Results of treatment aortocoronary vein · British HeartJournal, I973, 35, 53I-537. Results ofconservative treatment of angina pectoris in candidates for aortocoronary saphenousvein

British HeartJournal, I973, 35, 53I-537.

Results of conservative treatment ofangina pectoris in candidates for aortocoronarysaphenous vein bypass'

Lotfy L. Basta, J. Michael Kioschos, and Francois M. AbboudFrom the Department of Internal Medicine, University of Iowa Hospitals, Iowa City, Iowa 52240, U.S.A.

The results of conservative treatment of 30 patients with symptomatic coronary disease who would have beengenuine candidates for aortocoronary saphenous vein bypass graft surgery are reported. These patients hadsevere angina and at least 75 per cent occlusion of one or more coronary arteries associated with good distalrun-off (diameter 2 mm or more distal to the obstruction) and adequate myocardial function. The patientswere followedfor a period of i to 5 years.

Six patients had single vessel disease, 5 of whom improved and I deteriorated. Twelve patients had two-vessel disease: 6 improved, 4 remained the same, I deteriorated, and died. Twelve patients had three-vesseldisease and none improved: 5 of them died, 4 deteriorated, and 3 remained the same.

Electrocardiographic findings correlated with the clinical course in patients with two-vessel disease; thus,5 of the 6 patients who did not improve had electrocardiographic abnormalities at rest or after Master'sexercise test, whereas 4 of the 6 patients who improved had normal resting and post-exercise electrocardio-grams, and in one of the other cases the electrocardiogram became nornal at follow-up.

It is suggested that many patients with single-vessel disease or two-vessel disease and normal electrocardio-grams and who are currently considered for saphenous vein bypass surgery may have a favourable clinicalcourse if treated conservatively.

Since the introduction of aortocoronary saphenousvein grafts to bypass proximal lesions in the maincoronary arteries (Johnson et al., i969), this opera-tion has largely replaced all previously known surgi-cal procedures employed in the treatment of ischae-mic heart disease. However, while the operation wasfirst intended for the symptomatic relief of anginapectoris, growing interest has extended the indica-tions for this operation to cover most of the mani-festations of ischaemic heart disease, including:acute coronary insufficiency (Auer et al., I97I;Segal et al., I972), the early stages of myocardialinfarction (Cohn et al., I97I; Hill et al., I97I),arrhythmia (Mitchell et al., 1970; Ecker et al., I97I),cardiogenic shock (Buckley et al., I97i), and heartfailure (Johnson, Auer, and Tector, 1970).The increasing enthusiasm for aortocoronary by-

pass operations probably arises from the lack of aneffective treatment of atherosclerotic heart diseaseReceived 2I September 1972.1 Supported by a grant from the National Institutes ofHealth.

andfromthefactthatthis operation has been shown tobe associated with an acceptable mortality (Daniel-son, Gau, and Davis, I97I; Effler, Favaloro, andGroves, 197I) and that impressive relief of anginapectoris was often described after operation (Mitchelet al., I970; Effler et al., 197I).The natural history of angina pectoris has been

identified (Block et al., I952; Kannel and Feinleib,I972), and the mortality has been correlated withthe number of coronary arteries showing significantlesions on cineangiography (Moberg, Webster,and Sones, 1972), and with the electrocardio-graphic abnormalities at rest (Block et al., I952) andafter exercise (Robb and Marks, I967; Blomquist,197I). Despite this there have been no reportsdescribing the clinical course of patients with dis-abling or increasing angina who are currentlythought to be candidates for aortocoronary saphen-ous vein bypass surgery if these selected patientswere treated conservatively with adequate medicaltherapy. Such reports would be expected to help inthe evaluation of the merits of operation until an

on February 21, 2021 by guest. P

rotected by copyright.http://heart.bm

j.com/

Br H

eart J: first published as 10.1136/hrt.35.5.531 on 1 May 1973. D

ownloaded from

http://heart.bmj.com/

532 Basta, Kioschos, and Abboud

TABLE I Initial findings and follow-up data on patients with single-vessel disease:

