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Persistence of New Vascular Channels Following Cardiopexy
PROGRESS IN CARDIOVASCULAR SURGERY
Persistence of New Vascular Channels Following Cardiopexy Necropsy Demonstration of Extracardiac Blood Supply 15 Months and 11 Y2 Years After Operation* M.
S.
MAZEL, M.D. AND ROGELIO RIERA, M.D.
Chicago, Illinois
T
surgically produced blood supply remained patent and functioning for 11 Y2 years.
HE CONCEPT OF CORRECTING MYOCAR-
dial ischemia caused by occlusion of coronary arteries was originally presented by Beck' in 1935. This was essentially a method of producing pericardial-myocardial adhesions in order that a new supply of blood could be brought to the myocardium from a source other than the coronary arteries. By means of further study and changes in technique, by Beck,' Thompson,' Vineberg,' Mazel and others,' the surgical procedure known as cardiopericardiopexy has been established. In this operation the myocardium and pericardium are scarified and a fibrinous adhesive pericarditis is induced by means of insufflation on an irritant, usually talcum powder (magnesium silicate or asbestos) over the entire surface of the myocardium into the pericardial sac. Blood vessels from this connective tissue anastomose with vessels in the myocardium and the inter-coronary vessels and furnish an additional blood supply to relieve the ischemia. However, many serious students of cardiac disease raised the question that there was no evidence that the newly produced blood supply did not become obliterated rapidly either by replacement of fibrous tissue or by advancing atherosclerosis. A partial answer was given when in one case these vessels were found patent 15 months after the operation' (Fig. I). In this case, the patient, after the above period of symptom free living, expired following the rupture of an aneurysm of the abdominal aorta. Another case is now presented of a patient who had a cardiopexy, in whom the
CASE REPORTS CASE I
A 47-year-old truck driver was admitted to the Edgewater Hospital during November, 1952. One year earlier, he had suffered multiple infarctions with coronary insufficiency relieved by rest and nitroglycerin. On admission, he had a positive Master two-step exercise test, abnormal electrocardiogram with markedly depressed ST segments and many unifocal ventricular systoles. There were slight systolic murmurs at the apex and base. Cardiopexy was performed on December 2, 1952. Afterward, he was free from pain and was able to continue work as a truck driver. On September 16, 1963, he was admitted to the Edgewater Hospital with partial return of angina and a pulsating mass in the left side of the abdomen. He had been forced to limit himself to non-strenuous activities, but was not completely idle. Physical examination at that time revealed a well-developed, well nourished man not acutely ill. His heart rate was 62 and his blood pressure 130/80. A slight systolic murmur was present at the apex with a roughening of the second aortic sound. An electrocardiogram showed evidence of left heart strain and first degree heart block. Laboratory studies and urinalysis were within normal limits. X-ray examination of the abdomen revealed a dilated abdominal aorta. The patient was managed medically and was discharged from the hospital on September 21, 1963 with the following diagnoses: arteriosclerotic heart disease old myocardial infarction first degree heart block exacerbation of coronary insufficiency rheumatic heart disease (mitral insufficiency) cardiopexy aneurysm of the abdominal aorta mild aortic stenosis The aneurysm of the abdominal aorta was removed and replaced by a graft at another hospital between September, 1963 and January, 1964.
*From Edgewater Hospital.
651
Oi..,..es of the Chest
MAZEL AND RIERA
FIOURE I: Microphotograph of epicardium showing persistence of newly formed capillaries in the gran ulation tissue after 15 months. Hand E stain, IOOX.
FIOURE 2: Microphotograph of epicardium showing magnesium silicate crystals, foreign body giant cells,
mononuclear leukocytes and
several small bloods vessels after 11 y, yean. Hand E stain, IOOX.
3: Microphotograph of external portion of myocardium showing severe foreign body reaction and several blood vessels lined by plump endothelial cells after 11 Y2 yean. H and E stain, IOOX.
FIOURE
Volume 47. No.6
June
1965
CARDIOPEXY
4-: Pericardial adhesions from anterior wall of heart showing many small blood vessels, foreign body giant cells containing magnesium silicate crystals and lymphocytes after seven years. H and E stain 90X. FIGURE
FIGURE 5: Pericardial adhesions from posterior wall or heart showing a few blood vessels, lymphocytes and foreign body giant cells after seven years.
