Palliative Coronary Artery Surgery in Patients With Severe Noncardiac Diseases

T treatment of patients with severe noncardiac diseases, who suffer from disabling angina refractory to medical therapy and are unsuitable for balloon angioplasty, is an uncommon but unsolved issue for cardiologists and cardiac surgeons. Due to poor systemic conditions and the severity of noncardiac pathology, whole body inflammatory reaction induced by extracorporeal circulation is badly tolerated in this subgroup of patients, and the risks of conventional surgical revascularization are too high to be justified in most of these cases. Coronary artery grafting without the use of extracorporeal circulation is an established surgical procedure for selected patients.1,2 To the best of our knowledge, it has never been used as a palliation in patients with severe systemic diseases. • • • Between January 1992 and October 1996, 8 patients (6 men and 2 women, mean age 69.2 years, range 67 to 76) with severe noncardiac diseases and medically refractory angina underwent surgical revascularization without extracorporeal circulation (Table I). In 6 cases, preoperative coronary angiograms revealed 3-vessel disease; in all patients only the vessels considered to be responsible for the symptoms were treated (the left anterior descending artery in 3 cases, the circumflex artery in 2 cases, the left anterior descending and a marginal branch in 2 cases, and the right coronary artery and a marginal branch in 1 patient). Identification of the culprit lesion was based on stress tests (when available), ischemic electrocardiographic modifications, coronary anatomy, and segmental ventricular contraction. Myocardial revascularization was performed, without the use of extracorporeal circulation, through a median sternotomy in 5 cases or a small left anterior (minimally invasive) thoracotomy in the remaining 3 cases. The small thoracotomy was used to revascularize the left anterior descending artery alone, whereas the median sternotomy was used in all other cases. The postoperative course was uncomplicated in all patients. Two patients with respiratory failure were removed from ventilatory support after 2 days. At a mean follow-up of 34 months, no patient complained of cardiac symptoms after surgery and complete relief from angina was achieved in all cases; 5 of the 8 patients died from their noncardiac pathology. After surgery the patients with cancer were able to undergo palliative chemotherapy (these patients were contraindicated before revascularization due to the severity of their cardiologic status). • • • Due to low surgical mortality and morbidity, palliative myocardial revascularization can be offered to patients with severe noncardiac diseases, who are affected by disabling angina refractory to medical therapy and unsuitable for angioplasty. In this subgroup of patients, the poor long-term prognosis related to noncardiac disease minimizes the importance usually assigned to the completeness of the revascularization. If conversion to median sternotomy during minimally invasive revascularization is necessary, it is still possible to avoid the cardiopulmonary bypass procedure by performing a beating heart revascularization.