Cases Age Blood Serum Vessel affected Initial electrocardiogram Left ventricular function(yr) pressure cholesterol

(mmHg) (mg/loo ml) Rest Exercise EF LVEDP AV 02

MC 58 I28/60 200 Left circumflex 75% Inferior infarction - 0-7 9 3.8CW 42 130/90 I85 LAD go% T inversion - o-6 8 4.2GJ 52 150/I00 280 LAD complete Anterior infarction 0*5 7 5.IWN 45 150/92 202 LAD complete Normal Negative 0-7 I0 3-8GH 42 I60/95 340 Left circumflex 90% Normal Positive 0-7 8 4.2HL 36 130/80 265 LAD complete Normal Negative o-8 I0 3-8

EF = ejection fraction; LVEDP = left ventricular end-diastolic pressure (mmHg); AV 02= arteriovenous oxygen difference(vol. %).

TABLE 2 Initialfindings andfollow-up data on patients with two-vessel disease:

Cases Age Blood Serum Vessels sigmficantly Initial electrocardiogram Left ventricular function(yr) pressure cholesterol diseased

(mmHg) (mg/loo ml) Rest Exercise EF LVEDP AV 02

GL 50 175/98 245 LAD complete, right go% Normal Positive o-6 I2 3.8PG 41 130/78 2I5 LAD 90%, right 85% Normal Negative 0°7 9 4-2BR 40 ii6/73 360 LAD complete, right 75% Normal Positive 0°7 5 3.8SM 48 I20/85 260 LAD 75%, left 75%, Normal Negative o-6 I4 4-3

circumflexAL 69 I40/80 200 LAD 75%, right complete Abnormal 07 5 4-2KG 39 I40/80 275 LAD 85%, right 90% Abnormal T -os 6 4-7

inversionNE 38 130/85 250 LAD 90%, right 90% Normal Negative o-6 6 4-IML 56 126/66 225 Marginal go%, right 75% Normal Negative 0-7 I0 4.IAK 45 I30/90 342 LAD go%, right 75% Abnormal - 05 8 4-8

(infarction)NP 50 I20/80 240 LAD 90%, left Normal Negative o-6 9 40

circumflex 75%TG 45 120/70 285 Marginal 90%, circum- Normal Positive o065 8 3-8

flex 75%DG 42 I50/90 200 LAD complete, circum- Abnormal -o55 i8 4.8

flex 9o% (infarction)

TABLE 3 Initial findings and follow-up data on patients with three-vessel disease:

Cases Age Blood Serum Initial electrocardiogram Left ventricular function(yr) pressure cholesterol

(mmHg) (mg/Ioo ml)Rest Exercise EF LVEDP AV 02

MP 39 I28/80 245 Abnormal ST-T - o-6 12 4.8BS 49 140/90 255 Normal Positive 0-7 I4 4.6CD 41 I40/90 270 Normal Positive o07 II 5.2PW 38 120/70 223 Normal Inadequate 0-7 I0 4.4CV 54 I55/88 245 Normal Positive o-6 I2 5-0CH 50 190/112 293 Abnormal, infarction -055 I4 5.2LO 5I I30/90 224 Abnormal, infarction -048 I0 5.1KR 42 I40/90 220 Normal Positive 0-4 I4 5-4

HR 43 132/88 280 Normal Positive o-6 I2 4.8PR 55 I30/I00 340 Abnormal, infarction - 0-4 8 5-4LM 45 I20/80 2I5 Normal Positive 0-7 5 4-3RK 43 I00/60 195 Normal Positive 0-5 8 4.4



j.com/

Br H


ownloaded from


Conservative treatment of angina pectoris in candidates for aortocoronary saphenous vein bypass 533

average follow-up 24 months

Follow-up Follow-up electrocardiogram Follow-upcourse period

Rest Exercise (mth)

Improved Old infarction 48Improved Normal Negative 28Improved Old infarction 24Improved Normal Negative I7Deteriorated Normal Positive 13Improved Normal Negative I2


