[Surgical indications of ischemic heart disease: a physician's viewpoint]

Surgical indications for patients with ischemic heart disease are discussed from a physician's viewpoint. Among the subsets of this disease, surgical treatment is undoubtedly recommended for patients with serious complications following acute myocardial infarction (MI) such as cardiac rupture, interventricular septal perforation, acute severe mitral regurgitation and left ventricular mural thrombi complicated by systemic emboli, because these subsets have little or no response to medical treatment. Patients with left ventricular aneurysm are also surgical candidates, if they have refractory left heart failure or ventricular arrhythmias. Indications for coronary artery bypass surgery (CABS) for patients with angina pectoris are as yet controversial in Japan among physicians and surgeons, because the Japanese comply well with medications, and medically-treated patients have favorable prognoses. Indication standards for CABS may consist of three components; the first, an essential condition of the institution where CABS is performed. It includes the physician's ability to precisely diagnose angina pectoris, availability of skilled surgeons and anesthesiologists for heart surgery, a well-organized system for patient management during and after CABS and an acceptable success rate. The second includes a clinical indication. It is considered valid that candidates for CABS should be basically patients unresponsive to medical treatment, in so far as there would be a risk such as perioperative MI or operative death. Angina pectoris is judged to be medically-resistant when chest pain at rest does not resolve, or an exercise capacity necessary for patients' social rehabilitation is not achievable, after the appropriate administration of antianginal agents including a combination of nitrates, calcium antagonists and beta-blockers. The last problem is an anatomical indication. Recent advances in percutaneous transluminal coronary angioplasty (PTCA), an effective therapeutic procedure for coronary revascularization, has greatly influenced indications for CABS, and it makes it difficult to strictly distinguish medical from surgical treatment. The purpose, clinical indications, and efficacy of PTCA are similar to those of CABS. However, patients' physical, emotional and socioeconomic burdens relative to PTCA are remarkably less than those of CABS. Thus, it seems reasonable that CABS should be recommended to patients who have contraindications to or high risks with PTCA, such as left main trunk lesions; whereas in general, there are no anatomical contraindications to CABS.