T.F. Luscher M. Turina E. Braunwald (Eds.)
Coronary Artery Graft Disease Mechanisms and Prevention
With 159 Figures, Some in Colour
Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona Budapest
Professor Dr. med. THOMAS F. LUSCHER Abteilung Kardiologie, Inselspital 3010Bem Switzerland
Professor Dr. med. MARKO TURINA Herz-GeHiBchirurgie, Universitiitsspital 8091 Zurich Switzerland
Professor Dr. med. EUGENE BRAUNWALD Department of Medicine Harvard University and Brigham and Women's Hospital Boston, MA 02115-6195 USA
Cover drawing reprinted with permission from Mayo Clinic Proceedings 61:3-8 (1986)
ISBN-13 :978-3-642-78639-6 e-ISBN-13:978-3-642-78637-2
DOl: 10.1007/978-3-642-78637-2
Library of Congress Cataloging-m-Publication Data. Coronary artery graft disease: mechamsm and prevention I T. Luscher, M Turina, E. Braunwald, eds. p. cm. Includes bibliographical references and index 1. Coronary artery bypass-Complications. 2. Graft reJectIon. I. Luscher, Thomas F (Thomas Felix) II. Tunna, Marko. III. Braunwald, Eugene, 1929- [DNLM: 1 Coronary Disease-therapy. 2. Coronary Artery Bypass-adverse effects. 3. Graft Rejectionprevention & control. WG 300 C81965 1994] RD59835.C67C685 1994 617.4'120592 -dc20 DNLMIDLC for Library of Congress 94-16135
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Preface
In 1969, Rene Favaloro published his landmark paper entitled "Saphenous vein graft in the surgical treatment of coronary artery disease: operative technique", which changed the care of patients with ischemic heart disease and the speciality of cardiovascular surgery forever. Since then, the use of coronary artery bypass grafting has relieved intractable angina pectoris in millions of patients worldwide and prolonged survival in countless others.
Despite the emergence and popularity of percutaneous transluminal coronary angioplasty and related techniques, coronary artery bypass surgery remains firmly entrenched as the only revascularization technique that has been demonstrated to improve the natural history of coronary artery disease. An increasing number of candidates for this operation are, in fact, now patients who have previously undergone angioplasty or bypass surgery. As a consequence, the total number of surgical revascularizations continues to rise steadily both in the United States and in Europe.
Even when it is successful technically, however, coronary artery bypass surgery is not a curative procedure. One major problem is coronary graft disease, a series of interrelated complications, some of which may commence at operation and others which continue for decades; all of them ultimately negate the benefit of the procedure, however. This book deals with the most important complications of the most important cardiovascular operation. Fortunately, the enormous advances in vascular pathobiology made in the past 15 years have shed much light on this problem and have pointed to its potential prevention and management. Approaches include the preoperative selection of the conduit(s) to be employed and their intraoperative handling, and the early and late postoperative care of the patient. We have learned that blood vessels are complex, living organs rather than simple mechanical conduits, that arteries differ considerably from veins when used for coronary bypass, and that the endothelium is an active tissue that influences profoundly both the fluidity of the blood and the tone and growth of the underlying smooth muscle.
VI Preface
The understanding of the cellular and molecular mechanisms involved in bypass graft disease may set the stage for more specific therapeutic interventions in the future which may help to prolong the patency and function of implanted grafts.
Assessment of the grafts, of course, is essential in the postoperative patient. While coronary arteriography remains the gold standard for the recognition of graft disease, a variety of noninvasive methods - radionuclide scintigraphy, duplex ultrasonography, magnetic resonance imaging, positron emission tomography and angiography - can all provide valuable information regarding the status of the graft and of both the viability and function of the myocardium that it perfuses. When considering reoperation in patients with diseased grafts, it is essential to evaluate the quality of salvageable myocardium perfused by diseased grafts and native vessels.
Management of the patient with coronary grafts may be divided into two phases. Prevention of graft disease, which should be applied to all patients, currently involves the use of antiplatelet drugs, vigorous control of lipid abnormalities, and strict smoking cessation. In patients with established graft disease, percutaneous trans luminal angioplasty, sometimes aided by intraluminal stents, is often helpful. When these measures fail or are not suitable, reoperation - despite its higher risk - may be in order. Heart transplantation always remains a last resort for patients with severe graft disease, but it is an effective last resort since the long-term outcome has improved substantially in recent years.
It is fitting, therefore, that as we celebrate the silver anniversary of coronary artery bypass surgery, we re-examine this important operation and describe approaches that may protect the many patients who have already undergone it and the even larger number who will do so in the future.