Follow-up Follow-up electrocardiogram Follow-upcourse period

Rest Exercise (mth)

Improved Normal Negative 6iImproved Normal Negative 59Died 43Improved Normal Negative 37

Same RBBB - 35Deteriorated, Abnormal 3I

infarctionImproved Normal Negative 29Same Normal Positive 26Same Abnormal, old 24

infarctionImproved Normal Negative 13

Improved Normal Positive I2

Same Abnormal - I2


Follow-up course Follow-up electro- Follow-upcardiogram period

(mth)Rest Exercise

Died in office - 52Died after MI andLVF - 3Same Normal Positive 54Deteriorated, angina at Normal Positive 39

rest, operationSame Normal Positive 40Died-infarction 21Pains at rest Abnormal I9Died - angina worse, - 5LVF

Deteriorated, increased Normal Positive I5pain, operation

Died - infarction 3Same Normal Positive i5Increase in frequency Normal Positive I4

of pain

adequately controlled randomized study becomesavailable.

In this paper we report on the follow-up of 30patients suffering from angina pectoris who weretreated medically, but who would have been candi-dates for saphenous vein bypass operation accordingto our indications.

Subjects and methodsThis study comprises 28 men and 2 women treated in theUniversity of Iowa and the Veterans AdministrationHospitals. Their ages ranged from 36 to 69 years. Thesepatients were followed for a period of i to 5 years (aver-age 27 months) and were chosen from I92 patients whohad undergone selective coronary cineangiography be-tween I967 and I97I for suspected coronary arterydisease. They fulfilled our present criteria for saphen-ous aortocoronary bypass procedure, i.e. (I) frequentattacks or a recent increase in the severity of angina pec-toris; (2) with at least 75 per cent narrowing of one ormore coronary arteries; (3) with good or fair distal run-off (vessel diameter of at least 2 mm distal to the ob-struction); (4) with adequate myocardial function, i.e.ejection fraction more than 30 per cent, arteriovenousoxygen difference of less than 6 volumes per cent, andleft ventricular end-diastolic pressure less than 20 mmHg. We excluded from this analysis patients with diffusecoronary artery disease and those with associated valvu-lar disease or large myocardial aneurysms; as in theselatter patients, the prognosis is influenced by the associ-ated disease. All 30 patients were treated conservativelysince aortocoronary bypass operation was not then per-formed at the University of Iowa Hospitals. The medi-cal treatment included control of the risk factors forcoronary disease, and, in the majority of cases, with acombination of propranolol I6o-240 mg daily and sorbidenitrate 5 mg sublingually 4 to 6 times daily.

These 30 patients were fully investigated, includingelectrocardiograms at rest and after Master's exercisetest, right and left cardiac catheterization, and coron-ary cineangiography using the standard techniques.Left ventricular volumes and ejection fraction were cal-culated using the method described by Dodge, Hay, andSandler (I962).The patients selected for this report and who survived

the follow-up period were re-evaluated, including clinicalexamination and electrocardiograms at rest and ongraded treadmill exercise test. The stage at which apatient developed angina pectoris or significant STabnormalities was noted and the findings were com-pared with the previous exercise electrocardiogramstaken at comparable heart rates during the previousMaster's test. Those who did not develop pain and/orST abnormalities were allowed to continue until 85per cent of the maximal heart rate predicted for theirage, according to the method of Bruce and Hornsten(I969).The patient's course was identified as follows:

I) Death: the follow-up period was taken as the periodfrom the time of cineangiography until the time ofdeath.



j.com/

Br H


ownloaded from



2) Deterioration: an increase in the frequency of anginalattacks with decrease in the effort tolerance; develop-ment of a new myocardial infarction exclusive of theinitial period in hospital or the development of leftventricular failure.3) No improvement: the amount of exercise needed toprecipitate angina did not change significantly at com-parable heart rates, as observed during the treadmillexercise test. Some patients claimed that they had lessfrequent angina, but this apparent improvement was dueto the patient's learning to avoid the precipitating causesof angina rather than to a real improvement in the efforttolerance.4) Improvement: a decrease in the frequency of anginalattacks and an increase in effort tolerance, confirmed byobserving the patients during the treadmill exercise test.

