Chapter 68 - Coronary artery bypass procedures

Summary

Coronary artery disease (CAD) is a common condition in the USA, but the majority of patients are treated conservatively with pharmacologic and percutaneous coronary interventions (PCI) by interventional cardiologists. However, approximately 150,000 patients in the USA undergo surgical revascularization for treatment of CAD annually. Coronary artery bypass grafting (CABG) is performed for the relief of anginal symptoms and to prolong life. Extended relief of angina can be expected in approximately 90% of those with reasonable distal vessel targets. Coronary artery bypass surgery is indicated in patients with angiographically proven CAD with unstable angina refractory to medical therapy or to percutaneous transluminal coronary angioplasty (PTCA), positive results on exercise or thallium stress testing, significant left main coronary artery disease, or complex double or triple-vessel CAD. Coronary artery bypass, when compared with medical therapy, has been shown to provide a survival advantage in patients with left main coronary artery stenosis, triple-vessel disease, double-vessel disease with proximal left anterior descending (LAD) artery stenosis, and in patients with depressed left ventricular function. The recently published results of the multi-institutional randomized SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial confirmed that CABG remained the preferred method over PCI for treatment of patients with three-vessel or left main coronary artery disease. In those patients presenting with chest pain and an evolving myocardial infarction of less than 6 hours duration, either percutaneous or surgical revascularization are plausible treatment modalities. Intractable ventricular arrhythmias may be an additional indication for emergent surgical intervention since control of arrhythmias and ultimate survival may result despite the grave prognosis.