The long-term influence of coronary bypass grafts on myocardial infarction and survival.

Approximately 1,000 coronary bypass procedures were performed at New York University between February 1968 and December 1973. This report reviews all elective operations performed for angina between 1968 and 1972, a total of 448 patients. In this five-year period the percentage of diseased arteries bypassed rose from 40% to 84%, and operative mortality decreased from 28% to less than 3%. There were a total of 28 operative deaths, mostly from myocardial infarction and low cardiac output. Operability was nearly 95%. The only fixed contraindication was chronic congestive failure. Over one-half of the patients had an abnormal ventriculogram, and there was some history of mild congestive failure in nearly 20%. Elevation of left ventricular end-diastolic pressure above 20 mm before operation was associated with a higher operative mortality, but the late mortality was similar to those with a normal preoperative end-diastolic pressure. In 383 surviving patients, angina was eliminated or greatly improved in 86%, unimproved in 12% and worse in 2%. Late angiograms were performed on 201 patients, studying a total of 445 venous grafts with an overall patency rate of 71%. Graft occlusion was sporadic and unpredictable, but over 90% of patients with multiple grafts remained with at least one patent graft. A late myocardial infarction occurred in 32 out of 420 patients surviving operation, and was fatal in eight. The cumulative incidence over a period of five years was 17%. Twenty-three deaths occurred following discharge from the hospital. Life-table analyses showed a five-year survival of 77% when all deaths were included, and a five-year cardiac survival of 81% when non-cardiac deaths were withdrawn alive at the time of death. The expected survival in a comparable population group without coronary disease was 92%, while data published by Sones of patients treated without operation showed a five-year cardiac survival of 66%. Current operative techniques have an operative mortality of 2-3% and a subclinical infarction rate of 5-10%. The ideal graft is yet evolving, but data with internal mammary artery grafts are most encouraging. A future goal should be a five-year graft patency of at least 80%. Because many infarcts probably develop from a relatively small decrease in coronary blood flow, either during rest or mild activity, the likelihood that future data will demonstrate a marked increase in longevity with bypass grafting is great.