Long-term appraisal of coronary bypass operations in familial hypercholesterolemia

Long-term results of coronary artery bypass grafting (CABG) in consecutive 32 patients with familial hypercholesterolemia, 6 homozygotes and 26 heterozygotes between 1976 and 1990, were analyzed. Seventeen patients in the early series underwent CABG with vein grafts alone. Subsequently, 15 patients underwent CABG with internal mammary artery grafting to the left anterior descending artery and received intensive lipid-lowering treatments early after CABG. All homozygotes and 1 heterozygote received intermittent low-density lipoprotein apheresis after CABG. There was only one late noncardiac death (3%), and the actuarial rates of freedom from cardiac events (myocardial infarction, cardiac death, and angina pectoris) were 60% at 5 and 10 years for homozygotes, and 87% and 73% for heterozygotes. The cardiac event-free curve for the heterozygous familial hypercholesterolemia group was comparable with that for the random age-matched subset of patients without familial hypercholesterolemia who underwent CABG during the same period. Two of 3 homozygotes and 4 of 14 heterozygotes in the early series had one or more cardiac events, whereas no patients in the late period had cardiac events. The patency rate of internal mammary artery grafts to the left anterior descending artery from 1 to 3 years after CABG was significantly higher than that of vein grafts to the left anterior descending artery (92 versus 45%; p < 0.05). Abdominal aortic aneurysm developed postoperatively in 2 homozygotes and 2 heterozygotes without sufficient cholesterol reduction. In conclusion, internal mammary artery grafting in combination with postoperative intensive lipid-lowering treatments, including low-density lipoprotein apheresis, may provide acceptably good long-term results of coronary revascularization in patients with FH.