Increasing the Blood Flow

Of the estimated 25 million Americans who suffer from coronary artery disease, fewer than 10 million have their problem neatly confined to a plug of fatty or chalky material in a single artery --what doctors call "segmental disease." The majority have a diffuse disease involving several artery branches, vastly complicating all efforts to boost blood flow to the oxygen-starved heart muscle. Because there is as yet no proof that medical treatment with diet, drugs, exercise and control of weight and blood pressure does much good, Santa Monica's Dr. James A. Mc-Eachen told the American College of Cardiology, countless victims may eventually turn to the surgeon for whatever help he can give. And inventive sur geons are meeting the challenge with new and ingenious operations.

Mammary Implant. For the minority of patients with a relatively small and clearly defined blood block, Dr.

McEachen favored what he called "direct operations," in which the surgeon reams out the plugged artery. This procedure, technically "endarterectomy," was first' attempted by Dr. Charles P.

Bailey (TIME cover, March 25, 1957); now, says McEachen, the reaming-out (see diagram), which he does in the di rection opposite to that of the blood flow to reduce the risk of clotting, may have to be combined with the graft of a patch into the side of the diseased artery to restore its full bore. Under any circumstances, he said, the heart-lung machine is needed during the operation, and the surgeon has to use "microsurgical instruments, magnifying lenses, tiny sutures and great care." Of six Santa Monica patients followed for up to three years, five have derived major benefit from the procedure.

When it comes to correcting the more diffuse type of coronary disease, most cardiac surgeons base their work on a technique first used in 1950 by Montreal's pioneering Dr. Arthur M. Vine-berg. The left internal mammary artery, which is not very important in man, is implanted in the heart wall so that its blood flow may reinforce the coronaries. One internal mammary is big enough to carry an adequate blood supply for the entire left ventricle (the heart's main pumping chamber), and if the blood still does not reach all the starved areas, the right mammary artery can be used to supply the right ventricle.

Now, Dr. Vineberg told the cardiologists, he has combined this technique with an even more extensive operation for heart-disease victims who have blocks in two or three coronaries. In addition to implanting the mammary artery, Dr. Vineberg now opens the heart sac and removes all of its inner layer (the epicardium). Then he wraps the heart in what amounts to a blanket of tissue that is rich in blood vessels. To get this material, he cuts through the diaphragm and takes out a 6-inch by 10-inch piece of the omentum, the apron of fat that lies over the intestines. Dr. Vineberg closes the diaphragm incision and wraps the omentum around the heart. Although it has been cut away from its natural blood supply, it soon develops new arterial and venous connections, and shares its generous blood flow with the heart muscle.

In three years, said Dr. Vineberg, he has done this combined operation on 87 patients with disease in all three major coronary branches, including 21 who had been confined to bed or chair. Among the 66 who were up and about, there have been only three deaths connected with surgery, and at least 40 previously disabled patients are now back at work.

Muscle Tunnel. Research surgical teams from two major medical centers told the College of Cardiology about new techniques based on the Vineberg principle but using different vessels to carry blood to the heart muscle. Cleveland's Dr. Earle B. Kay reported that he and Dr. Akio Suzuki cut out a piece of the left lung's arterial network with "a multitude of side branches," and sew the "trunk" end into the descending aorta. Then they implant the smaller branches in the heart muscle. The advantage of this method, which has so far been successful in four out of six patients, said Dr. Kay, is that the blood vessels borrowed from the lung can be sewn into any part of the heart muscle.

Dr. C. Walton Lillelehi's team from the University of Minnesota described a similar technique, using part of the network of veins from the patient's own thigh. The trunk vein is sewn into the aorta, and the branches are set in tunnels in the heart-wall muscle-tunnels through which a surgical knife has been run, deliberately cutting several small, transverse arteries, to open them up so that they can receive the new blood supply. Ten of these patients, said Dr. Randolph M. Ferlic, who suffered from crippling angina even when they were sitting down and not exerting themselves, are now free of pain; seven have been back at work for periods up to a year or more.

Though the assembled cardiac surgeons offered an impressive variety of new and different procedures, they agreed on one thing: any surgical repair for the heart's damaged circulation would be impossible without the techniques of cinearteriography developed by Cleveland's Dr. F. Mason Sones Jr. (TIME, Nov. 7, 1960), which enables the surgeon to get moving-picture X rays of the blood flow through the coronaries.

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