Myocardial revascularization at the community hospital level

Abstract

Modern revascularization surgery was introduced by Sones's technique for selective coronary arteriography. 1 Whatever surgical efforts were expended before are of historical interest only, and it does little good to dwell on past failures; besides, the statute of limitations for an earlier era should have expired by now. The current era of revascularization surgery began in 1960 with mammary implantation, endarterectomy and patch-graft reconstruction, but things didn't really move until Favaloro popularized vein grafts in May 1967. 2 The simplicity of vein graft procedures and the obvious benefits that were immediately obtained stimulated interest even among individuals who had been militantly opposed to the concept of coronary artery surgery. At this writing, direct revascularization surgery is in high fashion. In the past 5 or 6 years a large and vocal group of surgeons and cardiologists have loaded the medical literature and crowded medical forums to express their views, both pro and con. Those who favor revascularization surgery point to the less than impressive results of medical treatment, the obituarial statistics of coronary atherosclerosis, the relatively low failure rate of modern surgery and the impressive rehabilitation that may be accomplished in the patient with coronary disease who has undergone surgery. The antagonists, usually die-hard cardiologists of the proverbial Old School, set up a succession of defense lines based on the theories that true revascularization is rarely accomplished, that myocardial metabolism is unaltered even if it is and that revascularization surgery, even if successful, will have little impact upon the longevity of the patient who is a victim of coronary atherosclerosis. It is of particular interest, and somewhat amusing, that the gladiators of both sides have found only one common point of agreement--revascularization surgery must not fall into the hands of every Tom, Dick, and Harry. This