Severe Kawasaki heart disease treated with an internal mammary artery graft in pediatric patients. A first successful report

Two Japanese boys, 6 and 10 years old, required operation for severe Kawasaki heart disease. Both had multiple coronary arterial aneurysms and stenoses, and one had mitral regurgitation as well. The operations consisted of anastomosis between the left internal mammary artery and the left anterior descending artery and insertion of an autologous saphenous vein between the aorta and the posterior descending artery in both patients. The mitral valve was replaced in the one with mitral regurgitation. Angina pectoris has been completely relieved as confirmed by postoperative angiocardiography. Late results of coronary bypass grafting with the saphenous vein in pediatric patients with Kawasaki disease have been less than satisfactory because of the high occlusion rate of the graft. The internal mammary artery may be superior, at least theoretically, to the saphenous vein graft because it is a "living graft" with a high possibility of growing and with less susceptibility to degeneration. This is the first report of successful operation utilizing an internal mammary artery graft in coronary bypass for Kawasaki disease.

The fate of arm veins used for aorta-coronary bypass grafts

Arm veins have been a common second choice conduit for those patients having insufficient saphenous veins for coronary bypass operations. To define the patency and durability of arm vein grafts, we reviewed our patients with one or more arm vein grafts used for coronary revascularization between 1974 and 1982. A total of 59 patients required at least one arm vein graft and 51 are presently alive. Postoperative arteriograms were obtained in 28 patients. Of 56 arm vein grafts used, 32 (57%) were patent and 24 (43%) had failed at 2 years. Seven of the patent grafts had a localized area of stenosis. Sixteen internal mammary artery grafts also had been used in this group of patients, and 15 (93%) were patent. We conclude that arm vein grafts have a high failure rate and are not as dependable as saphenous vein grafts or internal mammary artery grafts.

Comparison of late changes in internal mammary artery and saphenous vein grafts in two consecutive series of patients 10 years after operation

Postoperative angiographic studies were carried out at 1 month, 1 year, and 10 years in two groups of patients: 238 patients with saphenous vein (SV) grafts and 40 patients with internal mammary artery (IMA) grafts. Cumulative patency was better in IMA grafts, both at 1 year (88.5% vs 76.4%) and at 10 years (84.1% vs 52.8%). Atheromatous changes in patent grafts at 10 years were frequent in SV grafts (29/66 or 43.9%) and uncommon in IMA grafts (1/19 or 5.2%; p less than .02). Attrition rate (11.8%) during the first year in IMA grafts (representing our initial experience with IMA grafts) was comparable to that of SV grafts (15.2%) in a group of patients operated on after 2 years of experience. Therefore, early attrition rate may be related to both experience and type of conduit. Later, at 10 years, the conduit itself appears to be the dominant factor. Furthermore, patients who received IMA grafts had a better survival rate at 10 years (84.3% vs 70%) than those who underwent SV bypass grafting.

The role of the sequential internal mammary artery graft in coronary surgery

The use of sequential internal mammary artery grafts is a possible method of improving overall long-term graft patency in patients receiving coronary artery bypass grafts. Twenty-nine patients who had sequential grafts were studied. The left internal mammary artery was anastomosed side-to-side to the diagonal and end-to-side to the left anterior descending coronary artery (LAD) in 24 patients, side-to-side to the proximal LAD and end-to-side to the distal LAD for proximal and midvessel obstruction in four patients, and in one patient the left internal mammary artery was grafted side-to-side to the first marginal branch of the circumflex artery and end-to-side to the second marginal branch. There were no operative deaths, but one patient died 10 months after surgery from viral pneumonia. There was no evidence of left ventricular failure. None of the patients suffered perioperative myocardial infarction or return of their angina. Eleven patients underwent postoperative stress tests and results were negative in all. Graft visualization in three patients showed patent grafts without kinking or narrowing. These findings suggest that the sequential internal mammary artery graft is safe and should improve overall long-term patency. We particularly recommend its use in the younger patient.

Conditional probability of multiple coronary graft failure

To assess the potential capability of using artery-specific factors to predict the success of coronary bypass grafting, we classified each graft according to the type of graft (mammary, single vein, or multiple skip vein), the degree of obstruction in the native coronary artery, and the size of the grafted artery. The mean patency rates for each category of graft were determined by performing early postoperative (mean 6.6 months) arteriograms in 354 patients. We found that mammary arteries gave the best results for every graft category. Skip vein grafts had a higher mean patency rate than single vein grafts for arteries with obstructions between 70% and 90% and lumina less than 2.0 mm in diameter. The results for vein and skip grafts were equivalent for the category with arteries greater than 2.0 mm and obstruction greater than 90%. Vein grafts produced better results than skip grafts for the remaining categories. Patients were classified into subgroups according to the number of actually observed graft failures. The probabilities that specific numbers of grafts would fail were calculated for each patient. These probabilities were based upon the observed patency rates for the category appropriate for each graft and the hypothesis that individual grafts within a patient fail independently. We observed an excess number of patients with no failures or multiple failures than would be expected according to the hypothesis of independent failure and category-specific patency rates. Conversely, there were fewer patients than expected who had single failures. Therefore, we postulate that there may also be global factors which influence early graft patency.

