Revascularization of the Ischemic Posterior Myocardium

¹ New York, New York

A four-phased experimental program to develop an effective method for revascularization of the "posterior" wall of the left ventricle was undertaken in the fall of 1963. All experiments involving intramyocardial implantation of "new" arteries created by grafting techniques (autologous venous or arterial segments) proved disappointing. Finally reasoning that such necessarily totally denervated graft "arteries" would not respond to what Vineberg12 has called "arteriotaxis" like normally innervated arteries (such as the internal mammary) a search was made for a suitable "expendable" abdominal artery.

The right gastroepiploic artery was chosen as best fulfilling the various assumed requirements and a series of animals was submitted to "implant revascularization" with a pedicle containing this artery. The experimental results with respect to prolonged patency and eventual vascular communication with the natural coronary arterial branches were essentially identical to those seen with the implanted internal mammary artery.

A clinical series of 27 patients, chosen and monitored with the help of selective coronary cineangiography was commenced. Only patients with clearly delineated severe obstructive disease of one or more of the major coronary trunks were selected. The procedure, even when combined with anterior implantation of the internal mammary artery, proved to be well tolerated even in older patients (oldest 72).

Excluding patients less than one month postoperatively (seven) all but one of the survivors report significant improvement with respect to anginal pain. Nine of the series report dramatic relief—essentially no pain under conditions of normal living.

Injection studies (at necropsy) of the heart of the one patient in this series who died of unrelated causes four months after a double implant operation revealed early and equal development of anastomosis from the internal mammary and right gastroepiploic arteries to the respective contiguous distal coronary arterial branches.

This evidence, while promising, does not yet constitute final proof of the validity of this proposed method for revascularization of the posterior myocardium. However, theoretical presumptions based upon the structural similarities between the anterior and posterior ventricular walls and the similarities in behavior of the implanted gastroepiploic and internal mammary arteries encourage us to continue this study.