ResultsPatients with single-vessel diseaseTable i shows the findings and follow-up data ofthe 6 patients included in this group. Only one pa-tient deteriorated over a period of I3 months inspite of adequate control of her hypertension, dia-betes, and hyperlipidaemia. Of the 5 patients whoimproved, 2 patients developed myocardial infarc-tion shortly after the initial study; subsequentlythey became free of pain. A third patient had re-current ischaemic pain with ischaemic T wave in-version over the anterior myocardial surface; hesuffered a prolonged attack of pain not associatedwith enzyme increases after which he became freefrom angina pectoris and at present has a normalelectrocardiogram and normal response to submaxi-mal exercise test. Two others had normal electro-cardiograms at rest and with double Master's exer-cise tests. The electrocardiograms remained normaland the patients showed clinical improvement.

Patients with two-vessel diseaseTable 2 shows the findings and follow-up of the I2patients included in this group. One patient died 43months after the study; after an initial reportedimprovement the anginal pains increased in fre-quency and severity with subsequent inferior infarc-tion, after which anginal pains persisted and thepatient was found dead in bed. Another patient didnot improve and sustained a myocardial infarctionafter I8 months and is presently under treatmentfor heart failure.Of the 6 patients who improved on medical treat-

ment, 2 became free from pain with negative exer-cise test. Fig. 2 shows the relation of the electro-cardiographic findings to the clinical course in thisgroup of patients. It is shown that of the 6 patientswho improved, 4 had normal electrocardiograms atrest and after Master's exercise test, and a fifth

6

.0 4

0-

o 3-

DE2-z

0

=3-vessel disease

M2-vessel disease(17) E=1-vessel diseose

( )-Monthstr(27) (24)

l(3) 131)(13) E

Deoth Deterioration Stotionoiiry

(35)

(2b)

Improvement

FIG. I The follow-up course in different groups ofpatients according to the number of vessels significantlyoccluded. The numbers on the columns indicate themean follow-up period in months in each category.

V

Q-0~

o

E

z

ECGb- [3=Normol ot rest and after exercise

=Previously abnormol after exercise-s- -but became normol

*=Abnormol at rest or after exercise

4- ( )=Months (24)

2-VESSEL DISEASE I

2-

-

Death Deterioration Stationary Improvement

FIG. 2 The electrocardiographic findings and theclinical course in patients with two-vessel disease.

patient had, initially, a positive exercise test whichbecame negative on follow-up. By contrast, 5 of the6 patients who did not improve had abnormal elec-trocardiograms at rest or after exercise.

Patients with three-vessel diseaseTable 3 shows the results and follow-up data on theI2 patients included in this group. Of the 5 patientswho died during the follow-up period, 3 died within5 months of the study, after worsening of angina anddevelopment of infarction in spite of medical ther-apy; i patient developed a myocardial infarctionafter 2I months of no improvement, and i patient,whose angiograms revealed extensive intercoronarycollaterals, improved initially to a significant degreewith obvious increase in the effort tolerance, but



j.com/

Br H


ownloaded from



died suddenly after 52 months without premonitorysymptoms. The 4 patients who showed deteriora-tion in their symptoms claimed an initial sympto-matic improvement on adequate medical therapy.These 4 patients were later operated upon afterrestudy coronary cineangiography which indicatedno significant change from previous angiograms.Operation was performed 39, 2I, I5, and I4 monthsafter the initial study. No patient in this group withthree-vessel disease exhibited convincing evidenceof improvement at the follow-up study. All thepatients included in this group had electrocardio-graphic abnormalities at rest or after exercise.

