft. The clinical data of 5880 consecutive patients were studied. The sum of the real follow-up periods studied was 27,948 years. The hazard of total and cardiac mortality could be defined in three-phase parametric models with an early, a constant and a late phase. The total survival was 82% +/- 1% at 10 years and 59% +/- 3.6% at 15 years. The construction of a single IMA distal graft (using left or right IMA) had a positive influence on the hazard (P = 0.0004) in the late phase after surgery with a high estimate (-1.6). The cardiac survival was 89% +/- 0.8% at 10 years and 74% +/- 3.5% at 15 years. The use of the left IMA had a positive influence (P = 0.001) in the late phase after surgery with a very high estimate (-2.3). The generated simulation of the total survival of a median patient with an IMA graft is 97% at 5 years and 94% at 10 years; for a median patient without an IMA graft, it is 97% at 5 years and 88% at 10 years. If a patient has other risk factors reducing his life expectancy, the influence can be dissipated because of lower survival rates at 5 years after surgery, when the effect of the IMA becomes most apparent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Internal mammary artery grafting to the circumflex coronary artery

The in-situ left internal mammary artery (LIMA) was anastomosed to the circumflex coronary artery (Cx) in 20 patients. The right internal mammary artery, the saphenous vein and the right gastroepiploic artery were also utilized to bypass the other coronary arteries. Sequential LIMA grafting to the diagonal branch and CX was performed in 2 patients. The sites of LIMA anastomosis were 15 obtuse marginal branches and 5 posterior lateral branches. All LIMA-Cx anastomoses were performed with single 8-0 polypropylene continuous suture technique. Mean number of distal anastomosis was 3.1 ranged from 2 to 4. Mean aortic cross clamp time was 68.5 minutes ranged from 42 to 87 minutes, and mean cardiopulmonary bypass time was 116.6 minutes ranged from 73 to 167 minutes. One patient died of renal failure at 22nd postoperative day, and the other patients were alive with relief of angina. New Q wave was noted in 1 patient. Postoperative angiogram at mean 2.0 months showed 100% patency of LIMA in restudied 12 patients. We concluded that the in-situ LIMA grafting to Cx system can be done with acceptably low mortality and excellent patency rate, and its utilization is particularly desirable in younger patients.     

Risks of bilateral internal mammary artery bypass grafting

Although use of one internal mammary artery (IMA) for coronary artery bypass grafting does not appear to be associated with increased risk, the results with both IMAs are less certain; the potential for a higher incidence of sternal wound infection as a result of devascularization of the sternum is a major concern. During a 42-month interval ending July 1988, 1,566 patients had coronary artery bypass grafting alone or in combination with other procedures: 633 received only vein grafts, 687 had unilateral IMA grafting, and 246 had bilateral IMA grafting. The IMA patients were younger, were more often male, had better cardiac function, and underwent fewer emergent, urgent, or combined procedures than the patients receiving vein grafts (p less than 0.05). Thirty-day mortality was lower among the IMA patients (unilateral IMA group, 2.8%; bilateral IMA group, 3.7%; and vein graft group, 7.9%; p = 0.001). With the exception of sternal wound problems, occurrence rates for postoperative complications among the IMA patients did not differ significantly from or were lower (p less than 0.05) than those among the patients with vein grafts. Sternal infections occurred with greater frequency among the bilateral IMA patients (6.9%) than among the unilateral IMA (1.9%) or vein graft (1.3%) patients (p = 0.001). By univariate analysis, obesity, diabetes, bilateral IMA grafting, and need for prolonged (greater than 48 hours) mechanical ventilation were associated with a significantly higher incidence of sternal infection (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

The unligated left internal mammary artery side branch as the cause of angina after coronary artery bypass grafting

The left internal mammary artery (LIMA) is a widely used conduit during coronary artery bypass graft (CABG) surgery because of its excellent long-term patency. Although large LIMA side branches are typically ligated during the surgery, the occurrence of a coronary steal phenomenon related to these side branches following surgery remains controversial. Advocates for occlusion of LIMA side branches in the setting of left anterior descending artery (LAD) ischemia indicate that anginal symptoms often improve and that objective measures of LAD ischemia frequently resolve. We present a patient with ischemia in the LAD distribution secondary to coronary steal from a large LIMA side branch that was successfully treated using the Embolization Coil-IMWCE-3-PDA5 (Cook Medical, Bjaeverskov, Denmark).     

冠状动脉旁路移植术后患者心绞痛与自我管理行为相关性研究

目的了解冠状动脉旁路移植手术(CABG)后患者心绞痛与自我管理行为之间的关系,为建立相应的健康管理方案提供参考。方法对133例CABG术后3～9个月的患者,采用西雅图心绞痛量表(SAQ)及自行设计的自我管理行为问卷进行调查。结果CABG术后患者SAQ 5个项目得分为(38.28±22.03)～(83.65±42.65)分,自我管理行为总分78.69±15.67;自我管理行为与心绞痛发作频率及治疗满意度存在正相关(均P<0.05)。结论CABG手术可改善冠心病患者心绞痛,自我管理行为可提高手术效果。护士应采取有效措施提升患者的自我管理行为,从而减少术后心绞痛发生。     

