Surgical Treatment of 200 Consecutive Patients with Left Main Coronary Artery Disease

Surgical Treatment of 200 Consecutive Patients with Left Main Coronary Artery Disease Diane L. Jeffery, M.D., R. Vijayanagar, M.D., Diego A. Bognolo, M.D., Paul F. Eckstein, M.D., Edward Spoto, Jr., M.D., P. Natarajan, M.D., Edgar H. Willard, 111, M.D., and Richard G. Connar, M.D. ABSTRACT Two hundred consecutive patients underwent myocardial revascularization for left main coronary artery disease between January, 1975, and December, 1981. The mean age of this group was 64 ? 8 years, and 78.5% of the patients were men. The anginal pattern was chronic stable in 6% of the patients and progressive or unstable in the remainder. Resting electrocardiograms showed prior myocardial infarction in 45.5%. Left ventricular enddiastolic pressure was elevated in 145 patients, and ejection fraction was less than 50% in 40 patients. The mean number of bypass grafts per patient was 3.2 2 1.4 (standard deviation). Seventeen patients underwent major concomitant cardiovascular procedures. The operative mortality was 3.5%, and the incidence of perioperative infarction was 3%.Factors associated with reduced operative survival were increased age; unstable angina, or acute myocardial infarction, or both; female sex; circumflex-dominant circulation; and major concomitant procedures. Late mortality at a mean follow-up of 33.5 months was 6%, and 91% of the surviving patients assessed their quality of life as "excellent" or "good."

Coronary obstructive disease involving the left main coronary artery (LMCA) carries a high mortality rate with medical therapy. Coronary artery bypass grafting (CABG) is generally accepted as the treatment of choice in patients with this disease. We have reviewed the records of 200 consecutive patients treated surgically for left main coronary stenoses, and the data obtained form the basis of this report.

From the Tampa Heart Center, Tampa General Hospital, and the Department of Surgery, University of South Florida College of Medicine, Tampa, FL. Presented at the Twenty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Hilton Head Island, SC, Nov 4-6, 1982. Address reprint requests to Dr. Jeffery, One Davis Blvd, Suite 502, Tampa, FL 33606.

193

Patients and Methods Two hundred consecutive patients with severe LMCA disease underwent myocardial revascularization between January, 1975, and December, 1981. The degree of LMCA stenosis was graded angiographically as 50% or greater but less than 70% of luminal diameter in 37 patients, and as greater than 70% in 163. Forty-six stenoses were ostial. The 200 patients in this series represented approximately 15% of the total number of patients undergoing myocardial revascularization during the study period. Patients with LMCA lesions who underwent major cardiovascular procedures in addition to CABG were not excluded from the series. The study population consisted of 157 men and 43 women with a mean age of 64 k 8 (standard deviation [SD]) years (range, 36 to 85 years). All patients were symptomatic. The anginal pattern was chronic stable in 12 patients (6%), progressive in 80 (40%), and unstable in 108 (54%). Preoperative electrocardiographic findings are given in Table 1. Resting electrocardiograms were normal in only 29 patients (14.5%), and 91 patients had evidence of prior transmural myocardial infarction. Stress testing was performed in 80 patients and was positive in all, with an ST depression of less than 2 mm in 66 (82.5%). Coronary anatomy and left ventricular function were documented by cardiac catheterization in all patients. Most patients had multiple severe (50% or greater) coronary stenoses in addition to LMCA disease (Table 2). The right coronary system was dominant in 193 of the 200 patients. One hundred seventy-nine of these (93%) had marked stenoses of the right coronary artery (RCA); 84 of the 179 (47%)had RCA occlusion. Thirty-five patients with dominant RCA occlusion documented by angiography did not have electrocardiographic evidence of inferior wall myocardial infarction. Left ventricu-

194 The Annals of Thoracic Surgery

Vol 36 No 2 August 1983

Table 1. Preoperative Electrocardiographic and Stress Test Data

Table 2 . Distribution of Coronary Stenoses in 200 Patients Operated on for Left Main Coronay Arte y Diseasea

No. of

Patients

Result ECG (N =

Percent

200)

