Controversial aspects of coronary endarterectomy.

Between 1980 and 1987, 635 patients underwent coronary bypass grafting combined with coronary endarterectomy. A total of 728 vessels were endarterectomized and grafted. There were 15 early deaths (2.3%). The mortality rate was higher (7.8%) for multiple-vessel endarterectomy (p less than 0.05). The ratio of MB fraction of creatine kinase to total creatine kinase was greater than or equal to 0.10 in 48% of the cases. The first consecutive 132 survivors were followed for an average of 16 months (range, 4 months to 5 years). No late deaths occurred. Fifty-nine unselected patients underwent postoperative recatheterization at a mean interval of 18 months. An improvement in heart wall contractility could be detected in 13 patients (16.5%) and deterioration in 14 patients (17.7%). A more detailed analysis of wall contractility showed a higher rate of improvement in the posterior wall than in the anterior wall (p greater than 0.05). Furthermore, the better the contractility before operation, the greater the rate of deterioration after operation (p less than 0.05). Despite an average of 55% of all endarterectomized vessels being occluded or severely restenosed, 90% of the patients were clinically improved. A multiparametric analysis revealed that the revascularization of myocardial areas that required endarterectomy had no significant influence with respect to clinical improvement. Endarterectomy should be limited, whenever possible, to myocardial areas with already impaired contractility. Endarterectomy of multiple branches should be treated with caution because the risk of deterioration is potentiated, with a significantly higher perioperative mortality rate.