Clinical Application of Current Techniques and Treatment in Cardiology Adv. Cardio!., vo!. 17, pp. 134-138 (Karger, Basel 1976)
Surgical Treatment in Unstable Angina JOHN H.K. VOGEL, R. BRUCE McFADDEN, JACK LOVE and EDWARD JAHNKEjr. Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, Calif.
Introduction
In 1971 we suggested that unstable angina or preinfarction syndrome represented a leading indication for bypass surgery [VOGEL et al., 1971]. The purpose of this paper is to report our results as of this time with surgery in patients with unstable angina.
Methods 94 patients have undergone bypass surgery with a diagnosis of unstable angina. This includes 77 males with an average age of 53 years, ranging in age from 36 to 73, and 17 females with an average age of 56, ranging in age from 39 to 68. The majority of the patients had multi-vessel disease with 49 patients demonstrating triple-vessel disease, 24 double-vessel disease and 21 single-vessel disease. Significant ventricular dysfunction was present in a number of these subjects with a systolic ejection fraction by biplane cineangiography under 50% in 23 patients and over 50% in the remaining 71. Revascularization procedures included single bypass in 29, double bypass in 54, triple bypass in 11 and 15 underwent associated endarterectomy. Virtually all patients underwent restudy prior to discharge following their surgical intervention.
There were three early deaths in the 94 patients. These were due to ventricular failure in one patient, aortic dissection in one and cerebral vascular accident in a third. There were eight intraoperative myocardial infarctions, two of which were significant. Follow-up averages 25 months with a
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Results
135
range of 2-49 months. Of the 91 patients discharged from the hospital there have been four deaths and two myocardial infarctions. Late deaths have been due to an auto accident at 15 months, cerebral hemorrhage at 5 weeks, carcinoma of the esophagus at 16 months and sudden death at 11 months. The latter death is the only one attributed to coronary artery disease in this follow-up. Postoperative studies of graft patency were obtained in the majority of patients. In the first 19 months, 22 of 26 patients were restudied prior to discharge at a time prior to the use of the internal mammary artery. Of the 43 vein grafts, 19 of 22 to the right coronary artery, 12 of 18 to the left anterior descending and 2 of 3 to the circumflex were patent. During the subsequent 29 months, the internal mammary artery was used extensively in the left coronary artery system. 65 of the 68 patients operated on during that time underwent study prior to discharge. Of a total of 39 vein bypasses, 36 of38 to the right coronary artery were patent and one to the circumflex was patent. Of 89 internal mammary artery bypasses, 10 of 11 right internal mammary arteries in the right coronary artery were patent, 60 of 60 to the left anterior descending were patent, and, 15 of 15 to the circumflex were patent. 15 of 16 associated endarterectomies were patent. Analysis of biplane cineangiograms revealed an average increase in total wall motion, based on analysis of six wall segments, of 12.5%, an increase in average systolic ejection fraction from 53 to 61 %, and no significant change in left ventricular end-diastolic pressure, which remained at 15. Follow-up treadmill studies showed significant improvement. 37 patients underwent treadmill studies preoperatively. Most of these were of a limited nature. 35 were positive, 29 at a sub maximal level and 6 at a maximal level. Two were negative, one a submaximal, one a maximal. Postoperatively, treadmill studies have been performed in 78 patients. 59 of these have been negative, 38 at maximal load and 21 at submaximal load. There have been 19 positive treadmills, 10 at maximal load and 9 at sub maxi mal. Only one had pain, the rest being positive on the basis ofSTwave changes. When patients were analyzed on the basis of whether or not they had complete repair of all involved vessels, the results were more impreSSIve. In this group of patients, there were 14 preoperative studies, 13 being positive with 11 at the submaximallevel and two at the maximal level, with one negative at a submaximal level. There was a striking change postoperatively. Thus, of 25 patients undergoing postoperative study, 22 had negative treadmills, 17 at maximal loads and five at submaximal loads. There were only three positive studies, two maximal and one at submaximal. None had chest pain.
Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
VOGEL/McFADDEN/LoVE/JAHNKE
VOGEL/McFADDEN/LoVE/JAHNKE
136
Subjectively, 88% of the patients are free of angina and the majority have returned to their former activities. To evaluate the effects of internal mammary artery bypass on ventricular function, those patients with isolated internal mammary artery bypass without associated venous bypass, were analyzed. 13 patients were included in this group, all who underw~nt isolated left internal mammary artery bypass to the left anterior descending coronary artery. In this group of patients, six had undergone a limited treadmill study preoperatively at a submaximal level and all were positive by electrocardiographic analysis and symptomatic pain. However, postoperatively, 12 of the 13 have now undergone study and, in striking contrast, 11 are negative at maximal levels of exercise and one negative at submaximallevels. None of the patients have angina. This includes one patient, age 62, a marathon runner, who since internal mammary bypass has run the official marathon in 3 hand 59 min without electrocardiographic changes or chest pain.