Normal

29 48 19 18

14.5 24.0 9.5 9.0

Ischemic changes and old MI Ischemic changes and conduction

37

18.5

14

7.0

Old MI and conduc-

15

7.5

Ischemic changes, old MI, and conduction abnormality

20

10.0

80 66

100.0 82.5

Ischemic changes Old MI Conduction abnormality

abnormality

tion abnormality

STRESS TEST (N =

80)

Positive Positive with 3 2 mm ST depression in early stages

No. of

Location

Pa tien ts

LMCA only LMCA LAD LMCA + LCx LAD + LCx LMCA LMCA + RCA LMCA + LAD RCA LCx + RCA LMCA LMCA LAD + LCx + RCA Total

+ +

+ +

+

Percent

3 4 2 12 9 22 15 133

1.5 2.0 1.0 6.0 4.5 11.0 7.5 66.5

200

100.0

"Coronary stenoses are defined as those producing narrowing of luminal diameter of 50% or greater. LMCA = left main coronary artery; LAD = left anterior descending coronary artery (including major diagonal branches); LCx = left circumflex coronary artery (including obtuse marginal branches); RCA = right coronary artery (including posterior descending and posterolateral branches).

dial protection. Left ventricular venting has not been employed routinely. The mean number of bypass grafts per patient lar end-diastolic pressure (LVEDP) was normal was 3.2 k 1.4. Single-vessel bypass grafting (12 mm Hg or less) in 55 patients and elevated in was performed in 2 patients (1%); double-vessel the remainder. Abnormal LVEDP values ranged CABG, in 30 patients (15%);triple-vessel CABG, from 13 to 44 mm Hg, with a mean of 22.5 & in 105 (52.5%); quadruple-vessel CABG, in 60 6.7 mm Hg. Left ventricular ejection fraction (30%);and quintuple-vessel CABG, in 3 (1.5%). (LVEF) was normal in 160 patients and low (less The left internal mammary artery was used to than 50%) in the rest. The LVEF values in the bypass the left anterior descending (LAD) corosubgroup of patients with elevated LVEDP nary artery in 96 patients (48%),a single sapheranged from 20 to 89% (mean, 60 2 15%). nous vein graft was placed to the LAD coronary Twelve patients had severe valvular lesions in artery in 68 patients, and a sequential vein graft addition to LMCA disease, 1patient had a small in 33. The LAD coronary artery could not be left ventricular aneurysm, and another had a bypassed in the remaining 3 patients. Five pasecundum-type atrial septa1 defect. Three pa- tients had mammary grafts to diagonal or martients had undergone previous myocardial re- ginal vessels, and Gore-Tex grafts were placed vascularization procedures (2 direct, 1 indirect) to the RCA system in 2 patients. No endarterectomies were performed. at other institutions. Seventeen patients required one or more maAll patients were operated on using cardiopulmonary bypass and moderate systemic jor concomitant procedures, which are listed in hypothermia (26" to 28°C). Before 1976 intermit- Table 3. Intraaortic balloon counterpulsation tent aortic occlusion with reperfusion between was used preoperatively in 4 patients because cross-clamping periods was the usual tech- of medically refractory angina and precarious nique. Since 1976 we have exclusively utilized anatomy, and intraoperatively in 5 patients to cold hyperkalemic cardioplegic arrest combined aid in weaning them from cardiopulmonary with topical hypothermia for improved myocar- bypass. ECG

=

electrocardiogram; MI

=

myocardial infarction.

195 Jeffery et al: Surgical Treatment of LMCA Disease

Table 3 . Major Concomitant Procedures in 17 of 200 Patients Undergoing Coronary Bypass for Left Main Coronary Artery Disease Concomitant Procedure(s)

No. of Patients

~~

Aortic valve replacement Aortic valve replacement and mitral commissurotomy Aortic valve replacement and carotid endarterectomy Mitral valve replacement Mitral commissurotomy Carotid endarterectomy Closure of secundum atrial septa1 defect Plication of left ventricular aneurysm Femorofemoral bypass

6 1

2

1

1

Results Five patients died in the hospital and 2 died at home within 30 days of operation, yielding an early mortality of 3.5%. Causes of death were perioperative infarction in 3 patients, low cardiac output and upper gastrointestinal bleeding in 1 patient, ventricular fibrillation in 1, massive pulmonary embolus in 1, and acute hemorrhagic pancreatitis in 1 (Table 4). In 60 of the 195 hospital survivors, there were 70 instances of complications. Major complications included perforated duodenal ulcer; ventricular fibrillation; low cardiac output requiring intraaortic balloon counterpulsation, or inotropic agents, or both; cerebrovascular accident with residual neurological deficit; and sternal infection. Ten of the 195 (5.1%) had major complications (Table 5). Fifty patients (26%) had one or more

