T.F. Luscher M. Turina E. Braunwald (Eds.)

Coronary Artery Graft Disease Mechanisms and Prevention

With 159 Figures, Some in Colour

Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona Budapest

Professor Dr. med. THOMAS F. LUSCHER Abteilung Kardiologie, Inselspital 3010Bem Switzerland

Professor Dr. med. MARKO TURINA Herz-GeHiBchirurgie, Universitiitsspital 8091 Zurich Switzerland

Professor Dr. med. EUGENE BRAUNWALD Department of Medicine Harvard University and Brigham and Women's Hospital Boston, MA 02115-6195 USA

Cover drawing reprinted with permission from Mayo Clinic Proceedings 61:3-8 (1986)

ISBN-13 :978-3-642-78639-6 e-ISBN-13:978-3-642-78637-2

DOl: 10.1007/978-3-642-78637-2

Library of Congress Cataloging-m-Publication Data. Coronary artery graft disease: mechamsm and prevention I T. Luscher, M Turina, E. Braunwald, eds. p. cm. Includes bibliographical references and index 1. Coronary artery bypass-Complications. 2. Graft reJectIon. I. Luscher, Thomas F (Thomas Felix) II. Tunna, Marko. III. Braunwald, Eugene, 1929- [DNLM: 1 Coro­nary Disease-therapy. 2. Coronary Artery Bypass-adverse effects. 3. Graft Rejection­prevention & control. WG 300 C81965 1994] RD59835.C67C685 1994 617.4'120592 -dc20 DNLMIDLC for Library of Congress 94-16135

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Preface

In 1969, Rene Favaloro published his landmark paper entitled "Saphenous vein graft in the surgical treatment of coronary artery disease: operative technique", which changed the care of patients with ischemic heart disease and the speciality of cardiovascular surgery forever. Since then, the use of coronary artery bypass grafting has relieved intractable angina pectoris in millions of patients worldwide and prolonged survival in countless others.

Despite the emergence and popularity of percutaneous trans­luminal coronary angioplasty and related techniques, coronary artery bypass surgery remains firmly entrenched as the only re­vascularization technique that has been demonstrated to improve the natural history of coronary artery disease. An increasing number of candidates for this operation are, in fact, now patients who have previously undergone angioplasty or bypass surgery. As a consequence, the total number of surgical revascularizations continues to rise steadily both in the United States and in Europe.

Even when it is successful technically, however, coronary artery bypass surgery is not a curative procedure. One major problem is coronary graft disease, a series of interrelated com­plications, some of which may commence at operation and others which continue for decades; all of them ultimately negate the benefit of the procedure, however. This book deals with the most important complications of the most important cardiovascular operation. Fortunately, the enormous advances in vascular patho­biology made in the past 15 years have shed much light on this problem and have pointed to its potential prevention and man­agement. Approaches include the preoperative selection of the conduit(s) to be employed and their intraoperative handling, and the early and late postoperative care of the patient. We have learned that blood vessels are complex, living organs rather than simple mechanical conduits, that arteries differ considerably from veins when used for coronary bypass, and that the endothelium is an active tissue that influences profoundly both the fluidity of the blood and the tone and growth of the underlying smooth muscle.

VI Preface

The understanding of the cellular and molecular mechanisms involved in bypass graft disease may set the stage for more specific therapeutic interventions in the future which may help to prolong the patency and function of implanted grafts.

Assessment of the grafts, of course, is essential in the post­operative patient. While coronary arteriography remains the gold standard for the recognition of graft disease, a variety of non­invasive methods - radionuclide scintigraphy, duplex ultrasono­graphy, magnetic resonance imaging, positron emission tomo­graphy and angiography - can all provide valuable information regarding the status of the graft and of both the viability and function of the myocardium that it perfuses. When considering reoperation in patients with diseased grafts, it is essential to evaluate the quality of salvageable myocardium perfused by diseased grafts and native vessels.

Management of the patient with coronary grafts may be divided into two phases. Prevention of graft disease, which should be applied to all patients, currently involves the use of antiplatelet drugs, vigorous control of lipid abnormalities, and strict smoking cessation. In patients with established graft dis­ease, percutaneous trans luminal angioplasty, sometimes aided by intraluminal stents, is often helpful. When these measures fail or are not suitable, reoperation - despite its higher risk - may be in order. Heart transplantation always remains a last resort for patients with severe graft disease, but it is an effective last resort since the long-term outcome has improved substantially in recent years.

It is fitting, therefore, that as we celebrate the silver an­niversary of coronary artery bypass surgery, we re-examine this important operation and describe approaches that may protect the many patients who have already undergone it and the even larger number who will do so in the future.

