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The Journal of Thoracic and Cardiovascular Surgery, Vol 84, 849-855, Copyright © 1982 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
WJ Keon, HA Heggtveit and J Leduc
We have demonstrated a phenomenon occurring during coronary artery bypass
grafting (CABG) which has not been previously described. Thirteen instances
of fatal perioperative myocardial infarction following CABG were associated
with intraoperative atheromatous embolization in the coronary
microcirculation. In five cases the emboli originated from ulcerative
atherosclerotic lesions in the aortic root at the site of the vein graft
ostia; in two cases they likely emanated from coronary endarterectomy
sites; and in two cases from mechanical disruption of plaques in the major
epicardial coronary arteries during the operation. These nine cases
occurred during initial revascularization procedures. We have performed
4,095 initial CABG procedures, and the nine cases represent a risk of
0.22%. A further four cases occurred during repeat CABG procedures and
resulted from manipulative disruption of atheroma in old vein grafts. Our
total number of repeat CABGs is 175, and the risk at reoperation is 2.29%;
this represents a tenfold increase in risk for this complication at
reoperation. Inadequate histologic sampling of the myocardium at autopsy
will necessarily result in underestimation of the incidence of this
phenomenon. Analysis of angiograms prior to repeat CABG can identify
patients at increased risk who have severe graft atherosclerosis as opposed
to myointimal hyperplasia. To reduce the incidence of atheroembolism at
reoperation, we advocate ligation of the vein graft at the level of the
distal anastomosis as early as possible during dissection on reopening the
chest.
ARTICLES
Perioperative myocardial infarction caused by atheroembolism
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