Table 4. Details of Early Deaths among 200 Patients Treated Surgically for Left Main Coronary Artery Disease Patient Age (yr), Sex

Time of Death

Clinical Cause of Death

Triple CABG; AVR; insertion of IABP through transverse arch Triple CABG

POD 2

Low cardiac output; pneumonia

Massive infarction with all grafts open; prosthetic valve intact; acute pneumonia

POD 2

No postmortem examination

64, M

Triple CABG; MVR

POD 8

Low cardiac output; upper GI bleeding Ventricular fibrilla tion

78, M

Single CABG; AVR

POD 13

Sudden death at home

74, F

Triple CABG

POD 15

61, F

Quadruple CABG; open mitral commissurotomy Double CABG

POD 16

Global infarction by ECG on POD 12; recurrent arrhythmias Sudden death at home

Massive pulmonary embolus; all grafts patent

Multisystem failure (renal, hepatic, pulmonary; sepsis)

Acute hemorrhagic pancreatitis; extensive old anterior wall MI; no new MI; both grafts patent

76, M

69, M

82, M

Operation( s)

POD 17

Postmortem Findings

Old anterior wall MI with recent extension; cardiomegaly; all grafts patent; mitral prosthesis intact Acute lateral wall MI; LAD graft intact; prosthetic valve intact Acute thrombosis of LAD and RCA; concentric LV infarction; all vein grafts patent

CABG = coronary artery bypass grafting; AVR = aortic valve replacement; IABP = intraaortic balloon pump; MVR = mitral valve replacement; POD = postoperative day; MI = myocardial infarction; LAD = left anterior descending coronary artery; LV = left ventricular.

196 The Annals of Thoracic Surgery Vol 36 No 2 August 1983

Table 5. Complications in Hospital Survivors (N = 195) No. of

Type of Complication

Patients

Major complications Low cardiac output Ventricular fibrillation CVA with incomplete resolution Perforated duodenal ulcer Sternal infection Minor complications Postoperative hemorrhage Perioperative infarction

4 2 1 1 2

TIA or mild CVA with resolution Atrial fibrillation or flutter Premature ventricular contractions

Respiratory insufficiency Transient renal failure Transient psychosis Superficial infection (leg wound) CVA = cerebrovascular accident; TIA attack.

=

7 3 3 12 18 5 1 5 6

transient ischemic

minor complications, including postoperative hemorrhage, perioperative infarction without clinical manifestations, transient ischemic attacks or mild cerebrovascular accident with complete resolution, atrial fibrillation or flutter, premature ventricular contractions, respiratory insufficiency requiring ventilatory support for more than 24 hours, transient renal failure, transient psychosis, and superficial leg wound infection (see Table 5). The mean postoperative hospital stay was 11 k 3 days. Follow-up information on the 193 survivors was obtained from office and hospital records and by telephone interview. Twelve late deaths occurred 34 days to 7 years following operation. Five of these were definitely cardiac related. Three patients died suddenly at home, and postmortem examination was not performed. The other 4 deaths were known to have noncardiac causes (Table 6). Complete follow-up of the 181 patients still surviving has ranged from 13 to 97 months (mean, 33.5 months). The patients were asked to assess their quality of life as ”excellent,” ”good,” “fair,” or ”poor,” and each patient was questioned specifically to determine the presence or absence of anginal symptoms. Seventy-

eight patients rated their overall quality of life as ”excellent” (43%), 87 as “good’ (48%), 15 as ”fair” (8%), and 1 as “poor.” Three patients in the “good’ category have occasional exertional angina. Of the 15 patients in the “fair” category, 5 relate at least part of their problems to angina, which occurs at rest in 1 patient and with moderate to severe exertion in the other 4. The 1 patient in the ”poor” category is 42 years old and his exertional angina has never been relieved. He has inoperable diffuse distal disease documented by repeat cardiac catheterization, and also suffers from severe peripheral vascular disease and chronic obstructive pulmonary disease. The most common problems contributing to a less than excellent quality of life in our patients were arthritis, cerebral vascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, obesity, and complications of diabetes mellitus. Twenty of 41 survivors who are 60 years of age or younger are currently employed (49%), as are 6 of the 140 survivors who are now older than 60 years of age. Most of the patients who assessed their quality of life as ”excellent” or “good’ are enjoying active retirement.

