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Ann Thorac Surg 2004;78:1458-1460
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
Accepted for publication July 10, 2003.
* Address reprint requests to Dr Nair, Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK
unnikrishnan.nair{at}leedsth.nhs.uk
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A 53-year-old woman was referred for consideration of coronary revascularization after admission to the hospital with unstable angina. She had a background of diabetes mellitus, hypertension and Cushing's syndrome. Coronary angiography (Fig 1) and cardiac magnetic resonance image showed left main stem stenosis in an abnormal hypoplastic left coronary artery arising from the right coronary sinus dividing into a circumflex artery and a small left anterior descending (LAD) artery. The right coronary artery was free of disease. The findings during surgery confirmed the abnormal anatomy. The left coronary artery emerged from the anterior aspect of the aorta close to the origin of the right coronary artery. It then continued toward the left side between the aorta and the main pulmonary artery, dividing behind the main pulmonary artery to form a small LAD and a slightly larger obtuse marginal artery. The posterior wall of the heart was void of significant branches from the circumflex artery.
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The suggestion that the mammalian myocardium can be nourished by means of a flow of blood from the coronary venous system was proposed by Pratt [1] in 1898.
Prinzmetal and colleagues indicated the existence of arteriovenous coronary anastomosis after the recovery of glass spheres 70 to 170 microns in diameter from the coronary sinus after injection of the spheres into the left or right coronary arteries. They also implied that these anastomoses could serve as a source of oxygenated blood to the myocardium after coronary arterial occlusion [4].
In 1943, Roberts and colleagues suggested that an ischemic myocardium may be revascularized by anastomosis of a large artery to the coronary sinus and coronary veins. They carried out experiments in dogs in which they were able to demonstrate complete injection of the myocardial capillaries with Chicago Blue dye after injection in the coronary sinus [3].
In 1948, Beck and colleagues [6] reported the experiments that resulted in the description of "Beck's number two operation." In dogs, they positioned a carotid artery graft between the aorta and the coronary sinus. After that the coronary sinus was ligated. Then they ligated the LAD artery. When compared with controls, those dogs with patent anastomosis showed a benefit in terms of survival and myocardial damage. The authors hypothesized that a considerable amount of blood may pass through an arteriovenous fistula. Specimens of hearts were examined in reference to this possibility. A significant amount of blood was obtained from the left coronary artery after injection in the coronary sinus. These findings led them to state that there are communications between the venous and arterial sides of the circulation which, in the dead specimen, allowed blood flow in a retrograde direction. In January 1948, Beck and colleagues [6] carried out the described procedure using a brachial artery graft on a patient with severe coronary artery disease who survived the procedure.
The first report of arterialization of a coronary vein rather than the coronary sinus came from Arealis and colleagues [2] in 1973. They carried out experiments in calves in which the pedicled left internal mammary artery was anastomosed to the LAD vein. They were able to demonstrate reversal of ischemic electrocardiographic changes after ligation of the LAD artery by opening the left internal mammary artery graft. The LAD vein had been occluded proximally to prevent antegrade venous flow.
In 1975, Benedict and colleagues [7] published a series of three clinical cases of saphenous vein grafting from the aorta to a coronary vein in patients with intractable angina and previous unsuccessful revascularization procedures. Postoperative coronary angiograms revealed patency in two of the four grafts constructed. Myocardial scanning demonstrated uptake in the regions served by patent grafts. Previously they had carried out animal experiments in dogs that had demonstrated evidence of myocardial revascularization through the coronary venous system.
Oesterle and colleagues [5] recently reported a successful case of percutaneous in situ coronary venous arterialization in a patient with similar characteristics to the patient in this article.
The concept of arterialization of the coronary veins for myocardial revascularization was first laid in the 19th century [1]. Several articles on the same principle have been published during the last century. The successful outcomes, reported by Oesterle and colleagues [5] and by ourselves in the current article, support the idea that the selective arterialization of the coronary venous system should be considered in cases of coronary artery disease not amenable to traditional revascularization strategies.
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