Combined Internal Mammary Artery Implantation and Free Omental Graft Operation: A Highly Effective Revascularization Procedure: (A Study of 17 Cases)

One hundred and forty patients with coronary artery disease treated by internal mammary artery implantation were followed up from six months to 13 years. The mortality rate was 3%; improvement was obtained in 70%. Occlusive disease of all three major coronary arteries, however, requires more blood than can be supplied by the implant procedure, and the free omental graft operation was developed for the management of selected patients with this condition. Normally in animals triple coronary artery ameroid constriction results in 100% mortality. When the free omental graft operation, with or without internal mammary artery implantation, was performed, 80% of such animals survived. The free omental graft forms capillary anastomoses in three days and arteriolar vessels in eight days, which leave the base of the aorta, enter the omentum, thence to the myocardium. A combined internal mammary artery implantation and free omental graft operation was performed in 17 patients with triple coronary artery disease as shown by cine coronary arteriography. There was no operative mortality, and 12 of the patients are free of pain and have returned to work.     

Right Internal Mammary Artery Implantation into Right Ventricular Myocardium for Revascularization of the Entire Heart: Experimental Data and Preliminary Report

The left internal mammary artery implant combined with epicardiectomy and free omental graft provides three extra-coronary sources of blood. This operation tested in dogs with 92% main-stem occlusion of three coronary arteries protected 75% of the animals. Applied clinically in over 100 patients, the operation resulted in 90% improvement. To obtain complete myocardial revascularization, the right internal mammary artery has been used as a fourth source of extra-coronary blood. In 57 animals, the right internal mammary arteries were implanted into the anterior walls of the right ventricle; in 80% this vessel formed anastomoses with the right coronary tree, and in 65% with the right and left coronary arteriolar systems. Six patients are described who underwent right internal mammary artery implantation; five of these in addition had the combined operation of left internal mammary artery implant, epicardiectomy and free omental graft. All patients had completely blocked right coronary arteries; in addition, five had advanced disease of the left coronary arterial tree.     

Implantation of the Right and Left Internal Mammary Arteries with Epicardiectomy and Free Omental Graft: A Preliminary Experimental Report

In animal experiments the right internal mammary artery was implanted into the outflow tract of the right ventricle during performance of left mammary artery implantation with epicardiectomy and free omental graft. The effect of double mammary artery implantation operation was tested by triple coronary artery ameroid constriction in 24 animals. In 20 animals studied both implanted arteries remained open and had commenced to bud and branch at the time of examination. The double implant operation is still an experimental procedure.     

Results of 14 Years' Experience in the Surgical Treatment of Human Coronary Artery Insufficiency

Atherosclerosis obstructs the main stems of coronary arteries, restricting the coronary artery inflow tract. Nature develops intramyocardial collaterals but fails to form extracoronary collateral channels. It is only through surgical measures that extracoronary collateral channels may be formed, for example, by internal mammary artery implantation and omental graft without pedicle operations. Preoperative assessment, with particular reference to anginal pain, disease activity, indications for and contra-indications to surgery, is outlined. The importance of cine coronary arteriography is stressed. The results of internal mammary artery implantation with or without omental graft in patients followed up for two to 14 years are presented. Operative mortality in 103 consecutive patients was 2.9%. There was marked improvement in over 70% of 115 patients reviewed. Post-operative examination of 29 implanted internal mammary arteries showed that 76% were open when examined up to 10 years postoperatively; many of these were studied by cineangiography.     

The Continuity of Right and Left Ventricular Myocardial Sinusoidal Spaces and its Relation to Right Ventricular Implants

Evidence is presented which indicates that blood leaving side branches of an internal mammary artery implanted into the anterior wall of the right ventricle flows from the tunnel in which it lies through myocardial sinusoidal spaces of the anterior right ventricular wall across the midline to fill corresponding spaces in the anterior wall of the left ventricle and thence is carried to the left coronary sinus. The myocardial sinusoidal spaces of right and left ventricles have been well outlined, using injections of polyvinyl acetate and the technique of digestion casts. We have been able to show that there is no barrier between the myocardial sinusoids of the right circulation and those related to the anterior descending branch of the left coronary artery. In structure, these myocardial sinusoidal spaces are quite different from the intramyocardial coronary arteriolar zones which, in 93% of human hearts, are separated from one another without collateral communication.The continuity of the right and left ventricular myocardial sinusoids explains why implantation of a right internal mammary artery into the anterior wall of the right ventricle combined with a corresponding left implant, epicardiectomy and free omental graft, has been so effective in our hands in the treatment of far-advanced human coronary artery insufficiency.     

