Recent advances in coronary arterial surgery
Risk of operation
Perhaps the most significant development in the surgery of coronary arterial disease in the past several years has been the demonstration of a progressively declining risk of operation, both in terms of hospital mortality and cardiac-related morbidity. An analysis of our experience with isolated coronary bypass grafting procedures during an 8-year interval ending in December 1977 has demonstrated a statistically significant reduction in the subgroups of patients with left main and three-vessel disease (Table 1). As Table 1 indicates, selection of more favorable patients for operation has not been a factor contributing to the improved early results. The reduction in mortality has occurred despite an increase in the complexity of the procedures, as evidenced by an increase in the number of grafts inserted per patient. There has also been a substantial decline in the incidence of perioperative myocardial infarction. From our analysis, it has not been possible to isolate a single factor responsible for the improved early results. Factors considered important include (1) better anesthetic management; (2) increasing surgical experience and improved techniques; (3) more complete revascularization, and (4) perhaps most important, improved methods of intraoperative myocardial protection. We observed reductions in hospital mortality and especially in the incidence of perioperative infarction when profound myocardial cooling replaced intermittent ischemic arrest and more recently, when hypothermic cardioplegic techniques were implemented. These improved methods of myocardial protection have allowed more extensive revascularization and the addition of revascularization to other procedures such as valve replacement, ventricular aneurys-mectomy, and repair of rupture of the . . .