Bern, Switzerland Zurich, Switzerland Boston, USA
THOMAS F. LUSCHER
MARKO TURINA
EUGENE BRAUNWALD
Contents
The Problem
The Natural History of Saphenous Vein Grafts C.M. GRONDIN and J.C. THORNTON With 3 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Risks and Prediction of Adverse after Coronary Bypass Grafting based on a Single Center Experience P. SERGEANT With 11 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Mechanisms of Plaque Formation and Occlusion in Venous Coronary Bypass Grafts I.K. JANG and V. FUSTER With 2 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Surgical Aspects
Arterial and Venous Coronary Bypass Grafts: Surgical Techniques and Outcome F.D. Loop With 6 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Newer Arterial Coronary Bypass Conduits: Right Gastroepiploic and Epigastric Artery H. SUMA With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Diagnosis of Graft Failure
The Role of Radionuclide Imaging in the Diagnosis of Coronary Bypass Graft Failure F.J.T. WACKERS With 4 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
vm Contents
Coronary Artery Graft Disease: Diagnosis of Graft Failure by Magnetic Resonance Imaging P.T. BUSER and C.B. HIGGINS With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Positron Emission Tomography: Evaluation of Myocardial Blood Flow and Viability Before and Following Coronary Revascularization S.G. SAWADA and M. SCHWAIGER With 6 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Transcutaneous Assessment of Blood Flow in Internal Thoracic Artery to Coronary Artery Grafts D.P. DEBoNO With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Coronary Angiography in the Diagnosis of Graft Failure P.R. LICHTLEN and H. HAUSMANN With 23 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Left Ventricular Function: Systolic and Diastolic Alterations H.P. KRAYENBUHLt , M. JAKOB, and a.M. HESS With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Biological Characteristics and Coronary Bypass Grafts
Endothelium and Vascular Smooth Muscle Function of Coronary Bypass Grafts T.F. LUSCHER, Z. YANG, and B.S. OEMAR With 9 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Smooth Muscle Cell Proliferation Responses in Organ Cultures of Human Saphenous Vein G.D. ANGELINI and A.C. NEWBY With 4 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Chronic Changes in Venous Grafts After Implantation D.A. LEWIS and V.M. MILLER With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Contents IX
Pharmacological Intervention
Lipids and Lipid-Lowering Drugs and Graft Function H. DREXEL and F.W. AMANN With 2 Figures ..................... 0 0 0 0 0 0 0 • 0 0 • 0 0 0 •• 0 247
Treatment of Severe Hypercholesterolemia in Patients with Coronary Heart Disease by Means of Lipoprotein Apheresis Do SEIDEL With 4 Figures . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 • • 259
Antiplatelet Drugs l.H. CHESEBRO, Bol. MEYER, Ao FERNANDO-ORTIZ, I.K. lANG, and Vo FUSTER With 6 Figures 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 • 0 • 0 0 0 0 • 0 0 0 0 0 0 0 0 0 276
Anticoagulants and Antiplatelet Drugs to Prevent Aortocoronary Vein Graft Occlusion Mo PFISTERER With 13 Figures 0 0 0 0 • 0 •• 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 0 0 0 0 0 0 0 0 0 299
Calcium Antagonists in Patients Undergoing Coronary Artery Bypass Surgery So 0 0 GOTTLIEB With 5 Figures 000000000.000 •• 0 0 0 0 0 •• 0 0 • 0 0 0 0 • 0 0 0 •• 000 312
Revascularization Strategies
Percutaneous Transluminal Coronary Angioplasty in Patients with Failed Bypass Graft Surgery l. HOLLMAN With 5 Figures 0 •• 0 0 0 0 0 0 0 •• 0 0 0 0 0 0 0 0 0 0 •• 0 0 0 0 • 0 • 0 0 •• 0 0 0 327
Intraluminal Stents in Coronary Bypass Grafts Po URBAN and Bo MEIER With 10 Figures 0 • 0 0 0 0 •• 0 • 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 340
Reoperation: Techniques and Choice of Conduits L.K. VON SEGESSER and MoL. TURINA With 10 Figures 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 360
X Contents
Cardiac Transplantation for Ischaemic Heart Disease M. YACOUB
With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
List of Contributors
AMANN, F.W., PD Dr., Abteilung Kardiologie, Department fUr Innere Medizin, UniversiHitsspital Zurich, 8091 Zurich, Schweiz
ANGELINI, G.D., M.D., Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK
