Donald B. Effler

Acute coronary insufficiency (impending myocardial infarction and myocardial infarction): Surgical treatment by the saphenous vein graft technique

Abstract The development of direct coronary artery surgery by the saphenous vein graft technique for the first time provides a method that immediately increases the supply of oxygen to the myocardium. As a result, the area of myocardial infarction no longer depends only upon oxygen consumption. Emergency surgery was performed on 29 patients from April 1968 to May 1971; 18 operations were performed upon patients with impending myocardial infarction and 11 upon patients with acute myocardial infarction. Nineteen patients underwent coronary cineangiography before the acute episode; 9 were studied during an acute episode. Patients with impending myocardial infarction were operated upon within 24 hours of the acute episode. Nine patients with acute infarction were operated upon within 4 to 5 hours, 1 within 8 hours, and 1 within 10 hours. Three patients died after the operation; 2 in the group with impending myocardial infarction and 1 in the group with acute infarction. Twelve patients underwent repeat cineangiographic evaluation. All grafts but 1 were open. In the group with impending myocardial infarction, postoperative left ventriculography showed good function of the left ventricle. In the group with acute myocardial infarction, 4 patients showed good function of the left ventricle. In 1 the ventricle was unchanged, and in 2 impaired contraction was demonstrated. Although the present clinical experience is limited, certain conclusions can be made: (1) Emergency coronary cineangiography can be performed with minimal risk. (2) Patients with impending myocardial infarction can undergo operation with a low mortality rate and minimal complications. These patients are ideal candidates. The operation can prevent myocardial infarction. (3) When operations are performed within 6 hours of an acute myocardial infarction, most of the heart muscle can be preserved. (4) In patients with acute myocardial infarction and cardiogenic shock, assisted mechanical circulation is mandatory as the first step. The increase of well oxygenated blood supply should improve myocardial perfusion.

Vein Graft Surgery for Coronary Artery Disease: Survival and Angiographic Results in 1,000 Patients

One thousand patients were operated upon with vein graft techniques for severe coronary artery obstructions between May 1967 and July 1970, with a hospital mortality rate of 4% and a 5.6% incidence of angiographically confirmed in-hospital myocardial infarctions. Postoperative angiograms, performed in 619 of the survivors, revealed patency of one or more vein grafts in 84.2% of patients, and 82.5% of all grafts were patent in studies performed 1 to 49 months after surgery.The hospital survivors were followed for 22 to 60 months; only three patients were lost to follow-up. The survival curve for this group of patients was compared with that of another group of 469 patients who also had severe coronary artery disease and were potential surgical candidates, but were studied in an earlier period and did not have surgical treatment. The annual rate of attrition for each of the four years of follow-up in the surgical group averaged 4.8% per year (2.5% per year excluding hospital mortality), and 9.3% per year in the nonsurgical group. Remission of symptoms correlated closely with the completeness of revascularization.Myocardial revascularization with vein graft techniques can be accomplished successfully and with low risk in the majority of properly selected patients, resulting in a significant improvement in symptoms, as well as in long-term survival.

The Structural Study of the Saphenous Vein

From November, 1971, to September, 1974, 1,179 patients received aortocoronary saphenous vein bypass grafts at the Cleveland Clinic Hospital. Segments of saphenous vein from each patient were sent for microscopical analysis. These vein segments were classified as normal or abnormal (phlebosclerotic). Four hundred ninety-six normal vein grafts in 295 patients were restudied and had a patency of 87.9%. One hundred forty-four abnormal vein grafts in 86 patients were restudied and showed 89.5% patency. This study suggests that histopathological identification of an abnormal (phlebosclerotic) vein segment does not constitute a determining factor as far as late patency is concerned in a vein segment that is not grossly sclerotic.

Internal mammary--coronary artery anastomosis. "No-touch" technique.

A simple technique for internal mammary--coronary artery anastomosis that can be applied to all branches of the coronary circulation is described. The anastomosis can be constructed in 10 to 15 minutes. This technique eliminates pinching of the internal mammary artery by forceps.

Emergency myocardial revascularization

From April 1968 to December 1972, 100 patients received emergency aortocoronary artery saphenous vein bypass grafts at the Cleveland Clinic Hospital. Thirty-seven of these 100 patients received grafts during acute myocardial infarction and 63 during impending infarction. Coronary arteriograms were obtained in all patients before operation. In the group with acute infarction, operations were performed within 12 hours after the onset of acute chest pain in 29 patients and from 3 to 14 days after infarction in 8. In the group with impending infarction, most patients received grafts within 3 to 4 hours after the onset of chest pain. Six of the 100 patients died in the postoperative period, 2 with acute and 4 with impending infarction. Thirty patients with acute infarction and 55 with impending infarction became asymptomatic. Sixteen of the 37 patients with impending infarction and 20 of the 63 patients with acute infarction were restudied. The graft patency rate in these patients was 92 percent. Coronary arteriography can be performed during acute and impending myocardial infarction with minimal risk. Aortocoronary saphenous vein bypass grafting can prevent the development of acute infarction when properly performed during the stage of impending infarction. It may also prevent the extension of acute infarction when , performed during the early phase of this lesion.

