Revascularization with bilateral internal thoracic artery grafts in patients with left main coronary stenosis
Barner, Hb × Naunheim, Ks Willman, Vl Fiore, Ac Sergeant, Paul Vermeulen, Fee Okszulak, T Turina, M Fontan, F #
Elsevier science bv
European Journal of Cardio-Thoracic Surgery vol:6 issue:2 pages:66-71
Left main occlusive disease (LMD) is a potentially fatal lesion which is optimally treated with surgical revascularization. Although the internal thoracic artery (ITA) is recognized as having superior long term patency, there has been concern regarding possible flow limitation. Because of this concern, there may be reluctance to use only this conduit in patients with LMD in whom high graft flows are desirable. From 1985 to 1990, 45 patients (38 males, 7 females) with LMD ranging in age from 37 to 75 years (mean 55.9 +/- 8.7) underwent revascularization using bilateral ITA grafts placed to the left anterior descending and circumflex arteries. The right ITA was used as a free graft in 19 of 45 (42%) patients and the left ITA was used as a free graft in 3 of 35 (7%). No saphenous vein grafts were placed to the left coronary system in any patient. Over half of these patients (24 patients, 53%) also had occlusive disease in the right coronary artery. A saphenous vein graft was placed to the right coronary artery in 22 of 45 (49%) patients. Ventricular function in this patient subset was good (mean LV score 7.1 +/- 2.1). Intra-operative ITA graft flows were 49.7 +/- 29.1 ml/min for grafts to the left anterior descending and 45.5 +/- 31.7 ml/min for circumflex grafts. There were no perioperative deaths. Morbidity included myocardial infarction, stroke and reoperation for bleeding in 1 patient each (2.2). Low cardiac output occurred in 2 patients (4.4%). No patient had a mediastinal wound infection. These rates were not significantly different from those found in 708 other patients in whom both ITAs had been utilized for revascularization over the same time period. This experience provides no evidence of inadequate early graft flow or performance. There is no increased incidence of low cardiac output, perioperative infarct or death. This study suggests that utilization of bilateral ITAs as the only conduit for left coronary revascularization in patients with left main occlusive disease is safe and efficacious. The supposition that bilateral ITAs may provide inadequate myocardial blood flow in the early postoperative period is not supported by this study.