Bern, Switzerland Zurich, Switzerland Boston, USA

THOMAS F. LUSCHER

MARKO TURINA

EUGENE BRAUNWALD

Contents

The Problem

The Natural History of Saphenous Vein Grafts C.M. GRONDIN and J.C. THORNTON With 3 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Risks and Prediction of Adverse after Coronary Bypass Grafting based on a Single Center Experience P. SERGEANT With 11 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Mechanisms of Plaque Formation and Occlusion in Venous Coronary Bypass Grafts I.K. JANG and V. FUSTER With 2 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Surgical Aspects

Arterial and Venous Coronary Bypass Grafts: Surgical Techniques and Outcome F.D. Loop With 6 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Newer Arterial Coronary Bypass Conduits: Right Gastroepiploic and Epigastric Artery H. SUMA With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Diagnosis of Graft Failure

The Role of Radionuclide Imaging in the Diagnosis of Coronary Bypass Graft Failure F.J.T. WACKERS With 4 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

vm Contents

Coronary Artery Graft Disease: Diagnosis of Graft Failure by Magnetic Resonance Imaging P.T. BUSER and C.B. HIGGINS With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Positron Emission Tomography: Evaluation of Myocardial Blood Flow and Viability Before and Following Coronary Revascularization S.G. SAWADA and M. SCHWAIGER With 6 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Transcutaneous Assessment of Blood Flow in Internal Thoracic Artery to Coronary Artery Grafts D.P. DEBoNO With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Coronary Angiography in the Diagnosis of Graft Failure P.R. LICHTLEN and H. HAUSMANN With 23 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

Left Ventricular Function: Systolic and Diastolic Alterations H.P. KRAYENBUHLt , M. JAKOB, and a.M. HESS With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Biological Characteristics and Coronary Bypass Grafts

Endothelium and Vascular Smooth Muscle Function of Coronary Bypass Grafts T.F. LUSCHER, Z. YANG, and B.S. OEMAR With 9 Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Smooth Muscle Cell Proliferation Responses in Organ Cultures of Human Saphenous Vein G.D. ANGELINI and A.C. NEWBY With 4 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Chronic Changes in Venous Grafts After Implantation D.A. LEWIS and V.M. MILLER With 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

Contents IX

Pharmacological Intervention

Lipids and Lipid-Lowering Drugs and Graft Function H. DREXEL and F.W. AMANN With 2 Figures ..................... 0 0 0 0 0 0 0 • 0 0 • 0 0 0 •• 0 247

Treatment of Severe Hypercholesterolemia in Patients with Coronary Heart Disease by Means of Lipoprotein Apheresis Do SEIDEL With 4 Figures . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 • • 259

Antiplatelet Drugs l.H. CHESEBRO, Bol. MEYER, Ao FERNANDO-ORTIZ, I.K. lANG, and Vo FUSTER With 6 Figures 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 • 0 • 0 0 0 0 • 0 0 0 0 0 0 0 0 0 276

Anticoagulants and Antiplatelet Drugs to Prevent Aortocoronary Vein Graft Occlusion Mo PFISTERER With 13 Figures 0 0 0 0 • 0 •• 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 • 0 0 0 0 0 0 0 0 0 0 299

Calcium Antagonists in Patients Undergoing Coronary Artery Bypass Surgery So 0 0 GOTTLIEB With 5 Figures 000000000.000 •• 0 0 0 0 0 •• 0 0 • 0 0 0 0 • 0 0 0 •• 000 312

Revascularization Strategies

Percutaneous Transluminal Coronary Angioplasty in Patients with Failed Bypass Graft Surgery l. HOLLMAN With 5 Figures 0 •• 0 0 0 0 0 0 0 •• 0 0 0 0 0 0 0 0 0 0 •• 0 0 0 0 • 0 • 0 0 •• 0 0 0 327

Intraluminal Stents in Coronary Bypass Grafts Po URBAN and Bo MEIER With 10 Figures 0 • 0 0 0 0 •• 0 • 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 340

Reoperation: Techniques and Choice of Conduits L.K. VON SEGESSER and MoL. TURINA With 10 Figures 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 360

X Contents

Cardiac Transplantation for Ischaemic Heart Disease M. YACOUB

With 5 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391

List of Contributors

AMANN, F.W., PD Dr., Abteilung Kardiologie, Department fUr Innere Medizin, UniversiHitsspital Zurich, 8091 Zurich, Schweiz

ANGELINI, G.D., M.D., Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK

DE BONO, D.P., Department of Cardiology, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester LE3 9QP, UK

BUSER, P.T., M.D., Division of Cardiology, University Hospital, Petersgraben, 4031 Basel, Switzerland

CHESBRO, J.H., M.D., Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA

DREXEL, H., PD Dr., Abteilung Kardiologie, Department fUr Innere Medizin, Universitatsspital Zurich, 8091 Zurich, Schweiz

FUSTER, V., M.D., Ph.D., Chief, Cardiac Unit, Massachusetts General Hospital, BUL 105, Fruit Street, Boston, MA 02114, USA

