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(Circulation. 2001;103:483.)
© 2001 American Heart Association, Inc.

Editorial

Use of the Internal Mammary Artery Graft and In-Hospital Mortality and Other Adverse Outcomes Associated With Coronary Artery Bypass Surgery

Lawrence H. Cohn, MD

From the Department of Surgery, Harvard Medical School, and the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass.

Correspondence to Lawrence H. Cohn, MD, Chief, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail lcohn@partners.org

Key Words: Editorials • bypass • coronary disease

The use of the left internal mammary artery (LIMA) to bypass the left anterior descending artery (LAD) is the "gold standard" of coronary artery revascularization, recognized by interventionalists and surgeons alike. The better size match with the coronary artery, the single anastomosis, and the biochemical and physical qualities of this conduit for the most important coronary artery in the human circulation, the LAD, are clear advantages over the saphenous vein graft.¹ The seminal paper by Loop et al² showed the important influence of this operation on the longevity of patients who are operated on for coronary artery disease, and their data have been substantiated by others.^{3 4}

Nevertheless, the IMA has not been generally used by surgeons in the variety of clinical coronary artery syndromes requiring coronary artery bypass grafting (CABG) because of some relative contraindications. These have included left ventricular hypertrophy, severe left ventricular dysfunction, emergency operations, chronic obstructive pulmonary disease with enlarged lungs, advanced age, and an obstructed left subclavian artery.⁴ Theoretically, increased conduit blood flow is considered necessary in these situations, and this was thought best provided by a saphenous vein graft to the LAD rather than a LIMA. Thus, the LIMA was not recommended for emergent/urgent situations or in patients with the above complications. Also, the longer harvest time of the IMA and the increased bleeding tendency of the emergent patient, especially those undergoing interventional procedures in the cardiac catheterization laboratory who may be on some form of anticoagulation and in the fragile elderly, were also considered . . . [Full Text of this Article]

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