Effects of reperfusion after acute coronary occlusion on the beating, working heart compared to the arrested heart treated locally and globally with cardioplegia

To determine whether acutely ischemic myocardium could be more effectively salvaged by reperfusion on cardiopulmonary bypass (CPB) in the cardioplegia-treated heart than with reperfusion in the beating, working heart, 52 greyhound dogs underwent 3 hours of left anterior descending (LAD) occlusion and were randomly assigned to one of four groups. In Group I (19 dogs) the LAD occlusion was released at 3 hours and reperfusion continued in the beating, working heart for an additional 3 hours. Group II (six dogs), Group III (14 dogs), and Group IV (13 dogs) were placed on CPB and underwent 45 minutes of hypothermic ischemic arrest protected by aortic root potassium cardioplegia. In Group II, only aortic root potassium cardioplegia was given; in Group III, the ischemic area was perfused with potassium cardioplegic solution via a graft from the internal mammary artery (IMA) to the LAD. In Group IV, blood cardioplegic solution via the IMA-LAD graft was used. After the cross-clamp and local occlusion were removed, CPB was discontinued after an additional 45 minutes and reperfusion was continued off CPB for an additional 1 1/2 hours (total 6 hours). The ischemic area at risk was determined by injecting monastryl blue dye via the left atrium while the LAD was briefly reoccluded. After the animal had been sacrificed and the left ventricle had been sectioned, the area of myocardial necrosis was determined by nonstaining with triphenyltetrazolium chloride (TTC). For each group, the ratios of area of necrosis/area at risk (AN/AR) were calculated and postreperfusion arrhythmias were documented. Postreperfusion arrhythmias were noted in 11 of 12 animals in the beating, working heart group and only two of 24 in the combined CPB groups. The mean AN/AR was 66% +/- 2% in the beating, working heart (Group I), 59% +/- 6% after infusion of potassium cardioplegic solution into the aortic root (Group II), 57% +/- 6% with blood cardioplegia (Group IV), and 38% +/- 6.5% after global and local application of the potassium cardioplegic solution into the ischemic area (Group III). This study suggests that the reperfused ischemic myocardium will sustain less necrosis and less postreperfusion arrhythmias when the heart is protected by global and local cold potassium cardioplegia on CPB.

Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting

When the saphenous vein is absent or inadequate, options for multivessel coronary revascularization include bilateral mammary artery grafting and the use of conduits of unproven durability (arm vein, homologous umbilical vein, prosthetic graft). To evaluate the long-term effectiveness of bilateral mammary artery grafting, we reviewed the cases of 76 consecutive patients with multivessel disease (33 with two-vessel disease, 43 with three-vessel disease) who underwent revascularization with bilateral mammary artery grafts only during the period from 1971 to 1980. No hospital deaths occurred. Thirty-three free and 119 in situ grafts were used. Late follow-up was complete, ranging from 12 to 132 months (mean interval, 67 months) and revealed improvement by at least one New York Heart Association functional class in 59 of 71 survivors. Postoperative arteriograms (mean interval, 26 months) of 55 grafts in 28 patients showed that 49 grafts were patent (89%). Five late deaths (2 noncardiac) occurred. Actuarial survival was 97.2% to seven years and 90.2% at nine years after operation. Bilateral mammary artery grafting yielded excellent graft patency, relief of symptoms, and long-term survival. When saphenous vein is unsuitable for grafting, bilateral mammary artery grafts should be utilized before other conduits are considered.

Internal mammary artery versus saphenous vein graft. Comparative performance in patients with combined revascularisation

Thirty three patients with coronary artery disease undergoing combined myocardial revascularisation with internal mammary artery and saphenous vein grafts underwent angiographic studies up to 10 years after operation. Each patient had one internal mammary artery graft and one or more saphenous vein grafts. Eleven symptom-free patients, studies one month to five years (mean 1.9 years) after operation, had intact internal mammary artery and saphenous vein grafts in a good state of preservation. Of the six patients developing symptoms within the first year after surgery, three had evidence of poor flow in the internal mammary artery graft because of large side branches and the other three had stenosis or occlusion of the saphenous vein grafts. Sixteen patients developed symptoms after several years free of symptoms and were studied three to 10 years (mean six years) after operation. Of the 23 saphenous vein grafts in this group, 17 (74%) were either occluded or severely stenosed and six (26%) were in good condition. One internal mammary artery graft was occluded and the remaining 15 were in good condition. Saphenous vein graft failure was the predominant cause of late development of symptoms in patients with combined revascularisation. Long term performance of the internal mammary artery grafts is far superior to the saphenous vein grafts.