Comment Rationale for Surgical Therapy The dismal outcome of medical therapy for LMCA has been well documented in the literature. In a prospective study of 141 nonsurgical patients at the Cleveland Clinic, Lim and colleagues [l] found a 5-year mortality of 51% in patients with documented LMCA stenoses (50% or greater). Bruschke and associates [ 2 ]reported only 46% of patients alive at 6-year follow-up after documentation of LMCA disease, and in the series described by Cohen’s group 131, 50% of medically treated patients died within an average follow-up period of 25 months. In a retrospective study by Talano and co-workers [4] the mortality in 145 patients was 48% at 24 months, and the report of Takaro and associates [5] on the Veterans Administration Cooperative Study showed a 35% mortality at 30 months for patients who did not receive surgical treatment. In marked contrast are reports of surgical series from multiple centers that clearly demonstrate the superiority of surgical therapy for

197 Jeffery et al: Surgical Treatment of LMCA Disease

Table 6 . Late Deaths following Operation for Left Main Coronary Artery Disease Patient Age (yr), Sex" 75, M 67, M 64,M 57, M 54, M 54, M 76, M 58, F

44, M 64,M 70, M

48, F

Time of Death

Clinical Cause of Death

Other Relevant Information

Quadruple CABG Quadruple CABG Quadruple CABG Quad ru p 1e CABG Triple CABG Triple CABG Quadruple CABG Double CABG

34 days

Sudden death at home

...

2 mo

Massive CVA

3 mo

Renal, hepatic, and pulmonary failure CHF due to ASHD

Had known carotid and vertebral disease Had had no angina

Triple CABG Triple CABG Triple CABG

5 Y'

6 Y'

Disseminated intravascular coagulation following reoperation for MVR, tricuspid annuloplasty, and CABG to PDA

Double bypass

7 Yr

Sudden death at home

Operation(s)

5 mo

Had had no angina

12 mo

Unresectable lung carcinoma Massive MI, died in CCU

21 mo

Cor pulmonale

..

30 mo

CHF due to mitral regurgitation

5 Yr

Acute hemorrhagic pancreatitis Sudden death at home

Had known 2+ mitral regurgitation at time of CABG; valve not repaired Had had two negative stress tests postoperatively Had had no angina

12 mo

Had had previous double Vineberg procedure

Postmortem examination showed old massive MI at posterior wall and anterior papillary muscle, old LAD and diagonal sequential graft patent, old RCA graft occluded, new PDA graft patent, mitral prosthesis and tricuspid repair intact. Cause of death: intraabdominal hemorrhage from multiple sites due to disseminated intravascular coagulation Had had no angina; both grafts patent at elective restudy 7 mo postoperatively

"Ages given are at time of death. CABG = coronary artery bypass grafting; CVA = cerebrovascular accident; CHF = congestive heart failure; ASHD = atherosclerotic heart disease; MI = myocardial infarction; CCU = coronary care unit; PDA = posterior descending artery; LAD = left anterior descending coronary artery; RCA = right coronary artery.

LMCA disease. Zeft a n d colleagues [6] in 1974 reported a 96% 2-year survival, a n d in 1975 Cohen a n d Gorlin [7] reported 90% survival at 42 months. Four prospective studies [4, 5, 8, 91 published between 1975 and 1978 demonstrated statistically significant improvement in survival for patients with LMCA disease treated surgically compared with that for patients w h o had medical treatment. Farinha and co-workers [ 101 in 1978 reported an 86% survival a t 474 years,

with 75% of survivors free of angina. These statistics are similar to those reported by Loop a n d associates [ l l ] t h e following year. In the report of Lawrie's group [12], 134 patients were followed for 5 years o r longer. Late attrition after operation in this series w a s almost normal for patients with good left ventricular function. The report of Killen a n d colleagues [13] in 1980 was similarly impressive in documenting that the 5year actuarial survival for 271 patients operated

198 The Annals of Thoracic Surgery Vol 36 No 2 August 1983

on for LMCA disease was the same as the expected survival for a general population with the same age and sex distribution. Results of two large collaborative studies reported recently by Chaitman and co-workers [14] and Takaro and associates [15] have shown highly significant improvement in patients treated surgically compared with those treated medically for LMCA disease.

