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Ann Thorac Surg 2007;84:49-50
© 2007 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Invited commentary

Louisiana Cardiovascular and Thoracic Institute, 211 4th St, Alexandria, LA 71301

(Email: cable_david{at}suddenlink.net).

Technologic advances of the last 2 decades have had little impact on saphenous vein graft disease. Graft failure is multifactorial, but outside of immediate technical deficiencies, current research suggests serial progression from neointimal hyperplasia to atherosclerosis. The organ culture model is well established, and we demonstrated that human radial and internal mammary arteries and saphenous veins reacted similarly to clinical observations [1]. A vast amount of literature supports this model.

A threshold was witnessed lately with the advent of drug-eluting stents. With the recent controversy in stent therapy, surgical revascularization may rebound. It would be a simplification to state that our specialty can rest upon its laurels. Novel methods to increase the durability of bypass grafts must be actively sought.

The authors [2] should be congratulated on such an advance. They have taken a simple observation (ie, increased levels of homocysteine and copper after heart surgery) and extrapolated it to formulate a method by which vein graft disease may be attenuated. Veins were embedded in organ culture to eliminate extraneous variables. Microtubules were clearly visualized in the culture medium. Staining confirmed the presence of the endothelium. The present study observed that the combination of homocysteine and copper inhibited microtubule formation. Inhibition of homocysteine will allow microtubule formation, perhaps delaying degeneration of saphenous vein grafts.

Homocysteine levels can be reduced by as much as 72% by L-methylfolate, vitamin B12, and vitamin B6 supplements. This therapy costs less than a dollar a day. What other common variables after coronary artery bypass grafting (CABG) can be addressed?

Aspirin is prescribed after CABG. Some patients are prescribed 81 mg, whereas others are prescribed 325 mg. How many surgeons are using evidence-based medicine to formulate their decisions? Should antiplatelet therapy be optimized by currently available monitoring devices [3]? Aspirin and clopidogrel resistance may be commonly prescribed after CABG. Clopidogrel (Plavix) (Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership) is postoperatively prescribed by some surgeons, but not by others; this medicine is advocated by some surgeons for off-pump coronary artery bypass, but not by others. Beta-blockers can reduce postoperative atrial fibrillation. How common are these routinely and postoperatively ordered by the surgeon? Omega-3 fatty acid has been shown to reduce postoperative atrial fibrillation and reduce hospital length of stay [4]. Two other issues without consensus are Mupirocin (Bactroban) (GlaxoSmithKline, Research Triangle Park, NC), which is used to reduce sternal wound infections and statin therapy, which is used to reduce graft disease.

Many surgeons in our specialty pride themselves on attention to detail. The authors have addressed a detail rarely thought of in the operating room (ie, the neo vasa vasorum of vein grafts). Our specialty will only grow because of this attention to detail and an active search for methods to improve results.

	References

Top References

 

1. Cable DG, Caccitolo JA, Caplice N, et al. The role of gene therapy for intimal hyperplasia of bypass grafts Circ 1999;100(Suppl 19):II392-II396.[Medline]
2. Shukla N, Angelini GD, Jeremy JY. Interactive effects of homocysteine and copper on angiogenesis in porcine isolated saphenous vein Ann Thorac Surg 2007;84:43-50.[Abstract/Free Full Text]
3. Cannon CP, McLean DS. Critical pathways using platelet testing to potentially optimize the use of oral antiplatelet therapy Am J Cardiol 2006;98:33N-38N.[Medline]
4. Calo L, Bianconi L, Colivicchi F, et al. N-3 Fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a randomized, controlled trial J Am Coll Cardiol 2005;45:1723-1728.[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 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 G. Cable Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cable, D. G. Search for Related Content PubMed PubMed Citation Articles by Cable, D. G. Related Collections Coronary disease Related Article