Coronary artery surgery using inverted internal mammary artery

A 56-year-old man requiring multiple coronary artery bypass grafts but without enough suitable vein was operated upon using the retrograde flow of the right internal mammary artery to supply to posterior descending coronary artery. Relief of angina and non-ischaemic areas on the scan with thallium-201 supports our intention to use this method when other techniques are not possible.

[Long-term results of isolated anterior interventricular bypasses: analysis of the prognostic factors. Apropos of a series of 187 patients operated on between]

A total of 187 patients underwent isolated aorto-left anterior descending artery (LAD) bypass grafting with the internal saphenous vein (ISV) (= 65) and left internal mammary artery (IM) (n = 122). The respective indications of the two techniques were not systematized: the comparison of the main preoperative data of the two groups showed a statistically higher number of risk factors (p less than 0,01), more multivessel coronary lesions (p less than 0,02) and more patients with dyskinetic left ventricles (p less than 0,05) in the ISV bypass group. There were no statistical differences between the two groups in early postoperative mortality (IM: 0,8 p. 100, ISV: 1,5 p. 100), early postoperative infarction (IM: 2,5 p. 100, ISV: 1,5 p. 100), or late postoperative infarction (IM: 3,8 p. 100, ISV: 2,6 p. 100). The survival rates in the two groups were very similar with a global 90 p. 100 survival at 5 years and 78 p. 100 at 9 years. A comparison of the functional result in the two groups did not reveal significant difference: globally, 56 p. 100 of patients had no recurrence of angina 5 years, and 41 p. 100 after 9 years. Age, sex previous infarction, the number of cardiovascular risk factors, the technique used, had no prognostic significance on survival or on the quality of the postoperative functional results, contrary to the quality of left ventriculography and the number of coronary stenoses (83 subjects with isolated LAD disease, 104 subjects with multiple vessel disease). Nevertheless, patients with multiple coronary lesions had their vital prognosis improved (annual mortality less than 3 p. 100) compared to the spontaneous risk by isolated isolated aorto-LAD artery bypass surgery.

Investigations on the morphophysiological basis of revascularization of the myocardium by the Vineberg method

A study was carried out on the dynamics of vasculogenesis and the formation of mammary-coronary anastomoses within the first seven months after implantation of the internal mammary artery in the left ventricular myocardium, according to the Vineberg method. The efficiency of these anastomoses was demonstrated 4 to 7 months later by the absence of lesions 8 to 10 days after transitory and permanent myocardial ischaemia induced by coronary obliteration. The lesions could not be prevented in the case of thrombosis of the internal mammary artery or when ischaemia was produced concomitantly with the implant or before the mammary-coronary arteriolo-arterial anastomotic network developed.

Internal mammary arteriography: a new catheter technique by right brachial approach

A technique for catheterization of both internal mammary arteries (IMAs) by right brachial approach is described. A special preformed catheter was used in 75 patients with coronary artery disease, including ten patients with direct IMA grafts. No complications occurred. The IMAs were studied to examine the question of their usefulness in direct myocardial revascularization. There were individual variations in the size of IMAS with poor correlation to age (r = -0.432)) and body surface area (r = 0.517). Seventy percent of the women had adequate IMAs. The IMA diameter was equal to or larger than the left anterior descending coronary artery (LAD) in 72% and the right coronary artery (RCA) in 34% of comparisons. Of the ten patients with direct IMA grafts, three instances of large side branches were seen. These branches appeared to carry large flows at the expense of the grafted coronary artery. Preoperative internal mammary arteriography should be done if the use of this vessel is contemplated in direct myocardial revascularization to assure the use of an IMA of adequate caliber compared to the recipient coronary artery. The side branches should be meticulously ligated during the operation.

The internal mammary bypass graft: a superior second coronary artery

In a study of the initial 1,004 consecutive patients who had direct coronary artery bypass at Ochsner Medical Institutions, computer methods of data processing were used to compare the clinical results between patients who had saphenous vein (SV) grafts and those who had internal mammary artery (IMA) grafts. The factors compared were the long-term mortality rates, nonfatal myocardial infarction rates, relief or persistence of angina, and the percentage of patients who acquired congestive heart failure. A simple comparison showed the patients with IMA grafts did better in all four categories; however, in a subsequent analysis in which maldistributed factors were removed, the rates of anginal relief and congestive heart failure were not significantly improved. The major benefit appears to be an increase in longevity among patients who had IMA bypasses.