DiscussionOne ofthe major difficulties encountered in assessingthe efficacy of therapy for angina pectoris is thequantitation of improvement. The decrease in fre-quency of pain attacks and/or in the need for nitro-glycerin tablets has generally been taken to indi-cate of improvement. Using these indicatorsalone, sham operations (Dimond, Kittle, andCrockett, I960), unsuccessful operations ( Cobb etal., I959; Dart et al., I970; Balcon et al., I970), andmany forms of inappropriate medical therapy havebeen followed by favourable symptomatic relief.Therefore, we did not consider these as indicationsof improvement unless they were associated withan increase in the effort tolerance as obtained bycareful analysis of the history and by observing thepatients on graded treadmill exercise. It is notablethat some of our patients who are reported as 'notimproved' claim that they have been feeling signifi-cantly better.The prognosis of patients with angina pectoris

seems to follow the number of vessels affected. Thus,our patients with three-vessel disease had a signifi-cantly higher mortality (P <005 at two years' fol-low-up) than the rest of the patients, and the major-ity either died or deteriorated, while none showedsustained improvement over the follow-up period.These data conform with other studies indicatingmore than a threefold increase in the mortalityfigures in patients with three-vessel disease if com-pared to those with single-vessel disease (Moberget al., I972). In that study, the mortality figure forthose with coronary disease limited to one vesselwas nearly 3 per cent per year, which is not differentfrom previously reported death rates among a con-trol group of individuals not suffering from clinicalcoronary disease (Block et al., I952).Three patients with single-vessel disease pre-

sented initially with an acute onset angina that in-creased steadily over days or weeks and was fol-lowed by myocardial infarction in two of them and

a more prolonged ischaemic attack without electro-cardiographic or laboratory evidence of infarction inthe third. Subsequently, all three patients becamefree from pain or other symptoms. Such a courseconforms with the known clinical observation thatangina pectoris is frequently ameliorated after myo-cardial infarction (Friedberg, I966), and in view ofthe high incidence (almost 30%) of myocardial in-farction during aortocoronary saphenous vein by-pass surgery in some series (Keelan et al., I97I), itis possible that such a mechanism might be at leastpartly responsible for the reported postoperativesymptomatic relief.The electrocardiographic findings were signifi-

cantly (P <o o5) helpful in predicting the subse-quent course in patients with two-vessel disease.Among these patients, those who died, deteriorated,or failed to improve - with the exception of one -had abnormal electrocardiograms either at rest orfollowing Master's exercise test, while 5 of the 6patients who improved had normal resting and post-exercise electrocardiograms at follow-up. Theseobservations are in accordance with previous studiesthat indicate a less favourable course for patientswith angina pectoris and abnormal resting electro-cardiograms (Block et al., I952) or positive exercisetests (Robb and Marks, I967).

Presently, some centres advocate bypass surgeryfor occluded coronary arteries regardless of thediameter of the vessel distal to the obstruction asseen in the cineangiograms (Glassman et al., I971)and others might accept patients with poor myo-cardial function (Johnson and Lepley, I970). In thisstudy we did not include such cases because thereis still controversy regarding the acceptability ofthese patients for operation. We thus attempted topresent a selected group of patients that might beacceptable to most conservative centres. This studysuggests, however, that many such patients, who arecurrently recruited for aortocoronary saphenousvein bypass operation, have a favourable course atleast for a few years, irrespective of operation. Inthis favourable group, the merits of saphenous veinbypass operation have to be re-examined especiallybecause the data available so far indicate that graftsmight undergo occlusive changes not long afteroperation (Johnson et al., 1970; Grondin et al.,1971; Vlodaver and Edwards, I97I), and that themyocardial function may or may not improve andmight even deteriorate after operation (Johnson andO'Rourke, 197I; Keelan et al., 1971; Arbogast,Solignac, and Bourassa, I972).

