Evidence that revascularization by ventricular-internal mammary artery implants increases longevity. Twenty-four year, nine month follow-up.

Revascularization of the heart is a means of relieving symptoms of coronary artery disease--such as angina, fatigue, and dyspnea. The question of whether revascularization prolongs the life of the patient has been debated. My colleagues and I have reviewed our years of experience with patients treated by implantation of internal mammary arteries into the ventricles. We have compared our series with other groups of patients treated medically. Our conclusion is that revascularization via internal mammary artery implants does increase longevity.

Revascularization via healthy myocardial arteriolar networks compared with that through diseased surface coronary arteries.

Myocardial mammary artery implants revascularize via the undiseased coronary microcirculation. Such implants, followed for up to 20 years, showed no atherosclerosis, while the coronary arteries of the patients became totally occluded. Implant patency with collateralization was 80%; some patients were living entirely on blood supplied by mammary implants. Operative mortality was 2%. There was improvement in anginal pain in 85% of the cases and in left ventricular failure, in 67%. Studies of 43 patients with single implants, followed for up to 20 years, showed that 54% survived for an average of eight years and 46% have survived for an average of 12 years, and are still living. Double-ventricular implants in 42 patients with triple coronary artery disease showed that 90.5% survived for an average of five years, compared with 53% for medically treated patients. The technique of mammary implants is described and the procedure is compared to aortocoronary bypass grafts.

Revascularization of the entire heart by internal mammary artery implantation, epicardiectomy and free omental graft.

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author's experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were "bed-chair cripples" (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.

Direct revascularization of acute myocardial infarction by implantation of left internal mammary artery into infarcted left ventricular myocardium.

This is a preliminary report. Clearly, the internal mammary artery implanted into the infarcted anterolateral portion of the wall of the left ventricle has been of help in decreasing the size of the infarction and in maintaining the life of the dogs and normal function six hours after a large left ventricular wall myocardial infarction had been created. More animals need to be studied at the end of six hours, eight hours, and ten hours after implantation. More studies are needed to learn if ligation of the coronary veins at the same time as the arteries is beneficial or not. Two internal mammary arteries may act better than one when implanted side by side into a 5 by 5 centimeter infarction. In man, both internal mammary arteries and the right gastroepiploic artery could be used to revascularize acute myocardial infarctions in the posterior and anterolateral parts of the left ventricle.

The continuity of right and left ventricular myocardial sinusoidal spaces and its relation to right ventricular implants.

Evidence is presented which indicates that blood leaving side branches of an internal mammary artery implanted into the anterior wall of the right ventricle flows from the tunnel in which it lies through myocardial sinusoidal spaces of the anterior right ventricular wall across the midline to fill corresponding spaces in the anterior wall of the left ventricle and thence is carried to the left coronary sinus. The myocardial sinusoidal spaces of right and left ventricles have been well outlined, using injections of polyvinyl acetate and the technique of digestion casts. We have been able to show that there is no barrier between the myocardial sinusoids of the right circulation and those related to the anterior descending branch of the left coronary artery. In structure, these myocardial sinusoidal spaces are quite different from the intramyocardial coronary arteriolar zones which, in 93% of human hearts, are separated from one another without collateral communication.The continuity of the right and left ventricular myocardial sinusoids explains why implantation of a right internal mammary artery into the anterior wall of the right ventricle combined with a corresponding left implant, epicardiectomy and free omental graft, has been so effective in our hands in the treatment of far-advanced human coronary artery insufficiency.

Revascularization of both cardiac ventricles by right ventricular implants.

Implantation of the right internal mammary artery into the wall of the right ventricle has been performed in 48 patients whose cases have been followed up for longer than six months. The procedure was done at the same time as a left ventricular implantation or subsequent to this operation because of recurrence or persistence of symptoms. Relief of anginal pain has been achieved in 78% and of chronic left ventricular failure in 75%. Of the 40 patients who had already had one or more myocardial infarctions preoperatively, 36 are still alive, with an average survival of over 5 years.

Right internal mammary artery implantation into right ventricular myocardium for revascularization of the entire heart: experimental data and preliminary report.

The left internal mammary artery implant combined with epicardiectomy and free omental graft provides three extra-coronary sources of blood. This operation tested in dogs with 92% main-stem occlusion of three coronary arteries protected 75% of the animals. Applied clinically in over 100 patients, the operation resulted in 90% improvement. To obtain complete myocardial revascularization, the right internal mammary artery has been used as a fourth source of extra-coronary blood. In 57 animals, the right internal mammary arteries were implanted into the anterior walls of the right ventricle; in 80% this vessel formed anastomoses with the right coronary tree, and in 65% with the right and left coronary arteriolar systems. Six patients are described who underwent right internal mammary artery implantation; five of these in addition had the combined operation of left internal mammary artery implant, epicardiectomy and free omental graft. All patients had completely blocked right coronary arteries; in addition, five had advanced disease of the left coronary arterial tree.