MAZEL AND RIERA
l'he patient expire'd on January 28, 1964. Necropsy was performed by Dr. Grover L. Seitzinger, pathologist, in the patient's home town of Danville, Illinois, and the heart and aortic graft were sent to the Edgewater Hospital for further examination. Patholog)' Report: "The coronary arteries are completely obliterated by calcified atheromatous plaques. The right ventricular wall is 5 mm. thick and the myocardium is a homogeneous dark brown. The left ventricular wall varies from 10 mm. thick in the posterior and lateral wall to 15 mm. thick in the anterior wall. The myocardium of the lateral and posterior walls is mottled dusky red and reddish brown with areas of pearly gray fibrous tissue. The endocardium of the left ventricle is diffusely thickened except over the interventricular septum and there is a tigroid appearance of the endocardium of the posterior and lateral walls of the left ventricle . . . The parietal pericardium is adherent to the visceral pericardium . , . Microscopic . .. Sections of the heart sho\v the ep~cardium to be markedly thickened by a granulomatous reaction. There are numerous crystals present in the dense fibrous stroma which is infiltrated with Inononuclear cells and multinucleated giant cells. This granulomatous reaction extends into the myocardium of the left auricle and the lateral wall of the left ventricle" (Dr. Grover L. Seitzinger). Numerous small blood vessels and capillaries lined by pI u m pen dot h eli a I cells were seen throughout this tissue (Figs. 2 and 3). These demonstrated clearly that the vessels which developed as a result of the cardiopexy had remained patent for 11 Y2 years. Injection studies were performed on the blood vessels in the granulomatous tissue. This showed that the small blood vessels did in fact remain patent and communicated with branches of the coronary vessels. This is a case in which a patient lived and his heart functioned after both coronary arteries had been occluded. That this was no recent occurrence is demonstrated by the calcified atheromatous tissue which obstructed both arteries. Since the myocardium cannot function without a blood supply, an adequate volume must have been furnished from the channels created by the cardiopexy. CASE
2
A different picture is presented by this 53-yearold woman who had recurrent anginal pain, but who had never had a real heart attack. Eventually she suffered a severe attack, went into shock and was dead on arrival at the hospital. A postmortem examination performed by Dr. Lucito G. Gamboa revealed the follov.ring: "Cardiovascular system: The epicardial surface is smooth and shiny. The valves are moder-
Diseases of
the Chest
ately dilated and contain fluid and clotted blood. The myocardium is firm and reddish brown and is completely free of recent or old infarcts. The endocardium is smooth and whitish . . . The main trunk and major branches of the left coronary artery are almost completely free of atherosclerotic changes and are patent. However, the main trunk of the right coronary artery shows severe atherosclerosis with extreme stenosis of the lumen. The lumen, which is pinpoint in size, is completely closed by thrombotic material. The thoracic aorta is free of atherosclerosis, but the lower portion of the abdominal aorta shows mild to moderate atheromatous deposits" (Dr. Lucito G. Gamboa). A contrast between these two cases is striking. The first suffered myocardial infarction and was subsequently treated by cardiopexy operation. A new blood supply was created for the heart. Although the atherosclerotic disease of the coronary was progressive and went on to complete obliteration of both vessels, the new blood supply was adequate and functioned for 11 Y2 years. The second case had no history of myocardial infarction, a good heart muscle and but one diseased coronary artery; yet, when that artery became occluded, there was no additional circulation to protect the heart muscle and the patient died. DISCUSSION AND CONCLUSIONS
