Coronary artery disease (CAD) remains the single largest killer of Americans, accounting for almost half a million deaths per year. It imposes a particular burden on the elderly, with more than 80% of all CAD deaths occurring in those over age 65.1 The magnitude of this impact takes on great significance because it is expected that the number of Americans older than 65 years of age will double over the next two decades.2 If you add to this aging population the anticipated increase in the prevalence of important risk factors for CAD such as diabetes mellitus and obesity, the population at risk for CAD can only be expected to increase.
Myocardial revascularization represents an effective treatment strategy shown to prolong survival. Techniques of revascularization include percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), which can be performed with or without cardiopulmonary bypass. Current techniques for CABG can be carried out with low perioperative morbidity and mortality, with excellent long-term outcomes despite an increasing risk profile.3 Coronary artery bypass graft surgery with cardiopulmonary bypass remains the standard by which the other techniques (ie, PCI, off-pump CABG) are measured.4,5 It is expected that it will continue to be a cornerstone in the management of CAD in the foreseeable future.
The modern era of myocardial revascularization with cardiopulmonary bypass began in 1954 when Dr. John Gibbon reported the development of the cardiopulmonary bypass machine.6 An additional seminal advance occurred with the development of coronary angiography by Mason Sones at the Cleveland Clinic in 1957, which opened the door to the elective treatment of coronary atherosclerosis by means of direct revascularization.7 Initial reports by Rene Favaloro and Donald B. Effler on their techniques to treat clinical events associated with stenotic lesions of the coronary arteries culminated in the first large series of aorto-to-coronary artery venous grafts reported in 1969.8 Simultaneously Dudley Johnson of Milwaukee published a series of 301 patients in 1969.9 The success of these techniques was soon demonstrated in larger series initiating the modern era of coronary artery surgery.
The indications for CABG are reviewed in detail in Chapter 19. In brief, the indications established by the American Heart Association and American College of Cardiology (AHA/ACC) consensus panel are based predominantly on the results of trials comparing surgical revascularization with medical therapy for patients with chronic stable angina.10 Three major trials, the Coronary Artery Surgery Study (CASS), the Veterans Administration Coronary Artery Bypass Cooperative Study Group, and the European Coronary Surgery Study (ECSS), demonstrated the greatest survival benefit of revascularization to be among those patients at highest risk of death from the disease itself as defined by the severity of angina and/or ischemia, the number of diseased vessels, and the presence of left ventricular dysfunction.11–13
Prediction of risk-adjusted outcomes permits both the surgeon and the patient to weigh the potential ...