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Ann Thorac Surg 2004;78:1515-1516
© 2004 The Society of Thoracic Surgeons

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Correspondence

The Quality of the Coronary Arteries Influences the Outcome of Bypass Surgery

Department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh

Eugene K. W. Sim, FRCS (Glasg), FRCSEd

Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074

rasul{at}agni.com
sursimkw{at}nus.edu.sg

To the Editor:

We would like to congratulate Kleikamp and colleagues [1] on their results after coronary artery bypass grafting (CABG) in a high-risk group of patients. The article emphasizes that the degree of the coronary arterial system pathology correlates with the event-free survival of the patients, which is an important issue that is not usually dealt with.

Coronary surgeons will intuitively agree that the quality of the coronary arteries is important in determining graft patency and, hence, outcomes. However, most reports on the outcome of CABG refer to the severity of coronary disease simply as single-, double-, or triple-vessel disease. The grading system used by Kleikamp and colleagues is admirable in its effort to highlight the importance of a more detailed examination of coronary arteries, but we believe that the following should be taken into consideration:

1. It gives equal weight to all 3 coronary arterial systems, whereas the left anterior descending system should have the greatest importance, and a dominant left circumflex system should have more importance than a nondominant right coronary arterial system [2].
   
2. It is probably true that evaluation of the number of myocardial segments that can be revascularized is an important way of calculating the severity of coronary artery disease [3]. One factor that determines the extent of possible revascularization is whether the vessels have multiple stenosis or diffuse vessel disease. More complete revascularization may be obtained by appropriate grafts on a vessel with multiple stenosis, but grafting of small or diffusely diseased vessels may not yield such a benefit. The system used by Kleikamp and colleagues does not distinguish between these 2 scenarios.
   
3. Grafting at more than 70% stenosis will be questioned by the many surgeons who graft coronary arteries with more than 50% stenosis.
   
4. Classification of stenosis as proximal and distal does not really do justice to the larger branches, which may be important in individual cases.
   

A more representative system may take into consideration all these factors. This would allow more accurate prediction of postoperative graft patency and function and, hence, outcome and logically follows Kleikamp and colleagues' contention that a properly functioning graft is one of the ultimate indices of outcome for CABG. In contrast, it is interesting to note that the analysis of the state of the coronary arteries is not taken into consideration in almost all current risk-scoring systems. Intraoperative determination of graft patency and flow may allow for further refinement of outcome prediction. Indices may be derived from transit time flowmetry, thermal camera imaging, or intraoperative coronary angiography. For the derivation of such parameters, transit time flowmetry may be a particularly good noninvasive method.

Finally, one would ask whether the authors' conclusion that a patient with poor coronary arteries should be considered unsuitable for revascularization translates to refusal to operate in such cases. One would tend to think not and that the patient's informed consent is the proper basis of decision making.

References

1. Kleikamp G, Maleszka A, Reiss N, Stüttgen B, Körfer R. Determinants of mid- and long-term results in patients after surgical revascularization for ischemic cardiomyopathy. Ann Thorac Surg. 2003;75:1401–1406 3
2. Corbineau H, Lebreton H, Langanay T, Logeais Y, Leguerrier A. Prospective evaluation of coronary arteries: influence on operative risk in coronary artery surgery. Eur J Cardiothorac Surg. 1999;16:429–434[Abstract/Free Full Text]
3. Ragosta M, Beller GA, Watson DD, Kaul S, Gimple LW. Quantitative planar rest. redistribution ²⁰¹TI imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation. 1993;87:1630–1641[Abstract/Free Full Text]

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