Coronary Artery Surgery

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Presentation transcript:

Coronary Artery Surgery Floyd D. Loop, MD The Annals of Thoracic Surgery Volume 79, Issue 6, Pages S2221-S2227 (June 2005) DOI: 10.1016/j.athoracsur.2005.02.080 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Evolution of coronary artery surgery. This maze indicates significant events in the evolution of coronary artery surgery. The major discoveries of extracorporeal circulation and coronary arteriography enabled coronary artery bypass to be performed with improving rates of success. (CABG = coronary artery bypass grafting; IMA = internal mammary artery; OPCAB = off-pump coronary artery bypass grafting.) The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Trends in hospital mortality for isolated coronary bypass grafting are displayed by the bars (left ordinate). The severity score denotes a risk-adjustment calculation. The rising calculated risk is depicted by the curve, and the severity score is displayed on the right ordinate. Risk increased with time as a result of older age patients who have more comorbidity, yet the hospital mortality is decreasing to about 1% and reoperations are included. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 The rise in number of women surgical candidates during a 20-year period is shown, reaching approximately a quarter of surgical candidates today. Women tend to have more false-positive exercise tests than men and tend to be older at the time of surgery. Their risk is slightly higher because they are older and have more comorbidity. Complete revascularization is attained equally although women have a higher hospital mortality. Their long-term survival after surgery is approximately the same as men. (BSA = body surface area; CABG = coronary artery bypass grafting; Cor Athero = coronary atherosclerosis; PCI = percutaneous coronary intervention.) The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Serial angiographic studies of approximately 5,000 bypass grafts were examined at 1 year, 5 years, and up to 15 years after surgery [10]. Note the percentage of grafts that occluded with time continues to rise so that approximately 50% of grafts are closed at 15 years. Only a small percentage of patent grafts are free of perceptible atherosclerotic narrowing at 15 years. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 The Post Coronary Artery Bypass Graft Trial [14, 15] reviewed the results of aggressive (black bars) and moderate (gray bars) lipid-lowering therapy on the progression of vein graft atherosclerosis. The percentage of grafts patent with no progression is shown for each of the treatment categories. Aggressive lipid-lowering therapy correlated with less native vessel and vein graft occlusion and a lower incidence of new lesions in native vessels. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 An internal thoracic artery (ITA) graft to the left anterior descending coronary artery (LAD), with or without vein grafts, has been compared with vein grafts only during a period of 10 years [21]. The three frames depict one-vessel (left anterior descending disease), two-vessel with the left anterior descending involved, and three-vessel disease. In each instance, the patient who received an ITA graft to the left anterior descending, with or without vein grafts, had a better 10-year survival than those who received vein grafts only. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 This 15-year follow-up from the Coronary Artery Surgery Study (CASS) Registry [22] showed significantly higher survival for patients who received an internal thoracic artery (ITA) graft compared with those who received vein grafts only. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Although the incremental benefit of bilateral internal thoracic artery (BITA) grafting compared with single internal thoracic artery (SITA) grafting is not as large as the benefit of a left internal thoracic artery graft to the left anterior descending coronary artery compared with vein grafts only, the extended longevity in the second decade is readily apparent [23]. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 The prevalence of cardiac procedures is shown for the past decade from the northern New England Registry (E Nowicki, personal communication, 2004). Coronary artery bypass grafting (CABG) surgery peaked in 2000 and has fallen significantly in the past 2 years. The prevalence of coronary artery stenting is thought to account for this decrease in surgical procedures. In contrast, the number of aortic valve and mitral valve procedures has increased with time. The Annals of Thoracic Surgery 2005 79, S2221-S2227DOI: (10.1016/j.athoracsur.2005.02.080) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions