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Eugene Braunwald M.D Postgraduate Medical Journal (December 1976) 52, 733-738. Postgrad Med J: first published as 10.1136/pgmj.52.614.733 on 1 December 1976. Downloaded from Coronary artery bypass surgery-an assessment EUGENE BRAUNWALD M.D. Department of Medicine, Harvard Medical School, and Peter Bent Brigham Hospital, Boston, Massachusetts 02115 Introduction form of therapy that can, under appropriate circum- The surgical treatment of coronary artery disease stances, favourably alter the clinical expression of has a long, chequered and, until recently, undistin- arteriosclerotic coronary artery disease. Accompany- guished history. It has gone through a number of ing this widespread optimism, however, is a growing stages; surgical sympathectomy was suggested to- uneasiness that by simple common consent, rather wards the end of the last century and was reported than by rational analysis of data, we may be adopting as a successful treatment for angina pectoris in 1916; for general use a form of treatment that has yet to abrasion of the epicardium and of the pericardium prove itself. Some fear that even though the long- was introduced in the 1930s; the application of a term effectiveness of direct revascularization has not variety of pedicles or organs (omentum or spleen) yet been demonstrated, we may be propelled into a to the surface of the heart was introduced in the position in which it will be considered poor medical early 1940s; occlusion of the coronary sinus was practice to withhold this form oftherapy from almost carried out later in the same decade; anastomosis any patient with coronary artery disease and in Protected by copyright. between the aorta and the coronary sinus or arterial which the physician who does not recommend perfusion of the coronary venous circulation were coronary arteriography in almost every person who introduced in the late 1950s; ligation of the internal might have coronary sclerosis may be subject to mammary artery and then implantation of this vessel severe criticism. into the ventricle were utilized in the early 1960s. All of these procedures were initially announced with Unresolved issues enthusiasm which then rapidly waned. Many questions must be answered. First and fore- Accompanying the development of these opera- most, how do the survival rates compare in closely tions there has been an increasing appreciation of matched groups of patients with and without the the natural history of coronary artery disease. In operation? How does operation affect the incidence addition, there have been important advances in the of myocardial infarction, congestive heart failure, medical treatment of angina pectoris, particularly arrhythmias, angina and other symptoms? How do 3-adrenergic blockade, and there is now widespread the clinical effects of revascularization compare with recognition of the important placebo effects of a vigorous dietary and anti-lipaemic treatment, variety of treatments of a disease in which one of the particularly in patients with relatively mild disease? http://pmj.bmj.com/ principal clinical manifestations, i.e. angina pectoris, If the natural history of coronary artery disease is is largely subjective. favourably altered, then what are the implications With the development of aorto-coronary artery for patients with relatively few symptoms but with bypass surgery we have a procedure of qualitatively seriously disturbed coronary anatomy which may be greater importance than those hitherto available. suitable for surgical treatment? This question leads This operation (1) immediately delivers substantial inevitably to an even broader question-how are quantities of blood to previously ischaemic patients to be selected for coronary arteriography? on October 1, 2021 by guest. myocardium; (2) can be accomplished by a skilled, What are the long-term patency rates of the grafts? experienced surgical team with a relatively low mor- What are the long-term changes in the interposed tality; (3) results in the relief of angina pectoris in venous segment? Does the presence of hypertri- most patients. The procedure is being rapidly ex- glyceridaemia or other forms of hyperlipidaemia tended from patients with incapacitating angina increase the risk of graft closure? What is pectoris, in whom it was first applied, to those with the rate of development of arteriosclerotic acute myocardial infarction, unstableangina pectoris, disease in the coronary vessels distal to the anas- cardiogenic shock and, in some instances, even to tomosis when they are exposed to systemic pressure patients with minimal symptoms but anatomically and are no longer 'protected' by a more proxi- favourable lesions. mal stenosis? What is the mechanism of the dis- Clearly then, coronary bypass surgery represents a turbingly