Anatomical Considerations The incidence of severe LMCA obstructive disease has been reported to be in the range of 4 to 8% of all major coronary arterial stenoses documented by angiography [9, 14, 15, 161. The incidences of LMCA disease in surgical series reported by Zeft [6], Loop [ll],Bedard [MI, and their associates were 5.4%, 5.6%, and 8.1%, respectively. In our series the incidence was substantially higher at 15.5% (200/1,292). The reason for this discrepancy is not obvious but might possibly be because the average age of our patients was 10 to 14 years higher than that in the three series just cited. The incidence of ostial stenoses in our series was 46 in 200 patients (23%), and ostial stenoses were more prevalent in women. Eighteen of 43 women had ostial stenoses (42%), compared with 28 of 157 men (18%).These figures are in accordance with those of Loop and colleagues [ll], who reported ostial stenoses in 40% of the women and 17% of the men in their series. We found no correlation between patient age and the presence of ostial stenoses. The incidence of isolated LMCA stenosis in surgical series has been reported by other investigators to be between 3.4 and 13%[ll, 19-21]. In our series only 3 patients (1.5%)had obstructive disease involving solely the LMCA. The ages of these patients were 52 years, 70 years, and 73 years; 2 were men. Our data are consistent with others in that most patients had multiple severe coronary artery stenoses in addition to LMCA disease. DeMots and associates [19] reported coexisting disease in two or three vessels in 79.3% of patients, and Lawrie and colleagues [12] found a similar (81%)incidence of multivessel disease. In our series 24.5% of patients had severe stenoses in two vessels and 66.5% had stenoses in three vessels in addition

to the LMCA, yielding a 91% incidence of multiple vessel involvement. The incidence of associated RCA stenoses in patients with LMCA disease has been variable in previously published surgical series. Zeft [6], Loop [ll],and their co-workers found severe RCA stenoses in 66% of the patients in each series. Lawrie’s group [12] reported a 75% incidence of severe associated RCA disease. The data of Anderson and colleagues [22], showing an incidence of 93%, agreed exactly with our findings. The importance of associated RCA stenoses in terms of surgical outcome has been debated. Talano and associates [4] suggested that the risk of operation for LMCA disease is higher in patients without associated RCA disease because of decreased collateralization. Cohn and coworkers [23]reported that in their experience an additional RCA lesion increased the operative risk, while Brandt and colleagues [24] reported no correlation between surgical mortality and RCA stenoses. Results of multiple series [3, 5, 6, 9, 161 suggested that occlusion of the RCA increased the mortality of surgery for LMCA disease. Recently, however, Rittenhouse and colleagues [25] described a series of 60 patients with 70% or greater left main stenoses and RCA occlusion, who were surgically treated with a hospital mortality of only 4.3%. It is difficult to draw any meaningful conclusions regarding the effect of associated RCA disease from our series since the overall incidence of this entity was so high. Seven patients (3.5%) were circumflex dominant. Of the 193 rightdominant patients, 179 (93%) had severe RCA disease, including 84 (42%) with occlusion of the RCA. Among the 7 patients who died early, 3 had high-grade (80 to 99%)RCA lesions, 2 had RCA occlusion, and 2 were circumflex dominant. These data support the observation of Chaitman and associates [14] and of Takaro and colleagues [5] that coronary dominance is an important factor in determining surgical mortality in LMCA disease. In the series of Chaitman’s group [14], the operative mortality for circumflex-dominant patients was lo%, compared with 4.2% for the entire series; in the report of Takaro and colleagues [5], the mortality was 14% for circumflex-dominant patients compared

