HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ulrich Hake Hellmut Oelert Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hake, U. Articles by Oelert, H. Search for Related Content PubMed Articles by Hake, U. Articles by Oelert, H.

Ann Thorac Surg 2000;69:977
© 2000 The Society of Thoracic Surgeons

---

Correspondence

Outcome of coronary endarterectomy

^a Division of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University, Langenbeckstr 1, 55101 Mainz, Germany

To the Editor

We read with great interest the article entitled "Outcome of Coronary Endarterectomy: A Case-Control Study," published by Asimakopoulos and colleagues [1]. The aim of their retrospective study was to evaluate the role of endarterectomy in coronary artery bypass surgery.

The evaluation of endarterectomy directly leads to the question of benefit in grafting a diffusely diseased and functionally occluded coronary artery or to reopen an already chronically occluded arterial segment with respect to myocardial performance. The second question is whether this procedure is associated with an increased risk of myocardial infarction or not.

The relative low number of 56 endarterectomies in 1,366 patients performed by Asimakopoulos and colleagues within a period of 3 years clearly outlines the surgical judiciousness of the authors and the appropriate selection of patients. On the other hand, it is this low number of patients with coronary endarterectomy that renders any statistical analysis difficult. The definition of a perioperative myocardial infarction based mainly on electrocardiographic patterns is likely to underestimate the number of perioperative myocardial lesions. Postoperative echocardiographic wall motion abnormalities are nearly always present after open heart surgery and are usually of little diagnostic value. Serial measurements of specific myocardial enzymes indicative for a perioperative myocardial infarction have not been performed by the authors. Finally, the gold standard to review both the fate of the bypass graft and of the coronary artery is coronary angiography, which has not been performed.

In general, two indications for endarterectomy can be distinguished; one is more or less intentional and the second one can be described as inadvertent. Whenever the distal right coronary artery is approached in the presence of a proximal occlusion and retrograde filling of the postero-descending artery up to the crux, the necessity for endarerectomy can be anticipated. There are, however, no valid data to demonstrate that endarterectomy in these patients had been of any use. As a consequence, we favor the postero-descending artery as the primary anastomotic target vessel, which usually has an acceptable diameter of 1.5 mm and presents with an excellent and delicate arterial wall.

On the other hand, endarterectomy cannot always be avoided, especially with regard to the left coronary artery system. Local technical reasons like unexpected calcification of the arterial wall or a diffuse coronary sclerosis with an unsecure distal anastomotic end point comprise the main indication on the left side. The fact that the coronary vascular bed is frequently not totally occluded and is prone to secondary occlusion is a possible explanation for the higher incidence of a perioperative myocardial infarction associated with left coronary endarterectomy. A careful selection of the anastomotic site, ie, the exclusion of the bifurcation, may in fact lower the incidence of coronary endarterectomy even in patients with diffuse disease. Occlusion of a left-sided coronary artery is usually only segmental and frequently results in an uncompromised distal vascular part, where endarterectomy is rarely necessary. Asimakopoulos and colleagues reported three myocardial infarctions in the endarterectomy group. It would have been interesting to know whether these infarctions occurred in association with a left-sided coronary endarterectomy.

In conclusion, we agree with Asimakopoulos and colleagues that coronary endarterectomy should be an exceptional procedure as long as no beneficial effect has been clearly evaluated [2]. Diffuse disease must not automatically include endarterectomy but requires careful in situ analysis of coronary pathology on the left side to avoid perioperative myocardial infarction.

References

1. Asimakopoulos G., Taylor K.M., Ratnatunga C.P. Outcome of coronary endarterectomy. Ann Thorac Surg 1999;67:989-993.[Abstract/Free Full Text]
2. Djalilian A.R., Shumway S.J. Adjunctive coronary endarterectomy. Ann Thorac Surg 1995;60:1749-1754.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ulrich Hake Hellmut Oelert Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hake, U. Articles by Oelert, H. Search for Related Content PubMed Articles by Hake, U. Articles by Oelert, H.