GOTTLIEB, S.O., M.D., FACC, Johns Hopkins University School of Medicine, Midatlantic Cardiovascular Consultants, P .A., GBMC Pavilion, Suite 408, 6585 North Charles Street, Baltimore, MD 21204, USA

GRONDIN, C.M., M.D., Professor of Surgery, Case Western Reserve University, Cleveland, OH 44104, USA

HAUSMANN, H., M.D., Zentrum Innere Medizin, Abteilung Kardiologie, Hochschule Hannover, Konstanty-Gutschow-Str. 8, 30625 Hannover, Germany

HESS, O.M., M.D., Professor of Medicine, Department of Medicine, Cardiology University Hospital, 8091 Zurich, Switzerland

XII List of Contributors

HIGGINS, C.B., Department of Radiology, MRI Section, University of California, San Francisco, CA 94143, USA

HOLLMAN, J., M.D., Department of Cardiology, Ochsner Clinic of Baton Rouge, 16777 Medical Center Drive, Baton Rouge, LA 70816, USA

JAKOB, M., M.D., Division of Cardiology, University Hospital, 8091 Zurich, Switzerland

JANG, I.K., M.D., Ph.D., Assistant Professor of Medicine, Massachusetts General Hospital, BUL 105, Fruit Street, Boston, MA 02114, USA

KRAYENBUHL, H.P., M.D.t, Professor of Cardiology, Medical Policlinic, University Hospital, 8091 Zurich, Switzerland

LEWIS, D.A., Department of Surgery and Physiology, 9 Guggenheim Building, Mayo Clinic and Foundation, Rochester, MN 55905, USA

LICHTLEN, P.R., Prof. Dr., Zentrum Innere Medizin, Abteilung Kardiologie, Hochschule Hannover, Konstanty-Gutschow-Str. 8, 30625 Hannover, Germany

Loop, F.D., M.D., The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA

LUSCHER, T.F., M.D., Professor of Medicine, Cardiology, University Hospital, 3010 Bern, Switzerland

MEYER, B.J., M.D., Professor of Medicine, Cardiology, University Hospital, 3010 Bern, Switzerland

MILLER, V.M., Ph.D., Department of Surgery and Physiology, 9 Guggenheim Building, Mayo Clinic and Foundation, Rochester, MN 55905, USA

NEWBY, A.C., Ph.D., Reader Cardiovascular Biochemistry, Department of Cardiology, College of Medicine, University of Wales, Health Park, Cardiff CF4 4XN, UK

OEMAR, B.S., M.D., PD Dr., Department of Research, University Hospital, 4031 Basel, Switzerland

PFISTERER, M., MD, FESC, FACC, Professor of Cardiology, University Hospital Basel, 4031 Basel, Switzerland

SAWADA, S.G., M.D., University of Michigan Medical Center, 1500 E. Medical Center Dr., UH B1G505, Ann Arbor, MI 48109-0028, USA

List of Contributors XIII

SCHWAIGER, M., Prof. Dr., Nuklearmedizidische Klinik und Poliklinik, Technische UniversiHit Munchen, Klinikum rechts der Isar, Ismaningerstr. 22,81657 Munchen, Germany

VON SEGESSER, L.K., PD Dr., Department of Cardiovascular Surgery, University Hospital Zurich, 8091 Zurich, Switzerland

SEIDEL, D., PD. Dr., Direktor des Institutes fur Klinische Chemie, Klinikum Grosshadern, Ludwig-Maximilians-UniversiHit Munchen, Marchioninistrasse 15, 81366 Munchen, Germany

SERGEANT, P., M.D., Cardiac Surgery Department, Gasthuisberg, University Hospital, Herestraat, 3000 Leuven, Belgium

SUMA, H., M.D., Department of Cardiovascular Surgery, Mitsui Memorial Hospital, 1, Kanda Izumi-cho, Chiyoda-ku, Tokyo 101,Japan

THOMTON, J.C., M.D., Associate Professor of Surgery, Case Western Reserve University, Cleveland, OH 44104, USA

TURINA, M., M.D., Professor of Surgery, Chairman, Dept. of Cardiovascular Surgery, University Hospital Zurich, 8091 Zurich, Switzerland

URBAN, P., M.D., Professor of Medicine, Centre de Cardiologie, Hopital Cantonal Universitaire, 24, rue Micheli-du-Crest, 1211 Geneve, Suisse

WACKERS, F.J.T., M.D., Yale University School of Medicine, Department of Diagnostic Radiology and Medicine, 333 Cedar Street, TE-2, New Haven, CT 06510, USA

YACOUB, M., SIR, Professor of Surgery, National Heart & Lung Institute, Academic Department of Cardiothoracic Surgery, Dovehouse Street, London SW3 6LY, UK

YANG, Z., M.D., Cardiovascular Research, Cardiology, University Hospital, 3010 Bern, Switzerland