Coronary bypass surgery—as a planned, consistent therapy for patients with angiographically documented coronary atherosclerosis—was begun by F. Mason Sones, René Favaloro, and colleagues in 1967. The fundamental concept behind bypass surgery was that the symptoms and clinical events of coronary artery disease are related to stenotic coronary lesions that can be identified by angiography, and if those lesions are bypassed, then those symptoms and clinical events become less common. Experience has shown that concept to be correct.
Effective bypass surgery relieves symptoms of angina, and early randomized trials demonstrated that it prolongs life expectancy of some subsets of patients with severe coronary artery disease (CAD). The arrival of this anatomic treatment for CAD, the most common cause of premature death in Western countries, initiated a rapid growth in the personnel and medical infrastructure dedicated to bypass surgery. Along with the growth of bypass surgery came the development of endoluminal or percutaneous coronary intervention (PCI) of CAD. Also, pharmacologic treatments for CAD have progressed rapidly, particularly in the last decade. The roles of these complementary therapies for treatment of CAD continue to evolve.
In the early years of coronary artery bypass graft (CABG), patients were young and had limited CAD, good left ventricular (LV) function, and few comorbidities. Today, the surgical population is older and has extensive CAD and many comorbidities (Tables 65–1 and 65–2).1 The bypass surgery population has changed for multiple reasons: (1) Improved technology and experience have made it possible to operate on more complex and sicker patients with reasonable risk; (2) randomized trials demonstrated that the patients who derive the most benefit from CABG are those with left main or multivessel disease, diabetes, and abnormal LV function; (3) the population has been aging, and older patients have high expectations for their activity level; and (4) PCI provided an alternative treatment for patients with limited coronary lesions, removing many of those patients from being treated surgically.
Table 65–1. Preoperative Clinical Characteristics for the First 1000 Patients Per Year Undergoing Elective Primary Isolated Coronary Bypass Grafting |Favorite Table|Download (.pdf)
Table 65–1. Preoperative Clinical Characteristics for the First 1000 Patients Per Year Undergoing Elective Primary Isolated Coronary Bypass Grafting
|Age (years, median)||55||59||64||64||66||67||65|
|Age ≥70 y (%)||3||10||26||28||36||39||35|
|Single-vessel diseaseb (%)||15||8||3||9||10||10||5|
|Double-vessel diseaseb (%)||28||25||19||29||27||20||21|
|Triple-vessel diseaseb (%)||57||67||78||60||62||68||77|
|Left main coronary stenosis (≥50%) (%)||12||13||16||19||23||24||33|
|Left ventricular asynergy (%)||45||55||57||48||45||47||48|