DE BONO, D.P., Department of Cardiology, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester LE3 9QP, UK
BUSER, P.T., M.D., Division of Cardiology, University Hospital, Petersgraben, 4031 Basel, Switzerland
CHESBRO, J.H., M.D., Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
DREXEL, H., PD Dr., Abteilung Kardiologie, Department fUr Innere Medizin, Universitatsspital Zurich, 8091 Zurich, Schweiz
FUSTER, V., M.D., Ph.D., Chief, Cardiac Unit, Massachusetts General Hospital, BUL 105, Fruit Street, Boston, MA 02114, USA
GOTTLIEB, S.O., M.D., FACC, Johns Hopkins University School of Medicine, Midatlantic Cardiovascular Consultants, P .A., GBMC Pavilion, Suite 408, 6585 North Charles Street, Baltimore, MD 21204, USA
GRONDIN, C.M., M.D., Professor of Surgery, Case Western Reserve University, Cleveland, OH 44104, USA
HAUSMANN, H., M.D., Zentrum Innere Medizin, Abteilung Kardiologie, Hochschule Hannover, Konstanty-Gutschow-Str. 8, 30625 Hannover, Germany
HESS, O.M., M.D., Professor of Medicine, Department of Medicine, Cardiology University Hospital, 8091 Zurich, Switzerland
XII List of Contributors
HIGGINS, C.B., Department of Radiology, MRI Section, University of California, San Francisco, CA 94143, USA
HOLLMAN, J., M.D., Department of Cardiology, Ochsner Clinic of Baton Rouge, 16777 Medical Center Drive, Baton Rouge, LA 70816, USA
JAKOB, M., M.D., Division of Cardiology, University Hospital, 8091 Zurich, Switzerland
JANG, I.K., M.D., Ph.D., Assistant Professor of Medicine, Massachusetts General Hospital, BUL 105, Fruit Street, Boston, MA 02114, USA
KRAYENBUHL, H.P., M.D.t, Professor of Cardiology, Medical Policlinic, University Hospital, 8091 Zurich, Switzerland
LEWIS, D.A., Department of Surgery and Physiology, 9 Guggenheim Building, Mayo Clinic and Foundation, Rochester, MN 55905, USA
LICHTLEN, P.R., Prof. Dr., Zentrum Innere Medizin, Abteilung Kardiologie, Hochschule Hannover, Konstanty-Gutschow-Str. 8, 30625 Hannover, Germany
Loop, F.D., M.D., The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
LUSCHER, T.F., M.D., Professor of Medicine, Cardiology, University Hospital, 3010 Bern, Switzerland
MEYER, B.J., M.D., Professor of Medicine, Cardiology, University Hospital, 3010 Bern, Switzerland
MILLER, V.M., Ph.D., Department of Surgery and Physiology, 9 Guggenheim Building, Mayo Clinic and Foundation, Rochester, MN 55905, USA
NEWBY, A.C., Ph.D., Reader Cardiovascular Biochemistry, Department of Cardiology, College of Medicine, University of Wales, Health Park, Cardiff CF4 4XN, UK
OEMAR, B.S., M.D., PD Dr., Department of Research, University Hospital, 4031 Basel, Switzerland
PFISTERER, M., MD, FESC, FACC, Professor of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
SAWADA, S.G., M.D., University of Michigan Medical Center, 1500 E. Medical Center Dr., UH B1G505, Ann Arbor, MI 48109-0028, USA
List of Contributors XIII
SCHWAIGER, M., Prof. Dr., Nuklearmedizidische Klinik und Poliklinik, Technische UniversiHit Munchen, Klinikum rechts der Isar, Ismaningerstr. 22,81657 Munchen, Germany
VON SEGESSER, L.K., PD Dr., Department of Cardiovascular Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
SEIDEL, D., PD. Dr., Direktor des Institutes fur Klinische Chemie, Klinikum Grosshadern, Ludwig-Maximilians-UniversiHit Munchen, Marchioninistrasse 15, 81366 Munchen, Germany
SERGEANT, P., M.D., Cardiac Surgery Department, Gasthuisberg, University Hospital, Herestraat, 3000 Leuven, Belgium
SUMA, H., M.D., Department of Cardiovascular Surgery, Mitsui Memorial Hospital, 1, Kanda Izumi-cho, Chiyoda-ku, Tokyo 101,Japan
THOMTON, J.C., M.D., Associate Professor of Surgery, Case Western Reserve University, Cleveland, OH 44104, USA
TURINA, M., M.D., Professor of Surgery, Chairman, Dept. of Cardiovascular Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
URBAN, P., M.D., Professor of Medicine, Centre de Cardiologie, Hopital Cantonal Universitaire, 24, rue Micheli-du-Crest, 1211 Geneve, Suisse
WACKERS, F.J.T., M.D., Yale University School of Medicine, Department of Diagnostic Radiology and Medicine, 333 Cedar Street, TE-2, New Haven, CT 06510, USA
YACOUB, M., SIR, Professor of Surgery, National Heart & Lung Institute, Academic Department of Cardiothoracic Surgery, Dovehouse Street, London SW3 6LY, UK
YANG, Z., M.D., Cardiovascular Research, Cardiology, University Hospital, 3010 Bern, Switzerland