The surgical procedure of cardiopexy has developed to the point where, in properly selected cases, the risk is very small. In our series at the Edgewater Hospital, 187 such operations have been perfonned in the last 15 years with a total surgical mortality of 3 per cent. In the last 10 years, 138 operations have been done with only two surgical deaths. When you consider the cases that present themselves to us for surgery, with severe coronary disease, multiple infarctions, severe coronary occlusions, the results are excellent. We should consider therefore the operation from the standpoint of its possible value rather than its risk. On the basis of two cases in which an adequate blood supply was maintained for 15 months and 1112 years, we cannot say that every patient will be so protected. However, of 187 patients operated on in these past 15 years, 143 are still alive. All of these had the same indications-previous myocardial infarcts and definite evidence of coronary insufficiency. It is not too un-
Volume 47, No.6 June 1965
CARDIOPEXY
warranted a conclusion that some degree of protection was afforded to most of these people although their coronary disease continued to progress. Therefore, we maintain that good medical management, i.e., weight control, low-fat, low-cholesterol diet, appropriate drugs and anti-coagulants where indicated, and a moderate exercise program supplemented by cardiopexy will give better results and protection in preventing ventricular fibrillation than medical management alone. Simple arithmetic creates an interesting conclusion. If we add the minimal risk of the operation to the demonstrated possibility that a newly created blood supply may remain functioning for years, the result is a reasonable chance of improvement for a reasonable period of time. There is hope, therefore, that the tragic end of the second case may be prevented in similar cases by surgical intervention before the major occlusion. ADDENDUM: Since this article was submitted for publication, we wish to report another case, a woman aged 48, who was operated on in 1958 for coronary insufficiency, and who died on January 26, 1965, from an overdose of barbiturates (Fig. 4 and 5). The importance of this case, as we11 as those preceding, following our method of doing the cardiopexy operation with an atomizer technique, is that we are able to vascularize the entire heart rather than the anterior part of the heart.
Our operation is usually done extrapleurally and \vith the atomizer distributing the magnesium silicate over the entire heart. We have shown complete revasculization with no surgical mortality in our last 100 cases, making this a safe and sound procedure in carefully screened and selected cases.
2
3
4
5 6 7
8
9
REFERENCES BECK, C. S. AND TICHY, V. L.: "Production of Collateral Circulation to the Heart: Experimental Study," Am. Heart I., 10:849, 1935. THOMPSON, S. A. AND PLACHTA, A.: "Experiences with Cardiopericardiopexy in the Treatment of Coronary Disease," lAMA, 152: 678, 1953. VINEBERG, A. M. AND JEWETT, B. L.: "Development of Anastomosis Between the Coronary Vessels and a Transplanted Internal Mammary Artery," Canad. Med Assoc. I., 56:609, 1947. MAZEL, M. S., BERNSTEIN, M. M., CALLEN, I. R., SCHNAER, I. L., Wu, L. T. AND BoNK, A.: "A Simple Operation for the Treatment of Chronic Coronary Artery Disease, Arch. Surg., 70: 309, 1955. MAZEL, M. S.: "Combined Medical and Surgical Management of Coronary Heart Disease," I. Am. Ceriat. Soc., 6:643, 1958. MAZEL, M. S.: "Evaluation of the Bilateral Internal Mammary Artery Ligation," Angiology, 9: 353, 1958. MAZEL, M. S.: "Optimum Therapy in Coronary Heart Disease; Combined Medical-Surgical Management," Illinois Med. I., 116:208, 1959. MAZEL, M. S. AND BoLTON, H. E.: "Cardiopexy versus Endarterectomy" in the Treatment of Ischemic Heart Disease, Angiology, 12: 335, 1961. MAZEL, M. S.: "Persistence of New Vascular Channels Following Cardioperi-cardiopexy," lAMA, 158:36, 1955.
For reprints, please write Dr. Mazel, 5700 North Ashland, Chicago.
Readers are invited to submit articles for Progress in Cardiovascular Surgery. Please submit material to David P. Boyd, M.D., 605 Common~'ealth Avenue. Boston. Massachusetts.
CONGENITAL HEART DISEASE Two families demonstrating hereditary transmissIon of congenital heart dIsease and upper-extremity deformities are described. Three other such families are compared. CardIac septal defects and thumb anomal1es are consIstently present. It Is noted that many Isolated cases of congenital heart disease are associated wIth upper-extremlty deformIties. prIma-
rily of the digits. Several cl1nlcal syndromes representative of rather generalized abnormal1ties. but Including congenital heart disease and characteristic upper-extremlty deformities. are reviewed. HOLMES, L. W. : · 'Congenital Heart Disease and Upperextremity Deformities," Nt", Engl. ]. Mtd., 272:437, 1965.