It is in the group of patients with the less favour-able prognosis, despite full medical treatment, thatthe efficacy of operation has to be evaluated. Un-fortunately, there is obvious discrepancy in the



j.com/

Br H


ownloaded from



surgical results in this group of patients as reportedin different series so that the immediate operativemortality figures vary from I to 47 per cent (Daniel-son et al., I971; Mitchel et al., 1970; Johnson andLepley, I970), depending in part on the criteriafor selection. The late postoperative results are evenmore difficult to define, and sufficient data mightnot be available for many years. In two recent reports,in which the patients were followed for a periodof I to 30 months (Morris et al., 1972; Reul et al.,1972), impressive symptomatic improvement was re-ported in the majority of cases, even in those withmultiple vessel disease. Inthat study, however, alesioncausing only 50 per cent narrowing of a coronaryartery was considered significant and there is nodefinition of what parameters were taken to indicateimprovement. In addition, the later follow-upresults are not particularly discussed in terms of thenumber of the diseased vessels. Nevertheless,patients who reportedly did not improve usuallyhad three-vessel disease, and a late incidence ofmyocardial infarction in i i per cent of the operatedgroup is noteworthy.

ReferencesArbogast, R., Solignac, A., and Bourassa, M. G. (I972). Ven-

tricular volumes and ejection fraction one year after coron-ary vein-bypass-graft surgery (abstract). Clinical Research,20, 36I.

Auer, J. E., Johnson, W. D., Flemma, R., Tector, A. J., andLepley, D. (I97i). Direct coronary artery surgery for im-pending myocardial infarction (abstract). Circulation, 44,SuppI. 2, I02.

Balcon R., Leaver, D., Ross, D., Ross, K., and Sowton, E.(I970). Clinical evaluation of internal mammary-arteryimplantation. Lancet, I, 440.

Block, W. J., Crumpacker, E. L., Dry, T. J., and Gage, R. P.(I952). Prognosis of angina pectoris - observations in 6882cases. J7ournal of the American Medical Association, ISO,259.

Blomquist, C. G. (1971). Use of exercise testing for diagnosticand functional evaluation of patients with arterioscleroticheart disease. Circulation, 44, I120.

Bruce, R. A., and Hornsten, T. R. (I969). Exercise stress test-ing in evaluation of patients with ischemic heart disease.Progress in Cardiovascular Diseases, II, 371.

Buckley, M. J., Mundth, E. D., Daggett, W. M., DeSanctis,R. W., Sanders, C. A., and Austen, W. G. (I971). Surgicaltherapy for early complications of myocardial infarction.Surgery, 70, 814.

Cobb, L. A., Thomas, G. I., Dillard, D. H., Merendino, K.A., and Bruce, R. A. (I959). An evaluation of internal-mammary-artery ligation by double-blind technic. NewEngland Journal of Medicine, 260, II15.

Cohn, L., Fogarty, T. J., Daily, P. O., and Shumway, N. E.(I97I). Emergency coronary artery bypass. Surgery, 70,821.

Danielson, G. K., Gau, G. T., and Davis, G. D. (I97I). Earlyresults of vein bypass grafts for coronary artery disease(abstract). Circulation, 44, Suppl. 2, IOI.

Dart, C. H., Scott, S., Fish, R., and Takaro, T. (1970). Directblood flow studies of clinical internal thoracic (mammary)arterial implants. Circulation, 41, Suppl. 2, 64.

Dimond, E. G., Kittle, C. F., and Crockett, J. E. (I960).Comparison of internal mammary artery ligation and shamoperation for angina pectoris. American Journal of Cardi-ology, 5, 483.

Dodge, H. T., Hay, R. E., and Sandler, H. (I962). An angio-graphic method for directly determining left ventricularstroke volume in man. Circulation Research, II, 739.

Ecker, R. R., Mullins, C. B., Grammer, J. C., Rea, W. J., andAtkins, J. M. (197I). Control of intractable ventriculartachycardia by coronary revascularization. Circulation, 44,666.

Effler, D. B., Favaloro, R. G., and Groves, L. K. (I97I). Myo-cardial revascularization, Cleveland Clinic experience.J7ournal of Cardiovascular Surgery, I2, I.

Friedberg, C. K. (I966). Diseases of the Heart, pp. 744-746.W. B. Saunders, Philadelphia.

