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Ann Thorac Surg 1997;64:1559-1560
© 1997 The Society of Thoracic Surgeons

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Supplement: Cardiovascular Surgery: Then and Now

Severe Stenosis of the Left Main Coronary Artery With Endarterectomy and Graft: 33-Year Follow-up

The Duke University Medical Center, Durham, North Carolina, The Vanderbilt University Medical Center, Nashville, Tennessee

Abstract

In 1964, a patient with symptomatic, severe left main coronary artery stenosis underwent operative treatment. Endarterectomy and pericardial patch grafting were performed successfully. The original operation is described, and the 33-year follow-up is provided.

Severe stenosis of the left main coronary artery if untreated is likely to cause acute myocardial infarction. For this reason it is usually best managed by urgent coronary bypass. A patient with this condition was previously described and treated by a new procedure at that time consisting of proximal coronary endarterectomy and reconstruction of the coronary artery with a graft [1]. The patient is alive and well today 33 years later without cardiac symptoms.

Case Report

In 1964, a 39-year-old woman with a history of severe angina pectoris for the previous 4 years was referred to The Johns Hopkins Hospital from the Vanderbilt University Medical Center, where continuous electrocardiographic monitoring over a period of hours showed that T-wave abnormalities occurred during a night episode of chest pain. Coronary arteriograms demonstrated localized and severe stenosis of the left coronary artery at its origin. On admission the results of physical examination were essentially negative. The blood pressure was 140/80 mm Hg and the pulse was normal. The cholesterol level was 155 mg/dL and results of other laboratory tests were not remarkable. A repeat coronary arteriogram again showed marked stenosis of the left main coronary artery with slight poststenotic dilatation and normal circumflex and anterior descending coronary arterial branches. The right coronary artery was also normal. An exercise test caused anginal pain, and the electrocardiogram showed unequivocal ischemic changes.

Because of the severity of the patient's condition and severe stenosis of the left main coronary artery, a bilateral anterior thoracotomy was rapidly performed on May 18, 1964, using cardiopulmonary bypass with reduction of the body temperature to 30°C. The ascending aorta was opened distal to the aortic valve and a cannula was placed in the right coronary orifice for continuous perfusion with oxygenated blood under systemic arterial pressure. The left coronary orifice was almost obliterated, with only a tiny opening. A small probe was passed into the orifice and an attempt was made to incise the stenotic area, but the incision at the stenotic site perforated the proximal portion of the left coronary artery. To enlarge the proximal artery, a segment of pericardium was excised and used as an onlay graft in the stenotic area. While the pericardial graft was being sutured, a catheter was passed from within the aorta into the distal left coronary artery for constant perfusion of arterial blood from the pump. After placement of the pericardial graft the arterial reconstruction appeared quite satisfactory. The ventricle contracted normally throughout the procedure as both right and left coronary arteries were perfused continuously with oxygenated blood. At the end of the operation the body temperature was raised to 37°C and normal circulation was allowed to resume.

The early postoperative course was uneventful, although late in the recovery period signs and symptoms of postpericardiotomy syndrome appeared but spontaneously subsided. Five months after operation a coronary arteriogram showed a normal left coronary artery. The patient has since remained free of anginal pain.

In 1976, the patient was readmitted to the Vanderbilt University Medical Center, where during an exercise electrocardiogram chest pain did not develop but she had slight fatigue. Angiographic studies showed the left ventricle to have a normal configuration, and the coronary vessels were normal. Selective arteriography revealed the pericardial patch in the left main coronary artery was unchanged from the previous study done in 1965. The left coronary ostium was widely patent, and there was no narrowing of the coronary vessels. In 1988 the patient sustained a cerebrovascular accident without cardiac difficulties except for mild hypertension managed medically. She has since been followed up and continues to do well without cardiac signs or symptoms.

Comment

Coronary endarterectomy was performed first by Bailey [2] and later by Longmire [3], Dubost [4], and Sabiston [5]. Surgical correction of severe stenosis of the left main coronary artery has also previously been reported by Connolly and associates [6], Hitchcock and colleagues [7], Villemot and associates [8], Sullivan and Murphy [9], and Dion and coworkers [10]. It has been asserted that the surgical correction of severe stenosis of the left main coronary artery with an onlay graft has the advantage of requiring neither a saphenous vein nor internal mammary artery bypass graft, thus avoiding the changes that may occur in these vessels, leading to later obstruction. The onlay grafts on the proximal coronary artery appear to be well tolerated.

Severe stenosis of the left main coronary artery is known to be associated with severe symptoms of myocardial ischemia usually requiring surgical correction. The present report concerns a 71-year-old woman who, at the age of 39 years, first had intractable angina due to severe stenosis of the left main coronary artery. She was managed by coronary endarterectomy and a pericardial graft to relieve the coronary stenosis in 1964. She has been a long-term survivor and remains without cardiac symptoms. Endarterectomy and patch graft has been recommended as the preferred procedure for correction of coronary ostial stenosis [10]. The results in this patient confirm this point of view.

Footnotes

Presented at Cardiovascular Surgery—Then and Now, University of Virginia Medical Center, Charlottesville, VA, April 26, 1997.

Address reprint requests to Dr Sabiston, Duke University Medical Center, PO Box 2600, Medical Sciences Research Bldg, Durham, NC 27710.

References

1. Sabiston DC Jr, Ebert PA, Friesinger GC, Ross RS, Sinclair-Smith B. Proximal endarterectomy, arterial reconstruction for coronary occlusion at aortic origin. Arch Surg 1965;91:758.[Medline]
2. Bailey CP, May A, Lemmon WM. Survival after coronary endarterectomy in man. JAMA 1957;164:641.
3. Longmire WP, Cannon JA, Kattus AA. Direct-vision coronary endarterectomy for angina pectoris. N Engl J Med 1958;259:993.[Medline]
4. Dubost C, et al. Syphilitic coronary obstruction: correction under artificial heart-lung and profound hypothermia at 10°C. Surgery 1960;48:540.[Medline]
5. Sabiston DC Jr. Coronary endarterectomy. Am Surg 1960;26:217.[Medline]
6. Connolly JE, Eldridge FL, Calvin JW, Stemmer EA. Proximal coronary-artery obstruction. Its etiology and treatment by transaortic endarterectomy. N Engl J Med 1964;271:213.[Medline]
7. Hitchcock JF, Medina R, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease. J Thorac Cardiovasc Surg 1983;85:880–4.[Abstract]
8. Villemot JP, Godenir J, Peiffert B, et al. Endarterectomy of the left main coronary artery stenosis by a `transpulmonary artery approach'. Eur J Cardiothorac Surg 1988;2:453–7.[Abstract/Free Full Text]
9. Sullivan JA, Murphy DA. Surgical repair of stenotic ostial lesions of the left main coronary artery. J Thorac Cardiovasc Surg 1989;98:33–6.[Abstract]
10. Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg 1990;99:241–50.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David C. Sabiston, Jr Alan P. Kypson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sabiston, D. C. Articles by Friesinger, G. C. Search for Related Content PubMed PubMed Citation Articles by Sabiston, D. C., Jr Articles by Friesinger, G. C.