Don’t Throw Your Pearls Before Swine

Or Biblical Warnings for Cardiac Surgeons

I try to make these blog pieces short (because everyone has attention deficit hyperactivity disorder - ADHD), but also include some personal stuff to make them interesting.  I hope this makes it easier to remember the principles.  I have already told you how my father’s being a minister north of Boston helped me get a patient cremated and buried at sea when I was a resident¹ and how it helped me get a copy of Clarence DeMar’s autobiography.² 

My childhood also left me with many indelible biblical phrases including Matthew 7:6: “…Do not throw your pearls before swine. If you do, they may trample them under their feet, and then turn and tear you to pieces.”³ That is how it’s phrased in the Berean Study Version of the Bible, but in the cardiologists’ version it reads, “Don’t let your cardiac surgeon bypass the left anterior descending coronary artery (LAD) using the left internal mammary artery (LIMA) if the LAD has less than a critical stenosis and there is no evidence of inducible, anterior cardiac ischemia.” 

Why? Because if there is competitive flow to the LAD from both the LAD and the LIMA, the LIMA often shrinks in diameter and may become a “string sign” or close.  This eliminates the LIMA as a viable bypass conduit if the patient’s non-critical LAD lesion progresses to critical.  This is now well-known, but Charlie Primiano, one of my colleagues at Hartford Hospital, was first author on an early report of this phenomenon.⁴   Previously, cardiac surgeons would sometimes bypass the LAD when not critical because “it will get tight someday.”  I don’t want to overstate this because the non-critical LIMA doesn’t always become a string, but at the least discuss this issue with the surgeon.  And try not to use the LAD if it is not tightly stenosed or if there is no clinical or imaging evidence of LAD ischemia.  Using the LIMA before you need to is “throwing your pearls before swine”.  

1.    https://pauldthompsonmd.substack.com/p/volunteer-discretionary-effort-constantly?utm_source=profile&utm_medium=reader2

2.    https://pauldthompsonmd.substack.com/p/grave-concerns-at-the-boston-marathon?utm_source=profile&utm_medium=reader2

3.    Berean Study Version of the Bible.

4.    Glazier JJ, Giri S, Primiano CJ.  Atresia of Internal Thoracic Artery Grafts Following Placement to Noncritically Obstructed Vessels.  Cathet. Cardiovasc. Diagn. 42:298–301,1997