199 Jeffery et al: Surgical Treatment of LMCA Disease

angina on maximum medical therapy, including intravenous nitroglycerin and intraaortic balloon counterpulsation in Patient 2 (balloon counterpulsation could not be used in Patient 1 because of severe peripheral vascular disease). Our data are in agreement with the reports of Brandt and co-workers [24] and Killen and asOperative Results and Mortality The reported operative mortality for patients sociates [13] in that we found no significant corundergoing myocardial revascularization for relation between LVEF and operative survival. LMCA disease has ranged from 1.5 to 13% in The mean LVEF ( ? SD) for patients who died various series [4-6, 11-15, 18, 20, 21, 23-27] re- intraoperatively and for survivors was 55 ? 8% ported during the past 8 years, with a general and 62 ? 15%, respectively. Left ventricular trend toward improved operative survival in re- end diastolic pressure for the same groups was cent years. The mortality of 3.5% in the present 24 ? 8 mm Hg and 19 k 2 mm Hg, respectively, report compares quite favorably with the figures and this difference also failed to reach statistical of other groups, especially considering that we significance. Overall, our data suggest that operative risk did not "purify" our series by excluding patients who had cardiovascular disease in addi- in myocardial revascularization for LMCA distion to LMCA obstructive disease. If the 17 ease is augmented by increased age; unstable patients who underwent major concomitant car- angina, or acute myocardial infarction, or both; diovascular procedures are excluded from con- female sex; circumflex-dominant circulation; sideration, the operative mortality is reduced to and major concomitant procedures. Our rate of perioperative infarction (demon3 of 183 patients, or 1.6%. Also, the mean age of our patient population (64 8 years) exceeded strated by the presence of new Q waves on that given in most other similar reports by ap- ECG) of 6 out of 200 (3%) was quite low comproximately 8 years [6, 9, 11-13, 18, 20, 22, 25, pared with other series [ll, 12, 22, 26, 281 that reported perioperative infarction rates in the 261. The breakdown of operative mortality in our range of 4.8 to 15%.Three of our 6 perioperative series according to sex was 4.7% for women and infarcts were fatal; the other 3 were not hemo3.2% for men. This discrepancy was less pro- dynamically important by clinical assessment. nounced than that in the series of Loop and Late deaths occurred in 12 patients, and were colleagues [ll]or Chaitman and associates [14] definitely cardiac related in 5, possibly cardiac who found the mortality for men compared related in 3, and of noncardiac causes in 4. All of with that for women to be 3.5% versus 7.5% and the patients who died late had undergone my4% versus 8%, respectively. ocardial revascularization only, and were younThe mean age of the 7 patients in the present ger (mean age, 57 years) than the patients who series who died during operation was 72 t 8 died within 30 days of operation. Mean LVEF years, compared with 64 ? 8 years for the sur- ( ? SD) of the 12 patients dying late and the 181 vivors. This difference was statistically sig- survivors was 56 k 14% and 62 ? 15%, respecnificant ( p < 0.02). All of the operative deaths tively. Mean LVEDP was also very similar at 17 occurred in patients with LMCA stenoses k 6 mm Hg and 19 k 8 mm Hg, respectively. greater than 70%. As indicated in Table 4, 4 of Neither the difference between mean LVEF these 7 patients underwent concomitant valve values nor that between mean LVEDP values replacement or commissurotomy. Patient 2 had was statistically significant. sustained a recent anteroseptal myocardial inThe incidence of persistent or recurrent anfarction with persistent medically refractory an- gina in this series was 5% (9/181). This is relagina. She also had a severe myeloproliferative tively low but was calculated at a mean followdisorder with a platelet count in excess of 1 mil- up of 33.5 months. Five- to ten-year data in this lion at the time of death. Patients l and 2 had regard will be of greater interest. acute subendocardial infarcts with persistent The assessment of quality of life as "excel-

with 6.5% overall. Our series was even more striking in this regard, with 2 of 7 (29%) circumflex-dominant patients dying within 30 days of operation, in contrast to an overall mortality of 3.5%.

*

200 The Annals of Thoracic Surgery Vol 36 No 2 August 1983

lent” or “good’ by 91% of surviving patients is gratifying, as is the 49%employment rate in patients 60 years of age or younger.

expeditious surgical technique, these patients will enjoy not only increased longevity but also marked improvement in quality of life.