Discussion
In this study we have reported our current results in patients with unstable angina who have been followed up to 49 months. Operative mortality continues to be low, averaging 3.2%, although several patients had severe multi-vessel disease and diminished ventricular function. Initial studies revealed graft patency to be less than acceptable, using veins for diseased left anterior descending coronary arteries. Therefore, 2 years ago the internal mammary artery was utilized for bypassing the left anterior descending and, subsequently, has also been applied to the circumflex and right coronary arteries. Results have been excellent, with 100% patency of the internal mammary artery into the left anterior descending. With an average followup of over 2 years, the late mortality has been 4% with only one death attributable to coronary artery disease in our group of 91 patients. This clearly represents a deviation from the predicted mortality rates with medical treatment in such patients. Not only have the predicted mortality rates been altered, but the symptomatic improvement has been excellent. Our results with internal mammary artery bypass suggest that this is the vessel of choice for bypass grafting. Not only has patency been excellent, but ventricular function has been satisfactory. Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
We would recommend that any patient with unstable angina, age and
general health permitting, should undergo coronary cineangiography and
Surgical Treatment in Unstable Angina
137
left ventricular function studies. The importance of cineangiography is clear from the numerous studies that have shown a wide variety of coronary artery changes with greatly different prognostic significance. Although medical treatment may be employed initially, in view of our low surgical morbidity and mortality, and excellent graft patency, we would consider surgical intervention for main left coronary artery disease, proximal left anterior descending disease, multi-vessel disease and any large single-vessel disease with persistent symptoms on good medical treatment.
Reference
JOHN H. K. VOGEL, MD, Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, CA 93111 (USA)
Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
VOGEL, J.H.K.; McFADDEN, R.B.; LOVE, J.W., and JAHNKE, E.J.: Emergency vein bypass for the pre-infarction syndrome. Chest 59: 606-609 (1971).
Surgical Treatment in Unstable Angina JOHN H.K. VOGEL, R. BRUCE McFADDEN, JACK LOVE and EDWARD JAHNKEjr. Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, Calif.
Introduction
In 1971 we suggested that unstable angina or preinfarction syndrome represented a leading indication for bypass surgery [VOGEL et al., 1971]. The purpose of this paper is to report our results as of this time with surgery in patients with unstable angina.
Methods 94 patients have undergone bypass surgery with a diagnosis of unstable angina. This includes 77 males with an average age of 53 years, ranging in age from 36 to 73, and 17 females with an average age of 56, ranging in age from 39 to 68. The majority of the patients had multi-vessel disease with 49 patients demonstrating triple-vessel disease, 24 double-vessel disease and 21 single-vessel disease. Significant ventricular dysfunction was present in a number of these subjects with a systolic ejection fraction by biplane cineangiography under 50% in 23 patients and over 50% in the remaining 71. Revascularization procedures included single bypass in 29, double bypass in 54, triple bypass in 11 and 15 underwent associated endarterectomy. Virtually all patients underwent restudy prior to discharge following their surgical intervention.
