The Surgical Treatment of Coronary Insufficiency

¹ The Division of Surgery, Hahnemann Medical College and Hospital, and The Bailey Thoracic Clinic, Philadelphia, Pennsylvania.
² The Division of Medicine, Hahnemann Medical College and Hospital, and The Bailey Thoracic Clinic, Philadelphia, Pennsylvania.

1. The surgical procedures devised for the treatment of coronary arterial insufficiency may be classified according to the objectives they seek to accomplish.

2. Measures which modify only the clinical manifestations of the coronary arterial insufficiency consist of those which destroy the sympathetic pathways mediating pain sensation from the heart by postganglionic resection of the upper dorsal and lower cervical chains, by division of the preganglionic fibers to these same areas, or by paravertebral injections of alcohol.

3. The only available method which modifies the degree of coronary insufficiency by decreasing myocardial demand is destruction of thyroid function by surgical or medical therapy.

4. Coronary insufficiency may be decreased by a variety of procedures which are designed to increase the size of the coronary vascular bed. These are best termed revascularization techniques, and represent the most physiological approach to the problem. They are classified according to their ability to increase the vascularity at a superficial level or throughout all layers of the myocardium.

5. The blood supply to the epicardium, or the layers immediately beneath the epicardium, may be augmented by omentopexy, myopexy, pneumonopexy, the intrapericardial insufflation of irritants, or the implantation of the bleeding end of the mobilized left internal mammary artery into the left ventricular wall. The intrapericardial instillation of a powdered silicate appears to be the most promising of the surface revascularization procedures.

6. The term total revascularization is applied to the techniques which create an anastomsis between the aorta and the coronary sinus either through a vascular graft (Beck II) or directly (Kralik modification) thus establishing a retrograde flow of arterial blood to the myocardial capillary bed by way of the venous channels. Such retrograde flow is transient but great augmentation of the adequacy of the intercoronary collateral system is produced and remains. Simple ligation of the coronary sinus also may be considered as a total revascularization procedure although a lesser degree of intercoronary overdevelopment is obtained by this procedure.

7. The selection of patients for the revascularization procedures is based upon those manifestations of the disease which indicate an ominous prognosis or seriously interfere with the ability of the patient to meet the requirements of ordinary living.

8. Resection of a ventricular aneurysm represents a promising surgical development in the management of a relatively recalcitrant and untoward cardiac complication which nearly always is the result of occlusive coronary arterial disease. The first historically successful case is herein presented.

9. The development of a seemingly satisfactory and rather safe surgical treatment for complete or varying heart block is detailed with presentation of the first apparently successful human operation.