选择性冠状静脉动脉化搭桥术中不同移植物的应用疗效比较

目的:对比选择性冠状静脉动脉化(SCVBG)搭桥治疗弥漫性右冠状动脉狭窄病变中选择乳内动脉和大隐静脉作为桥血管的治疗效果。方法:选择2008年10月到2014年10月在我院行SCVBG搭桥的84例患者资料,其中选择大隐静脉作为桥血管进行冠状静脉动脉化搭桥患者46例(大隐静脉桥组),选择乳内动脉作为桥血管进行冠状静脉动脉化搭桥患者38例(乳内动脉桥组)。随访记录两组患者的生存情况、近期复查超声心动图、冠状动脉CTA及心绞痛复发率。结果:乳内动脉桥组患者总生存率(100%)明显高于大隐静脉桥组(82.6%)(P0.05)。乳内动脉桥组患者桥血管和心中静脉通畅率(100%)明显大于大隐静脉桥组(54.35%)(P0.05)。两组患者左心室射血分数(LVEF)较治疗前明显增加,左心室舒张期末内径(LVEDD)较治疗前明显减小(P0.05)。治疗后,乳内动脉桥组患者心绞痛复发率明显小于大隐静脉桥组(P0.05)。结论:SCVBG搭桥治疗弥漫性右冠状动脉狭窄病变中,选择乳内动脉桥效果优于大隐静脉桥,能明显提高桥血管和心中静脉通畅率,降低心绞痛复发率。     

An Operation Designed to Promote the Growth of New Coronary Arteries,Using a Detached Omental Graft: A Preliminary Report

The human greater omentum exhibits a marked affinity for inflamed surfaces, to which it supplies numerous blood vessels. To achieve myocardial revascularization by omental graft the root of the aorta, the epicardium over both ventricles and the serosal layer of the pericardium were removed in 17 animals. A piece of greater omentum was removed from the abdomen, unfolded and wrapped around the entire heart, and fixed by interrupted sutures to the base of the aorta. Myocardial ischemia was created at the time of operation by ameroid constriction of coronary arteries. Vessels, arteriolar or larger, were found to grow from the root of the aorta, the myocardium and the pericardium into the detached free omental graft, which apparently acted as a conveyer for new vessels, including new coronary arteries, to reach the myocardium.     

Robotically assisted coronary endarterectomy

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.     

Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.     

Criteria for Internal Mammary Artery Implantation Based on Cine Coronary Arteriography

Preoperative coronary arteriograms were correlated, in a group of 50 patients, with left internal mammary angiograms obtained from 11 to 32 months, with a mean of 17 months, after mammary artery implantation. In all patients in whom the internal mammary artery was patent and considered functional with good angiographic opacification of the anterior descending coronary artery, the preoperative coronary angiogram showed total or subtotal obstruction of the latter vessel, with indirect evidence of decreased flow and pressure distal to the obstruction. This evidence was provided by the presence of a collateral circulation or, in a few cases of subtotal obstruction, delayed opacification of the vessel distal to the obstruction.In patients in whom the internal mammary artery was patent but showed no anastomotic connection with the anterior descending coronary artery or only opacification of small coronary branches, the degree of coronary obstruction was, in most cases, less than 90% of the lumen of the coronary artery in the absence of any collateral circulation or delayed opacification of the vessel distal to the obstruction.Occlusion of the internal mammary artery was seen as often in the presence of total or subtotal obstructions as with lesser degrees of anterior descending coronary artery obstruction, and is believed unrelated to the degree of pre-existing coronary artery disease.Successful internal mammary artery implantation can be related to specific coronary angiographic patterns recognizable before operation; these may serve as reliable criteria for the selection of patients.     

