Reversed left internal mammary artery grafting with retrograde flow to the left anterior descending coronary branch was used in five of 500 consecutive bypass operations. The indications were significant stenosis in the left subclavian artery (3 patients) or the proximal left internal mammary artery (1) and proximal damage to the left internal mammary artery during dissection from the thoracic wall (1). The postoperative clinical course was smooth in all five patients, with no evidence of myocardial ischemia. In follow-up averaging 14 months four patients were asymptomatic. The reversed internal mammary artery graft was visualized with digital subtraction angiography in four cases. Radionuclide imaging during exercise confirmed graft patency in all but the symptomatic patient, who was found to have an area of reversible ischemia anteriorly in the left ventricle.
One hundred consecutive patients were followed up for 6-36 months after coronary artery bypass surgery (CABS) for angina pectoris. Of the 98 survivors, 35 reported effort angina. Of the 63 angina-free patients, nine (14%), also had to interrupt ordinary activities such as walking upstairs/uphill, though now because of dyspnea. In exercise tests all nine denied chest pain, the limiting symptom being dyspnea. Chest radiograms were normal in these nine cases, and spirometry was largely unchanged from the preoperative findings (normal in 3 cases). Exercise tolerance was normal or near normal in six patients. The other three underwent pulmonary scintigraphy and cardiac catheterization at rest and during supine exercise. The scintigrams revealed no pulmonary emboli. Catheterization showed hypokinesis and raised pulmonary capillary wedge pressure during exercise in all three patients. The cause of the left myocardial failure was not established. Long-term evaluation of CABS should take into account both effort angina and effort dyspnea.
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