Coronary artery bypass grafting for unstable angina pectoris: risk analysis

Unstable angina pectoris is a broad, nonspecific diagnosis encompassing a wide variety of clinical syndromes. The intravenous administration of nitroglycerin preoperatively is indicative of a more acute clinical situation, and allows for selection and analysis of a more homogeneous patient population. We reviewed the results of coronary artery bypass grafting for unstable angina defined as angina necessitating intravenous administration of nitroglycerin preoperatively. There were 129 patients (83 men and 46 women) with a mean age of 63.2 years (range, 36 to 86 years). Complications included operative death in 6.2%, postoperative low cardiac output in 11%, and perioperative myocardial infarction in 9%. Twenty perioperative variables were analyzed to identify risk factors for these end points. For operative death, age (p less than 0.05), cross-clamp time (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant in the univariate analysis, but only age (p less than 0.05, F = 4.6) was an independent predictor using multivariate analysis (stepwise linear regression). For low cardiac output, univariate analysis demonstrated that cross-clamp time (p less than 0.01), preoperative use of an intraaortic balloon for angina (p less than 0.05), left ventricular score (p less than 0.05), number of diseased coronary vessels (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant variables. However, only use of an intraaortic balloon for angina (p less than 0.0001, F = 14.3) and left ventricular score (p less than 0.005, F = 11.1) were significant independent predictors in the multivariate model. For perioperative myocardial infarction, only diabetes requiring insulin (p less than 0.005) was a significant predictor.     

Aorta-coronary bypass grafting with the internal mammary artery: clinical experience in 70 patients.

Clincal and angiographic results in 70 patients who received free internal mammary artery (IMA) grafts are reviewed. One postoperative death occurred, but it was not related to the free IMA technique. Forty-seven patients underwent postoperative arteriography. The average interval between operation and catheterization was 10.7 months, and the patency rate for 49 free IMA grafts was 89.8 per cent. Of the 29 patients who recieved free IMA grafts as the only revascularization procedure, 21 patients (80 per cent) progressed to Functional Class I and only 5 patients did not have improvement in their functional status.     

机器人取乳内动脉小切口冠状动脉搭桥术体会

目的：总结达芬奇机器人获取左乳内动脉左前外侧小切口冠状动脉旁路移植术的技术要点,评价手术效果。方法回顾性的分析机器人获取左乳内动脉左前外侧小切口冠脉搭桥手术24例,分析结果并作以总结。结果术后患者均于手术当日顺利脱离呼吸机辅助,机械通气时间5.3±2.8 h,并均于术后18 h 内搬出 ICU。机器人获取乳内动脉时间在40~60 min 左右,术中出血量50 ml 左右,术后引流量较常规手术显著减少,平均90 ml 左右。全组患者无手术死亡和围术期并发症,在随访期间无再发心血管事件,其中11例患者术后复查冠脉 CT,9例接受冠脉造影复查发现桥血管通畅。结论机器人获取左乳内动脉左前外侧小切口搭桥手术的疗效满意,术后恢复快,并发症少,减轻了患者的痛苦,明显减少了死亡率,提高术后生存率。该手术是一项安全、有效的新技术,具有恢复快和美容效果,患者满意度较高。     

Clinical and angiographic assessment of complex mammary artery bypass grafting

The internal mammary artery has become the coronary bypass graft of choice in recent years because of enhanced long-term patency. Along with this trend, sequential, bilateral, and free mammary grafts have been employed more frequently in an effort to maximize the number of distal internal mammary anastomoses. This approach of maximally using the internal mammary artery (complex mammary grafting) seems logical, but at present little information about patency of the newer types of internal mammary artery grafts is available to justify the more complicated procedures. Over a 15 month period, 207 patients underwent bypass graft angiography from 1 to 32 weeks after operation. This is an 85% restudy rate for a consecutive series of coronary bypass procedures. Patency was defined as complete filling of the graft and distal vessel bypassed. A total of 841 distal vessels were grafted, or 4.1 per patient. The overall patency rate was 91% for 503 distal vein graft anastomoses and 99% for 338 internal mammary artery grafts. Individual patency rates of distal anastomoses, expressed as number patent/total (percent patent), were as follows: simple vein grafts, 262/285 (92%); sequential vein grafts, 196/218 (90%); left internal mammary artery to left anterior descending coronary artery, 109/110 (99%); left internal mammary to circumflex marginal artery, 14/14 (100%); right internal mammary to right coronary artery, 19/20 (95%); right internal mammary to left anterior descending coronary artery, 10/10 (100%); right internal mammary to circumflex marginal artery via transverse sinus, 18/20 (90%); sequential left internal mammary artery to left anterior descending system, 133/134 (99%); sequential left internal mammary to circumflex marginal system, 15/15 (100%); free internal mammary artery, 9/9 (100%); free sequential internal mammary artery, 6/6 (100%). Of the 18 patent transverse sinus right internal mammary grafts to the circumflex marginal artery, three exhibited very slow flow and probably were not functional. The hospital mortality associated with internal mammary revascularizations was 0.4% for nonemergency cases and 3.1% for emergency procedures. On the basis of clinical and postoperative graft patency data, expanded use of more complicated types of mammary grafts seems justified. Function of the right internal mammary graft to the circumflex marginal artery was suboptimal, and this method has been discontinued. All other complex mammary techniques had excellent patency rates as compared to vein grafts, and these differences may become even more significant in the late postoperative period.(ABSTRACT TRUNCATED AT 400 WORDS)