Persistence of New Vascular Channels Following Cardiopexy Necropsy Demonstration of Extracardiac Blood Supply 15 Months and 11 Y2 Years After Operation* M.
S.
MAZEL, M.D. AND ROGELIO RIERA, M.D.
Chicago, Illinois
T
surgically produced blood supply remained patent and functioning for 11 Y2 years.
HE CONCEPT OF CORRECTING MYOCAR-
dial ischemia caused by occlusion of coronary arteries was originally presented by Beck' in 1935. This was essentially a method of producing pericardial-myocardial adhesions in order that a new supply of blood could be brought to the myocardium from a source other than the coronary arteries. By means of further study and changes in technique, by Beck,' Thompson,' Vineberg,' Mazel and others,' the surgical procedure known as cardiopericardiopexy has been established. In this operation the myocardium and pericardium are scarified and a fibrinous adhesive pericarditis is induced by means of insufflation on an irritant, usually talcum powder (magnesium silicate or asbestos) over the entire surface of the myocardium into the pericardial sac. Blood vessels from this connective tissue anastomose with vessels in the myocardium and the inter-coronary vessels and furnish an additional blood supply to relieve the ischemia. However, many serious students of cardiac disease raised the question that there was no evidence that the newly produced blood supply did not become obliterated rapidly either by replacement of fibrous tissue or by advancing atherosclerosis. A partial answer was given when in one case these vessels were found patent 15 months after the operation' (Fig. I). In this case, the patient, after the above period of symptom free living, expired following the rupture of an aneurysm of the abdominal aorta. Another case is now presented of a patient who had a cardiopexy, in whom the
CASE REPORTS CASE I
A 47-year-old truck driver was admitted to the Edgewater Hospital during November, 1952. One year earlier, he had suffered multiple infarctions with coronary insufficiency relieved by rest and nitroglycerin. On admission, he had a positive Master two-step exercise test, abnormal electrocardiogram with markedly depressed ST segments and many unifocal ventricular systoles. There were slight systolic murmurs at the apex and base. Cardiopexy was performed on December 2, 1952. Afterward, he was free from pain and was able to continue work as a truck driver. On September 16, 1963, he was admitted to the Edgewater Hospital with partial return of angina and a pulsating mass in the left side of the abdomen. He had been forced to limit himself to non-strenuous activities, but was not completely idle. Physical examination at that time revealed a well-developed, well nourished man not acutely ill. His heart rate was 62 and his blood pressure 130/80. A slight systolic murmur was present at the apex with a roughening of the second aortic sound. An electrocardiogram showed evidence of left heart strain and first degree heart block. Laboratory studies and urinalysis were within normal limits. X-ray examination of the abdomen revealed a dilated abdominal aorta. The patient was managed medically and was discharged from the hospital on September 21, 1963 with the following diagnoses: arteriosclerotic heart disease old myocardial infarction first degree heart block exacerbation of coronary insufficiency rheumatic heart disease (mitral insufficiency) cardiopexy aneurysm of the abdominal aorta mild aortic stenosis The aneurysm of the abdominal aorta was removed and replaced by a graft at another hospital between September, 1963 and January, 1964.
*From Edgewater Hospital.
651
Oi..,..es of the Chest
MAZEL AND RIERA
FIOURE I: Microphotograph of epicardium showing persistence of newly formed capillaries in the gran ulation tissue after 15 months. Hand E stain, IOOX.
FIOURE 2: Microphotograph of epicardium showing magnesium silicate crystals, foreign body giant cells,
mononuclear leukocytes and
several small bloods vessels after 11 y, yean. Hand E stain, IOOX.
3: Microphotograph of external portion of myocardium showing severe foreign body reaction and several blood vessels lined by plump endothelial cells after 11 Y2 yean. H and E stain, IOOX.
FIOURE
Volume 47. No.6
June
1965
CARDIOPEXY
4-: Pericardial adhesions from anterior wall of heart showing many small blood vessels, foreign body giant cells containing magnesium silicate crystals and lymphocytes after seven years. H and E stain 90X. FIGURE
FIGURE 5: Pericardial adhesions from posterior wall or heart showing a few blood vessels, lymphocytes and foreign body giant cells after seven years.
