Direct myocardial revascularization

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Coronary artery operations using the aorto-coronary venous autograft have become the accepted surgical treatment for coronary atherosclerosis. Alleviation of cardiac pain has been the primary benefit, and results of a recent study1 indicate that direct coronary artery surgery prolongs life for patients with multiple vessel disease. Statistically, this longer life-span depends on a low operative mortality, and valid criticism has been leveled at the practice of myocardial revascularization when mortality figures have reached or exceeded 10%.

Since May 1967, when the first interposed saphenous vein grafting was performed at the Cleveland Clinic, the number of direct revascularization procedures has increased annually. More than 5,000 operations consisting of saphenous vein grafts and, more recently, internal mammary artery grafts have been performed; another 750 direct revascularization procedures were combined with valve repair or replacement or ventricular aneurysmectomy. We report here the results of bypass procedures only, omitting a detailed report on the combined procedures. However, the mortality for these combined procedures is also low.

From May 1967 to December 1973, 4,935 patients underwent direct myocardial revascularization without associated procedures. In all cases, preoperative evaluation included coronary angiography and left ventriculography. Indications for surgery included the following angiographic criteria:2 (1) an obstructive lesion of at least 70% in one or more major coronary vessels; (2) good distal runoff in the involved coronary artery with a lumen diameter greater than 1 mm and no further obstruction exceeding 50% in this distal portion; (3) ventriculographic evidence of normal or near normal contractility in the segment. . .



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