J Thorac Cardiovasc Surg 2006;132:442
© 2006 The American Association for Thoracic Surgery
Internal thoracic artery grafts to right coronary system
Byalal Raghavender Rao Jaganath, DNB,
Sanjay Theodore, MCh,
Kottrethu Mammen Cherian, FRACS
Department of Cardiac Surgery, Frontier Lifeline Pvt. Ltd. Hospital, KM Cherian Heart Foundation, Chennai, India
To the Editor:
We read with interest the article by Sabik and coworkers,
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"Influence of Patient Characteristics and Arterial Grafts on Freedom From Coronary Reoperation." We congratulate the team of surgeons from The Cleveland Clinic for coming up with another landmark article that will be of immense benefit to both surgeons and patients around the world.
We agree with Sabik and coworkers
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that aggressive risk factor modifications and more extensive use of arterial grafts are necessary for reduction of reoperations. They identified a reduced early hazard phase when there was incomplete right coronary artery (RCA) revascularization. During their discussion, they presented no valid reason for this apparently anomalous finding and remarked "It is hard to understand how incomplete revascularization to the RCA and elevated triglyceride level both lowered the early risk of reoperations."
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We have had similar experience with patients with a diffusely diseased RCA either bifurcating or trifurcating into small-caliber vessels, with none suitable for grafting. In this situation, not grafting the RCA would not disturb the native collaterals and would probably result in better immediate postoperative results, as demonstrated by Sabik and coworkers.
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Endarterectomy in this situation would still result in incomplete revascularization, because the plaque cannot be removed completely from the small distal vessels, consistent with the poor early results seen with RCA revascularization.
In the later part of the study, internal thoracic artery grafting to RCA did reduce reoperation rates. Sabik and coworkers should specify what proportion of these patients in the early and later portions of the study had the posterior descending artery grafted, in contrast to distal RCA grafts. Posterior descending artery grafts show significantly better patency rates and are associated with lower postoperative morbidity.
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We have observed fewer postoperative coronary events when the posterior descending artery is grafted instead of the distal RCA. We believe that the benefit observed in the later part of the study may have been due to a trend toward posterior descending artery grafting.
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References
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- Sabik 3rd JF, Blackstone EH, Gillinov AM, Banbury MK, Smedira NG, Lytle BW. Influence of patient characteristics and arterial grafts on freedom from coronary reoperation. J Thorac Cardiovasc Surg 2006;131:90-98.[Abstract/Free Full Text]
- Sabik 3rd JF, Lytle BW, Blackstone EH, Houghtaling PL, Cosgrove DM. Comparison of saphenous vein and internal thoracic artery graft patency by coronary system. Ann Thorac Surg 2005;79:544-551.[Abstract/Free Full Text]
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