MAZEL AND RIERA
l'he patient expire'd on January 28, 1964. Necropsy was performed by Dr. Grover L. Seitzinger, pathologist, in the patient's home town of Danville, Illinois, and the heart and aortic graft were sent to the Edgewater Hospital for further examination. Patholog)' Report: "The coronary arteries are completely obliterated by calcified atheromatous plaques. The right ventricular wall is 5 mm. thick and the myocardium is a homogeneous dark brown. The left ventricular wall varies from 10 mm. thick in the posterior and lateral wall to 15 mm. thick in the anterior wall. The myocardium of the lateral and posterior walls is mottled dusky red and reddish brown with areas of pearly gray fibrous tissue. The endocardium of the left ventricle is diffusely thickened except over the interventricular septum and there is a tigroid appearance of the endocardium of the posterior and lateral walls of the left ventricle . . . The parietal pericardium is adherent to the visceral pericardium . , . Microscopic . .. Sections of the heart sho\v the ep~cardium to be markedly thickened by a granulomatous reaction. There are numerous crystals present in the dense fibrous stroma which is infiltrated with Inononuclear cells and multinucleated giant cells. This granulomatous reaction extends into the myocardium of the left auricle and the lateral wall of the left ventricle" (Dr. Grover L. Seitzinger). Numerous small blood vessels and capillaries lined by pI u m pen dot h eli a I cells were seen throughout this tissue (Figs. 2 and 3). These demonstrated clearly that the vessels which developed as a result of the cardiopexy had remained patent for 11 Y2 years. Injection studies were performed on the blood vessels in the granulomatous tissue. This showed that the small blood vessels did in fact remain patent and communicated with branches of the coronary vessels. This is a case in which a patient lived and his heart functioned after both coronary arteries had been occluded. That this was no recent occurrence is demonstrated by the calcified atheromatous tissue which obstructed both arteries. Since the myocardium cannot function without a blood supply, an adequate volume must have been furnished from the channels created by the cardiopexy. CASE
2
A different picture is presented by this 53-yearold woman who had recurrent anginal pain, but who had never had a real heart attack. Eventually she suffered a severe attack, went into shock and was dead on arrival at the hospital. A postmortem examination performed by Dr. Lucito G. Gamboa revealed the follov.ring: "Cardiovascular system: The epicardial surface is smooth and shiny. The valves are moder-
Diseases of
the Chest
ately dilated and contain fluid and clotted blood. The myocardium is firm and reddish brown and is completely free of recent or old infarcts. The endocardium is smooth and whitish . . . The main trunk and major branches of the left coronary artery are almost completely free of atherosclerotic changes and are patent. However, the main trunk of the right coronary artery shows severe atherosclerosis with extreme stenosis of the lumen. The lumen, which is pinpoint in size, is completely closed by thrombotic material. The thoracic aorta is free of atherosclerosis, but the lower portion of the abdominal aorta shows mild to moderate atheromatous deposits" (Dr. Lucito G. Gamboa). A contrast between these two cases is striking. The first suffered myocardial infarction and was subsequently treated by cardiopexy operation. A new blood supply was created for the heart. Although the atherosclerotic disease of the coronary was progressive and went on to complete obliteration of both vessels, the new blood supply was adequate and functioned for 11 Y2 years. The second case had no history of myocardial infarction, a good heart muscle and but one diseased coronary artery; yet, when that artery became occluded, there was no additional circulation to protect the heart muscle and the patient died. DISCUSSION AND CONCLUSIONS