Bilateral coronary fistulae to pulmonic valve in presence of severe three-vessel coronary artery disease

A 62-year-old man was admitted to the coronary care unit due to anginal pain and palpitations--coronary angiography revealed three-vessel coronary artery disease. The unexpected finding was the presence of coronary to pulmonary artery fistulae bilaterally, from both the proximal RCA and the proximal LAD. Right heart catheterization revealed normal right ventricular and pulmonary artery pressure and absence of hemodynamically significant left to right shunt. The patient underwent a triple coronary bypass including the closure of bilateral fistulae, which were draining into the left sinus of the pulmonary valve. One month after the operation he was in good health and had no complaints. Bilateral coronary artery fistulae is a rare anomaly diagnosed in 0.002-0.0013% of adult coronary angiograms. (Int J Cardiovasc Intervent 1999; 2: 249-251).     

Traumatic ostial stenosis of internal mammary coronary graft

Because of the extensive use of arterial conduits for coronary surgery there is a growing interest in percutaneous intervention in these conduits. This kind of intervention presents a challenge for the interventional cardiologist owing to the anatomic and functional characteristics of this graft. In most cases significant internal mammary artery disease occurs at the distal anastomosis. Ostial stenoses are rare and their pathology uncertain. The authors report a case of an ostial graft lesion, most probably caused by repetitive ostial engagement of the left internal mammary artery in combination with atherosclerosis in the subclavian artery affecting the internal mammary artery.     

Revascularization of both cardiac ventricles by right ventricular implants

Implantation of the right internal mammary artery into the wall of the right ventricle has been performed in 48 patients whose cases have been followed up for longer than six months. The procedure was done at the same time as a left ventricular implantation or subsequent to this operation because of recurrence or persistence of symptoms. Relief of anginal pain has been achieved in 78% and of chronic left ventricular failure in 75%. Of the 40 patients who had already had one or more myocardial infarctions preoperatively, 36 are still alive, with an average survival of over 5 years.     

A Comparison of Genome-Wide DNA Methylation Patterns between Different Vascular Tissues from Patients with Coronary Heart Disease

Epigenetic mechanisms of gene regulation in context of cardiovascular diseases are of considerable interest. So far, our current knowledge of the DNA methylation profiles for atherosclerosis affected and healthy human vascular tissues is still limited. Using the Illumina Infinium Human Methylation27 BeadChip, we performed a genome-wide analysis of DNA methylation in right coronary artery in the area of advanced atherosclerotic plaques, atherosclerotic-resistant internal mammary arteries, and great saphenous veins obtained from same patients with coronary heart disease. The resulting DNA methylation patterns were markedly different between all the vascular tissues. The genes hypomethylated in athero-prone arteries to compare with atherosclerotic-resistant arteries were predominately involved in regulation of inflammation and immune processes, as well as development. The great saphenous veins exhibited an increase of the DNA methylation age in comparison to the internal mammary arteries. Gene ontology analysis for genes harboring hypermethylated CpG-sites in veins revealed the enrichment for biological processes associated with the development. Four CpG-sites located within the MIR10B gene sequence and about 1 kb upstream of the HOXD4 gene were also confirmed as hypomethylated in the independent dataset of the right coronary arteries in the area of advanced atherosclerotic plaques in comparison with the other vascular tissues. The DNA methylation differences observed in vascular tissues of patients with coronary heart disease can provide new insights into the mechanisms underlying the development of pathology and explanation for the difference in graft patency after coronary artery bypass grafting surgery.     