Glassman, E., Spencer, F. C., Tice, D. A., Weisinger, B., andGreen, G. E. (I97I). What percentage of patients withangina pectoris are candidates for bypass grafts ? Circula-tion, 43, Suppl. I, IOI.

Grondin, C. M., Meere, C., Castonguay, Y., Lepage, G., andGrondin, P. (I971). Progressive and late obstruction of anaorto-coronary venous bypass graft. Circulation, 43, 698.

Hill, J. D., Kerth, W. J., Kelly, J. J., Selzer, A., Armstrong,W., Popper, R. W., Langston, M. F., and Cohn, K. E.(197I). Emergency aortocoronary bypass for impending orextending myocardial infarction. Circulation, 43, Suppl. I,I05.

Johnson, A., and O'Rourke, R. (I97i). Effect of myocardialrevascularization on systolic time intervals in patients withleft ventricular dysfunction (abstract). Circulation, 44,Suppl. 2, I03.

Johnson, W. D., Auer, J. E., and Tector, A. J. (I970). Latechanges in coronary vein grafts (abstract). American Journalof Cardiology, 26, 640.

Johnson, W. D., Flemma, R. J., Lepley, D., Jr., and Ellison,E. H. (I969). Extended treatment of severe coronary arterydisease: a total surgical approach. Annals of Surgery, 170,460.

Johnson, W. D., and Lepley, D. (1970). An aggressive surgicalapproach to coronary disease. Journal of Thoracic andCardiovascular Surgery, 59, I28.

Kannel, W. B., and Feinleib, M. (I972). Natural history ofangina pectoris in the Framingham study - prognosis andsurvival. American journal of Cardiology, 29, I54.

Keelan, M. H., Tresch, D. D., Co., E. H., and Lange, R. L.(1971). Incidence, mortality rate and sequelae of myo-cardial infarction immediately after coronary artery bypasssurgery. Proceedings of the Central Society for ClinicalResearch, 44, 22.

Mitchel, B. F., Adam, M., Lambert, C. J., Sungu, U., andShiekh, S. (I970). Ascending aorta-to-coronary arterysaphenous vein bypass grafts. Journal of Thoracic and Car-diovascular Surgery, 6o, 457.

Moberg, C. H., Webster, J. S., and Sones, F. M. (I972).Natural history of severe proximal coronary disease asdefined by cineangiography (200 patients, 7 year follow-up) (abstract). American journal of Cardiology, 29, 282.

Morris, G. C., Reul, G. J., Howell, J. F., Crawford, E. S.,Chapman, D. W., Beazley, H. L., Winters, W. L., Peter-son, P. K., and Lewis, J. M. (I972). Follow-up results ofdistal coronary artery bypass for ischemic heart disease.American Journal of Cardiology, 29, i8o.

Reul, G. J., Morris, G. C., Howell, J. F., Crawford, E. S.,Sandiford, F. M., and Wukasch, D. C. (I972). Experiencewith coronary artery bypass grafts in the treatment ofcoronary artery disease. Surgery, 71, 586.



j.com/

Br H


ownloaded from



Robb, G. P., and Marks, H. H. (i967). Postexercise electro- Vlodaver, Z., and Edwards, J. E. (I97I). Pathologic changes incardiogram in arteriosclerotic heart disease: its value in aortic-coronary arterial saphenous vein grafts. Circulation,diagnosis and prosnosis. J7ournal of the American Medical 44,7I9.Association, 200, 9I8.

Segal, B. L., Likoff, W., Van Den Broek, H., Adam, A.,Blanco, G., Kimbiris, D., and Najmi, M. (I972). Saphen- Requests for reprints to Dr. Lotfy L. Basta, Departmentous vein bypass surgery for impending myocardial infarc- of Internal Medicine, University of Iowa Hospitals andtion (abstract). American Journal of Cardiology, 29, 290. Clinics, Iowa City, Iowa 52240, U.S.A.



j.com/

Br H


ownloaded from


Documents

Results of treatment aortocoronary vein · British HeartJournal, I973, 35, 53I-537. Results ofconservative treatment of angina pectoris in candidates for aortocoronary saphenousvein