Direct myocardial revascularization: A ten year journey: Myths and realities

Abstract

Direct myocardial revascularization, mostly by saphenous vein graft and mammary-coronary artery anastomosis, is performed routinely in thousands of patients in most cardiovascular centers around the world. However, this procedure remains controversial among cardiologists and cardiovascular surgeons as they strive to determine its proper perspective in the overall treatment of coronary arteriosclerosis. A point of view on the indications for direct myocardial revascularization is presented in this lecture. To clarify the current criteria it is essential and timely to analyze (1) the problems related to the operation (operative mortality, perioperative myocardial infarction, early and late graft occlusion and changes in the coronary vessels; (2) the natural history of coronary arteriosclerosis, which requires a proper classification of ischemic myocardiopathy to compare current medical and surgical treatment; the classification followed in Buenos Aires and prospective studies in progress; (3) the proper utilization of diagnostic procedures, clinical history, exercise electrocardiography, echocardiography, radioisotopes and coronary cineangiography. Although all of these methods are needed in our armamentarium, coronary cineangiography is mandatory and irreplaceable. A tabulation to read the coronary cineangiogram in relation to the ischemic area is presented. Classification by single, double and triple vessel disease is not enough to select patients adequately. After performing direct myocardial revascularization for more than 10 years, I believe that the indication for bypass surgery has been clarified and that enough evidence exists to state that the use of this technique in properly selected patients enhances the quality of life and improves life expectancy.