high incidence of the occlusion of the 734 Eugene Braunwald Postgrad Med J: first published as 10.1136/pgmj.52.614.733 on 1 December 1976. Downloaded from native vessel proximal to the insertion of the graft? Bent Brigham Hospital in 330 patients operated Does it represent a natural progression of coronary largely for disabling angina. The operative mortality artery disease? What are the relative advantages and was 1.2% and the long-term mortality over a 4-year disadvantages of using the internal mammary artery period was 4%. The results of their life-table analysis as opposed to the saphenous vein? What are the suggested that in patients with 2- and 3-vessel coron- possibilities of using synthetic materials? What are ary artery disease who received complete revascu- the effects of bypass surgery on the contractile acti- larization there was a significant prolongation of life vity of previously ischaemic myocardium? What is when compared to a large series of medically treated the mechanism ofpain reduction? How often is it due patients studied by coronary arteriography at the to increased perfusion? To what extent is there an Cleveland Clinic before the widespread use of bypass alteration ofsensory nerve function after the diseased surgery. A number of retrospective studies have de- vessels have been manipulated surgically? What role fined the annual mortality rate in medically treated does the placebo effect play? patients as 2% for 1-, 7%/ for 2- and 11% for 3- The problem of evaluating this operation is, of vessel coronary disease (Reeves et al., 1974). course, compounded by the fact that the answers to Dawson et al. (1974) have reported that the mor- these and other questions must be sought among tality rate following coronary artery bypass surgery many different groups of patients. The effects of the was higher in patients who had previously suffered a operation will have to be analysed in patients by myocardial infarction, particularly in those in whom sex, age, arterial pressure, number of previous in- it occurred within 2 months of operation. It has been farcts, extent of myocardial dysfunction, by the observed repeatedly that the mortality rate is high presence of risk factors such as diabetes, hyperlipi- and the clinical improvement limited in patients who daemia, hypertension, etc. Obviously, this will be a underwent myocardial revascularization primarily difficult task, but one that is essential; one hopes it because of symptoms of left ventricular dysfunctionProtected by copyright. will be carried out sooner rather than later. (Editorial, 1976). The inability to demonstrate ven- triculographic or haemodynamic augmentation of Effects of operation on mortality overall ventricular function after bypass operation is While ignorance in this field is great, some import- not surprising when it is recognized that improve- ant information has been accumulated in the last few ment could not be expected to occur either in years. First of all, there is agreement that the survival patients in whom ventricular function before opera- following surgical treatment is constantly improving, tion is normal nor in patients whose ventricular func- at least in those centres performing a large number of tion is impaired by previous infarction and scar or operations from which the results are reported. Thus, aneurysm formation. Cannom et al. (1974) reviewed the results of the A limited number of studies have provided a com- first 400 consecutive patients having saphenous vein parison between the surgical and non-surgical treat- coronary artery graft surgery at Stanford University ment of coronary artery disease in suitably matched Hospital; the operative mortality was 6'5%; those patients. In one of these, a prospective randomized in whom the operation was carried out electively had study, Mathur and Guinn (1975) found at follow-up a mortality of 0-8% and, despite the operative that 6% of the operated patients and 10% of the mortality, the operated patients showed a 3-year medically treated group had died, a difference which http://pmj.bmj.com/ survival of 88'5°/. Hutchinson et al. (1974) reported was not significant. Also, anginal symptoms im- an extremely low operative mortality rate of 0 8% proved in both the surgically and medically treated and of operatively induced infarctions (19y9%) in a groups, but a large fraction of the former became group of thirty-six consecutive patients. Tector and asymptomatic. Treadmill tests also revealed in- McNabb (1974) reported a 1-year series of 196 creased exercise tolerance in the patients who had consecutive patients who underwent coronary artery had surgery. Thus, whatever the mechanism that was bypass surgery without a hospital death, while responsible, the quality of life had certainly
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