There were three early deaths in the 94 patients. These were due to ventricular failure in one patient, aortic dissection in one and cerebral vascular accident in a third. There were eight intraoperative myocardial infarctions, two of which were significant. Follow-up averages 25 months with a
Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
Results
135
range of 2-49 months. Of the 91 patients discharged from the hospital there have been four deaths and two myocardial infarctions. Late deaths have been due to an auto accident at 15 months, cerebral hemorrhage at 5 weeks, carcinoma of the esophagus at 16 months and sudden death at 11 months. The latter death is the only one attributed to coronary artery disease in this follow-up. Postoperative studies of graft patency were obtained in the majority of patients. In the first 19 months, 22 of 26 patients were restudied prior to discharge at a time prior to the use of the internal mammary artery. Of the 43 vein grafts, 19 of 22 to the right coronary artery, 12 of 18 to the left anterior descending and 2 of 3 to the circumflex were patent. During the subsequent 29 months, the internal mammary artery was used extensively in the left coronary artery system. 65 of the 68 patients operated on during that time underwent study prior to discharge. Of a total of 39 vein bypasses, 36 of38 to the right coronary artery were patent and one to the circumflex was patent. Of 89 internal mammary artery bypasses, 10 of 11 right internal mammary arteries in the right coronary artery were patent, 60 of 60 to the left anterior descending were patent, and, 15 of 15 to the circumflex were patent. 15 of 16 associated endarterectomies were patent. Analysis of biplane cineangiograms revealed an average increase in total wall motion, based on analysis of six wall segments, of 12.5%, an increase in average systolic ejection fraction from 53 to 61 %, and no significant change in left ventricular end-diastolic pressure, which remained at 15. Follow-up treadmill studies showed significant improvement. 37 patients underwent treadmill studies preoperatively. Most of these were of a limited nature. 35 were positive, 29 at a sub maximal level and 6 at a maximal level. Two were negative, one a submaximal, one a maximal. Postoperatively, treadmill studies have been performed in 78 patients. 59 of these have been negative, 38 at maximal load and 21 at submaximal load. There have been 19 positive treadmills, 10 at maximal load and 9 at sub maxi mal. Only one had pain, the rest being positive on the basis ofSTwave changes. When patients were analyzed on the basis of whether or not they had complete repair of all involved vessels, the results were more impreSSIve. In this group of patients, there were 14 preoperative studies, 13 being positive with 11 at the submaximallevel and two at the maximal level, with one negative at a submaximal level. There was a striking change postoperatively. Thus, of 25 patients undergoing postoperative study, 22 had negative treadmills, 17 at maximal loads and five at submaximal loads. There were only three positive studies, two maximal and one at submaximal. None had chest pain.
Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
VOGEL/McFADDEN/LoVE/JAHNKE
VOGEL/McFADDEN/LoVE/JAHNKE
136
Subjectively, 88% of the patients are free of angina and the majority have returned to their former activities. To evaluate the effects of internal mammary artery bypass on ventricular function, those patients with isolated internal mammary artery bypass without associated venous bypass, were analyzed. 13 patients were included in this group, all who underw~nt isolated left internal mammary artery bypass to the left anterior descending coronary artery. In this group of patients, six had undergone a limited treadmill study preoperatively at a submaximal level and all were positive by electrocardiographic analysis and symptomatic pain. However, postoperatively, 12 of the 13 have now undergone study and, in striking contrast, 11 are negative at maximal levels of exercise and one negative at submaximallevels. None of the patients have angina. This includes one patient, age 62, a marathon runner, who since internal mammary bypass has run the official marathon in 3 hand 59 min without electrocardiographic changes or chest pain.
Discussion
In this study we have reported our current results in patients with unstable angina who have been followed up to 49 months. Operative mortality continues to be low, averaging 3.2%, although several patients had severe multi-vessel disease and diminished ventricular function. Initial studies revealed graft patency to be less than acceptable, using veins for diseased left anterior descending coronary arteries. Therefore, 2 years ago the internal mammary artery was utilized for bypassing the left anterior descending and, subsequently, has also been applied to the circumflex and right coronary arteries. Results have been excellent, with 100% patency of the internal mammary artery into the left anterior descending. With an average followup of over 2 years, the late mortality has been 4% with only one death attributable to coronary artery disease in our group of 91 patients. This clearly represents a deviation from the predicted mortality rates with medical treatment in such patients. Not only have the predicted mortality rates been altered, but the symptomatic improvement has been excellent. Our results with internal mammary artery bypass suggest that this is the vessel of choice for bypass grafting. Not only has patency been excellent, but ventricular function has been satisfactory. Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
We would recommend that any patient with unstable angina, age and
general health permitting, should undergo coronary cineangiography and
Surgical Treatment in Unstable Angina
137
left ventricular function studies. The importance of cineangiography is clear from the numerous studies that have shown a wide variety of coronary artery changes with greatly different prognostic significance. Although medical treatment may be employed initially, in view of our low surgical morbidity and mortality, and excellent graft patency, we would consider surgical intervention for main left coronary artery disease, proximal left anterior descending disease, multi-vessel disease and any large single-vessel disease with persistent symptoms on good medical treatment.
Reference
JOHN H. K. VOGEL, MD, Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, CA 93111 (USA)
Downloaded by: Université René Descartes Paris 5 193.51.85.197 - 2/16/2018 11:36:56 PM
VOGEL, J.H.K.; McFADDEN, R.B.; LOVE, J.W., and JAHNKE, E.J.: Emergency vein bypass for the pre-infarction syndrome. Chest 59: 606-609 (1971).