Measurement of the flow in coronary artery bypass grafts

The aim of our study was to measure the flow in coronary artery bypass grafts and to compare the flow between two groups of patients. In group A the arterial revascularization was performed with both internal thoracic arteries using as a Y graft and in group B conventional revascularization using left internal thoracic artery (ITA) attached to the left anterior descending artery (LAD) and venous grafts to the other branches of the left coronary artery was performed. The flow in all grafts was measured at six time points during the operation. The cumulative flow at the end of the operation in the group A (arterial Y graft) was 51.8 +/- 24.5 ml/min and in group B (conventional technique) it was 96.8 +/- 41.1 ml/min (p < 0.05). The flow in left ITA to LAD was similar in both groups (27.3 +/- 15.9 ml/min and 26.3 +/- 16.1 ml/min in group A and B). The flow in right ITA (25.2 +/- 18.4 ml/min) was significantly lower than in venous grafts (72.5 +/- 45.5 ml/min). The calculated flow reserve was 2.2 in group A and 2.1 in group B. We found that the cumulative flow in arterial Y graft was lower in comparison with conventional revascularization. This is due to the lower flow in the right ITA branch of the Y graft compared to venous grafts. However based on clinical results, we can postulate that the flow in the Y graft is sufficient to meet the demand of the myocardium originally supplied by the left coronary artery.     

Apparent Reversion to Trophism of a Free Omental Graft: A Preliminary Report

In a previous paper we reported evidence which suggested that a free omental graft has trophic characteristics similar to those of the chorionic epithelium of the early embryo, through which it establishes arteriolar or larger connections with aorta, heart and pericardium within 10 days after it has been placed in contact with the denuded surfaces of each structure. The theory of omental trophism was tested by dropping pieces of omentum completely detached into the pleural and peritoneal cavities of white rats. When examined 25 or more days later a percentage of omental grafts appeared healthy and were attached to pleura, lung, heart and to various structures in the peritoneal cavity. In the pleural grafts, histological sections revealed a continuity between the omental grafts and the sub-pleural tissues. A blood-hungry free omental graft appears to seek out its own blood supply. Neither pleura nor serosa was able to repel its primitive probing for a new blood supply.     

Bilateral internal thoracic artery grafting: current state of the art

The purpose of this article is to review the key literature and assess the current status of bilateral internal thoracic artery grafting. Numerous retrospective studies have demonstrated a benefit of bilateral internal thoracic artery grafting over single internal thoracic artery grafting in terms of the long-term risk of all-cause death, cardiac-related death, and cardiac events. The survival benefit of bilateral internal thoracic artery grafting manifests relatively early after operation for high-risk patients. The skeletonization technique reduces the risk of sternal wound complications in all patients and particularly in those with diabetes. Both the left and right internal thoracic arteries have better patency when grated to the left coronary territory than saphenous vein. However, the right internal thoracic artery does not always have good patency when grafted to the right coronary artery. Bilateral internal thoracic artery grafting using the skeletonization technique is recommended for revascularization of the left coronary territory.     

Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure

Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001.Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively.Results. All 133 patients were successfully revascularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by percutaneous coronary intervention. (Neth Heart J 2010;18:7-11.)     

Natural history of coronary artery disease in relation to angiographic, hemodynamic and clinical factors

Studying the natural history of coronary artery disease could provide a frame of reference for prognosis and appraisal of treatment for patients having this disease. We studied a total of 465 consecutive patients with angiographically significant coronary artery disease, defined as greater than 50% stenosis in at least one principal artery, who were followed with medical treatment only from 1 to 7 years. Excluding patients with left main coronary disease, there were 73 deaths, of whom 63 were cardiac. The 5-year cumulative survival rates were 72% for the entire group, 87% for single vessel disease, 73% for double vessel disease and 51% for triple vessel disease. In single vessel disease, patients with left anterior descending artery involvement tended to have higher mortality. In double vessel disease, survival was worse with the combination of left anterior descending and right coronary artery involvements than the other 2 combinations. A history of myocardial infarction was not significantly different from angina in 5-year survival rate. Nevertheless, an abnormal Q-wave in ECG was associated with lower survival. History of hypertension and electrocardiographic left ventricular hypertrophy did not affect survival. While congestive heart failure, abnormal resting LVEDP and left ventricular asynergy were all associated with reduced survival. The left ventricular ejection fraction had highly prognostic value, only 42% of patients survived with ejection fraction less than 0.3 at the end of 5 years after angiography.     

Revascularization of the Entire Heart by Internal Mammary Artery Implantation,Epicardiectomy and Free Omental Graft

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author''s experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were “bed-chair cripples” (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.