The surgical procedure of cardiopexy has developed to the point where, in properly selected cases, the risk is very small. In our series at the Edgewater Hospital, 187 such operations have been perfonned in the last 15 years with a total surgical mortality of 3 per cent. In the last 10 years, 138 operations have been done with only two surgical deaths. When you consider the cases that present themselves to us for surgery, with severe coronary disease, multiple infarctions, severe coronary occlusions, the results are excellent. We should consider therefore the operation from the standpoint of its possible value rather than its risk. On the basis of two cases in which an adequate blood supply was maintained for 15 months and 1112 years, we cannot say that every patient will be so protected. However, of 187 patients operated on in these past 15 years, 143 are still alive. All of these had the same indications-previous myocardial infarcts and definite evidence of coronary insufficiency. It is not too un-
Volume 47, No.6 June 1965
CARDIOPEXY
warranted a conclusion that some degree of protection was afforded to most of these people although their coronary disease continued to progress. Therefore, we maintain that good medical management, i.e., weight control, low-fat, low-cholesterol diet, appropriate drugs and anti-coagulants where indicated, and a moderate exercise program supplemented by cardiopexy will give better results and protection in preventing ventricular fibrillation than medical management alone. Simple arithmetic creates an interesting conclusion. If we add the minimal risk of the operation to the demonstrated possibility that a newly created blood supply may remain functioning for years, the result is a reasonable chance of improvement for a reasonable period of time. There is hope, therefore, that the tragic end of the second case may be prevented in similar cases by surgical intervention before the major occlusion. ADDENDUM: Since this article was submitted for publication, we wish to report another case, a woman aged 48, who was operated on in 1958 for coronary insufficiency, and who died on January 26, 1965, from an overdose of barbiturates (Fig. 4 and 5). The importance of this case, as we11 as those preceding, following our method of doing the cardiopexy operation with an atomizer technique, is that we are able to vascularize the entire heart rather than the anterior part of the heart.
Our operation is usually done extrapleurally and \vith the atomizer distributing the magnesium silicate over the entire heart. We have shown complete revasculization with no surgical mortality in our last 100 cases, making this a safe and sound procedure in carefully screened and selected cases.
2
3
4
5 6 7
8
9
REFERENCES BECK, C. S. AND TICHY, V. L.: "Production of Collateral Circulation to the Heart: Experimental Study," Am. Heart I., 10:849, 1935. THOMPSON, S. A. AND PLACHTA, A.: "Experiences with Cardiopericardiopexy in the Treatment of Coronary Disease," lAMA, 152: 678, 1953. VINEBERG, A. M. AND JEWETT, B. L.: "Development of Anastomosis Between the Coronary Vessels and a Transplanted Internal Mammary Artery," Canad. Med Assoc. I., 56:609, 1947. MAZEL, M. S., BERNSTEIN, M. M., CALLEN, I. R., SCHNAER, I. L., Wu, L. T. AND BoNK, A.: "A Simple Operation for the Treatment of Chronic Coronary Artery Disease, Arch. Surg., 70: 309, 1955. MAZEL, M. S.: "Combined Medical and Surgical Management of Coronary Heart Disease," I. Am. Ceriat. Soc., 6:643, 1958. MAZEL, M. S.: "Evaluation of the Bilateral Internal Mammary Artery Ligation," Angiology, 9: 353, 1958. MAZEL, M. S.: "Optimum Therapy in Coronary Heart Disease; Combined Medical-Surgical Management," Illinois Med. I., 116:208, 1959. MAZEL, M. S. AND BoLTON, H. E.: "Cardiopexy versus Endarterectomy" in the Treatment of Ischemic Heart Disease, Angiology, 12: 335, 1961. MAZEL, M. S.: "Persistence of New Vascular Channels Following Cardioperi-cardiopexy," lAMA, 158:36, 1955.
For reprints, please write Dr. Mazel, 5700 North Ashland, Chicago.
Readers are invited to submit articles for Progress in Cardiovascular Surgery. Please submit material to David P. Boyd, M.D., 605 Common~'ealth Avenue. Boston. Massachusetts.
CONGENITAL HEART DISEASE Two families demonstrating hereditary transmissIon of congenital heart dIsease and upper-extremity deformities are described. Three other such families are compared. CardIac septal defects and thumb anomal1es are consIstently present. It Is noted that many Isolated cases of congenital heart disease are associated wIth upper-extremlty deformIties. prIma-
rily of the digits. Several cl1nlcal syndromes representative of rather generalized abnormal1ties. but Including congenital heart disease and characteristic upper-extremlty deformities. are reviewed. HOLMES, L. W. : · 'Congenital Heart Disease and Upperextremity Deformities," Nt", Engl. ]. Mtd., 272:437, 1965.