The Free Internal Mammary Artery Bypass Graft: Use of the IMA in the Aorta-to-Coronary Artery Position

Abstract Transposition of the internal mammary artery (IMA) into the aorta-to-coronary artery position is described, and 4 patients who underwent this operation are reported. Currently, this type of bypass graft is reserved for those patients who have unsuitable or stripped saphenous veins. The free IMA grafts can be connected to any of the major coronary vessels, and in most instances optical assistance is not necessary. There was no significant difference in recorded blood flow between these free grafts and a large group of in situ IMA-to-coronary artery bypass grafts.

Heart Valve Replacement: Clinical Experience

HIS REPORT discusses our clinical experience in aortic and initral valve replacenient utilizing the Starr-Edwards prosT thesis. T h e basis for this report is a consecutive series of 224 operations performed in the period of September, 196 1, through February, 1964.t T h e reasons for the decision to utilize the Starr-Edwards prosthetic valve and to abandon the various types of valvuloplasty procedures have been detailed in previous coniniunications [ 10-1 51. Beginning in 1956, we tried a number of procedures designed to reestablish coinpetency of the aortic and the niitral valves, including corninissurotoiny, decortication, and a variety of plastic procedures designed to refurbish the valve cusps or leaflets. Many of these procedures warranted initial enthusiasm, but the late results were disappointing: Valves that were

Double Internal Mammary Artery-Myocardial Implantation Clinical Evaluation of Results in 150 Patients

A total of 248 double internal mammary artery-myocardial implantations have been performed at the Cleveland Clinic up to October 31, 1967. This report presents an analysis of the clinical experience with the first 150 patients. The majority of the patients were between 40 and 60 years of age. The overall hospital mortality was 9.3%. The lowest mortality rate (4.9%) was among patients between 51 and 60 years of age. The most common complication encountered in this series (22 patients) was atrial fibrillation. Acute myocardial infarction developed in 14 patients; all of them recovered with the usual medical treatment. All of the patients have been studied by Soness technique of selective coronary angiography and left ventriculography. We believe that this is mandatory in the selection of patients for coronary artery operations. The postoperative evaluation shows significant clinical improvement in the majority, 116 patients. Thirty-one have undergone postoperative angiographic studies. Of 61 opacified arteries, 58 remained patent, and 37 showed definite communication with coronary arteries. We believe our present operative technique allows us to increase myocardial perfusion in any region of the left ventricle.

Percutaneous Myocardial Biopsy of the Left Ventricle Experience in 198 Patients

A thin-walled Silverman needle has been used for 254 percutaneous punch biopsies of the left ventricle in 198 patients with closed chests at the Cleveland Clinic. The technic is described. The biopsy specimens were adequate for diagnosis in 192 patients. In all but three patients (who had lupus erythematosus, scleroderma, and chronic glomerulonephritis with congestive heart failure) cardiac catheterization and selective cardioangiographic studies were performed. There was angiographic evidence of primary myocardial disease, coronary atherosclerosis, or both, or rheumatic valvular disease in 175 patients. Cardiac catheterization and angiographic studies demonstrated no evidence of organic heart disease in 20 patients.Cardiac tamponade was a complication of myocardial biopsy in eight patients. Post-pericardiotomy syndrome occurred in four patients and ventricular fibrillation in one patient.Myocardium with no pathologic diagnosis and interstitial fibrosis or myocardial hypertrophy or both were the light microscopic findings in 165 patients. Representative sections of the biopsy in 27 patients demonstrated small-vessel disease, basophilic degeneration, focal interstitial myocarditis, amyloidosis, Aschoffs nodules, or vacuolar degeneration. The current experience suggests that myocardial biopsy combined with selective cardioangiography is of experimental value, improves the accuracy of diagnosis, and plays a role in the management of some patients.

Posterior ventricular aneurysms. Etiologic factors and results of surgical treatment.

Abstract An extensive infarction of the posterior (diaphragmatic) left ventricular wall often compromises the posterior papillary muscle and causes early death from severe mitral regurgitation. This single fact explains the scarcity of posterior aneurysms as a clinical entity. In 11 cases of large posterior ventricular aneurysms that infringed upon but did not damage the mitral-valve mechanism, aneurysmectomy was performed. Repair of postinfarction ventricular septal defects was also necessary in two patients. The clinical diagnoses were made or confirmed by ventriculography and coronary arteriography. Of the major symptoms associated with posterior ventricular aneurysms, congestive heart failure was the most common indication for surgery. No operative deaths occurred; one patient died of a myocardial infarction in the late postoperative period. The 10 surviving patients are active, with improvement over their preoperative condition.