Recommendations for Optimizing Early Surgical Results

References 1. Lim JS, Proudfit WL, Sones FM Jr: Left main coro-

nary arterial obstruction: long-term follow-up of Based on our experience with the 200 patients 141 nonsurgical cases. Am J Cardiol36:131, 1975 reported here, we believe that several factors 2. Bruschke AVG, Proudfit WL, Sones FM Jr: Progcan be identified that promote favorable surgical ress study of 590 consecutive nonsurgical cases of results in patients with LMCA disease. Aggrescoronary disease followed 5-9 years: I. Arteriosive medical management, including continued graphic correlations. Circulation 471147, 1973 3. Cohen MV, Cohn PF, Herman MV, Gorlin R: P-blockade up until the time of operation in all Diagnosis and prognosis of main left coronary patients and administration of intravenous niartery obstruction. Circulation 45:Suppl 1:57, troglycerin in those with unstable angina, has 1972 been extremely important. Patients with un4. Talano JV, Scanion PF, Meadows WR, et al: Instable angina require close hemodynamic monifluence of surgery on survival in 145 patients toring for control of heart rate and blood preswith left main coronary artery disease. Circulation 51:Suppl 1:105, 1975 sure, but we do not think that routine use of a 5. Takaro T, Hultgren HN, Lipton MJ, et al: The VA Swan-Ganz catheter is necessary or desirable. cooperative randomized study of surgery for We do use this monitoring device selectively in coronary arterial occlusive disease: 11. Subgroup patients with severe left ventricular dysfunction with significant left main lesions. Circulation (LVEF less than 30%). Similarly, although sev54:Suppl 3:107, 1976 6. Zeft HJ, Manley JC, Huston JH, et al: Left main eral groups [16,17,28,29] have emphasized the coronary artery stenosis: results of coronary byneed for routine use of the intraaortic balloon pass surgery. Circulation 49:68, 1974 pump prior to induction of anesthesia in pa7. Cohen MV, Gorlin R: Main left coronary artery tients with LMCA disease, our data and experidisease: clinical experience from 1964-1974. Cirence [30, 311 as well as those of others [18, 22, culation 52:275, 1975 251 do not support this concept. Many serious 8. Sung R, Mallon S, Richter S, et al: Left main coronary artery obstruction: follow-up of thirty paand some fatal complications have been associtients with and without surgery. Circulation ated with intraaortic balloon counterpulsation 51:Suppl 1:112, 1975 [32-351, and we therefore employ it preopera9. Alford WC Jr, Page HL Jr, Burrus GR, et al: Furtively only in patients in whom angina cannot ther evaluation of the surgical treatment of obbe controlled by medical therapy while an operstructive disease of the left main coronary artery. Ann Surg 187:658, 1978 ating room is being prepared. Critical factors that minimize our need for preoperative balloon 10. Farinha JB, Kaplan MA, Harris CN, et al: Disease of the left main coronary artery: surgical treatcounterpulsation are expert induction of anesment and long-term follow-up in 267 patients. thesia with meticulous control of heart rate and Am J Cardiol42:124, 1978 blood pressure, and rapid establishment of 11. Loop FD, Lytle BW, Cosgrove DM, et al: Atherocardiopulmonary bypass. Careful attention to sclerosis of the left main coronary artery: 5 year results of surgical treatment. Am J Cardiol44:195, myocardial preservation techniques and rapid, 1979 precise, and complete revascularization are 12. Lawrie GM, Morris GC Jr, Howell JF, et al: Imlikewise important. proved survival beyond 5 years after coronary byIn conclusion, we have demonstrated that pass surgery in patients with left main coronary success in the management of LMCA disease artery disease. Am J Cardiol44:612, 1979 can be achieved with surgical treatment in a 13. Killen DA, Reed WA, Kindred I, et al: Surgical therapy for left main artery disease. J Thorac Carnonselected elderly patient population in whom diovasc Surg 80:255, 1980 the incidence of unstable angina and associated 14. Chaitman BR, Rogers WS, Davis K, et al: Operacardiovascular disease is relatively high. With tive risk factors in patients with left main coroaggressive preoperative medical management, nary artery disease. N Engl J Med 303:953, 1980 well-monitored anesthesia, and accurate and 15. Takaro T, Peduzzi P, Detre KM, et al: Survival in

201 Jeffery et al: Surgical Treatment of LMCA Disease

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26.

27.

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32. 33. 34. 35.

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