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Ann Thorac Surg 2006;81:1255
© 2006 The Society of Thoracic Surgeons
Division of Cardiothoric Surgery, Washington University and Forest Park Hospital, 6125 Clayton Ave, Suite 430, St. Louis, MO 63139
(Email: hendrick.barner{at}forestparkhospital.com).
This report [1] provides extensive angiographic and intravascular ultrasound follow-up of patients having coronary ostial and left main (LM) angioplasty with a patch of the proximal right internal thoracic artery (ITA) and demonstrating excellent anatomic results at 7 to 79 months postoperatively.
Ostial stenosis represents fibro-calcific disease of the aortic wall, whereas LM disease is atherosclerotic. The prevalence of ostial stenosis was 2.7% of patients (8,509) having coronary artery bypass (CAB) and was isolated (no coronary disease) in 17% (38 of 228) [2]. Not all authors distinguish these two entities, but in the present report, 32 of 43 (74%) had ostial disease, and in Dion's series it was 24 of 49 (49%) [1].
Isolated ostial stenosis deserves ostialplasty in the minds of nearly everyone, but in recent years I have treated it with the left ITA to the proximal left anterior descending artery. If there is associated coronary disease, then ostialplasty (to avoid the potential for proximal coronary hypoperfusion) combined with CAB will allow access for subsequent percutaneous coronary intervention and is frequently appropriate. Calcification of the aortic wall at the ostium may preclude or compromise ostialplasty.
Patching of the LM is problematic and the experience is small as the authors emphasize. Despite their cautious approach, 1 of 5 patients with tubular LM stenosis required reoperative CAB for perioperatively undetected disease, which was subsequently identified as extending through the bifurcation. An initial experience in 23 patients with five technical failures was followed by 26 in which there were none, and which Dion attributes to the use of the anterior approach, better exposure with division of the pulmonary artery in 10 instances, and retrograde cardioplegia. Patients greater than 60 years of age, patients with heavy calcification of the LM, or patients with bifurcation disease are excluded, and the LM is carefully inspected to the bifurcation before incising it. These considerations favor conventional CAB for most LM disease with appropriate use of arterial conduits.
This report focuses on the patch for ostial/LM plasty. Either the saphenous vein or pericardium has been the usual choice with each having a 5% or less failure rate attributed to the patch (ie, intimal hyperplasia and atherosclerotic degeneration in the former and fibrosis or calcification in the latter) [3]. However, it is not clear that these proliferative or degenerative changes have resulted in failure, but rather that LM atherosclerosis has been the culprit. I have used both materials for the ostium, depending on ease of availability, and Dion believes either is fine for the ostium, but vein is necessary for the LM.
Using the right ITA is consonant with the proven performance of arterial conduits, but essentially prohibits future use of this conduit. The size of this patch is not overly generous and does not allow for a funnel-shaped ostium as favored by Dion. Assuming a 3.0-mm diameter would give a circumference (width) of 9.0 mm, and if 2.0 mm were included in each suture line, the patch would be 5.0 mm. The author's data reveal a late LM diameter of 5.6, 5.2, and 4.8 mm from proximal to distal, which is clearly adequate [1].
Other patch materials have been the bovine pericardium, synthetic material, radial artery and, most recently, the pulmonary artery. The latter is attractive because of its size, its durability as proven by the Ross operation, and its convenience if the anterior approach with pulmonary artery division is used [3].
Ostial stenosis patients are more frequently female (45%) than LM patients (12%) with more coronary disease in the latter, and 3% of the patients having none versus 17% in the former. Survival after CAB for those with ostial stenosis or LM stenosis is similar at 10 years [4].
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