1. Samuel Thomas Rayburn, III MD Cardiovascular Surgeon Jack Stephens Heart Institute April 25, 2015

2. CABG: The Gold Standard Coronary Artery Bypass Grafting (CABG) has been THE MOST STUDIED and scrutinized procedure in the history of medicine. Why? Rates of CABG declining substantially locally and nationally. Why? What is role of CABG in age of Percutaneous Coronary Intervention (PCI)? BMS and DES

3. CABG: The Gold Standard  No longer most common operation for Cardiac Surgeon  Current Role of Cardiology as “Gatekeeper”  Patient Preference?  Current CABG candidates – in general, those who can’t have PCI  Evidenced based Medicine??

4. CABG: The Gold Standard Randomized Trials (RCT) and Registries: CABG vs PCI: Acronyms Galore, BMS, DES, etc Outcomes: Mortality, Stroke, Re-intervention Rates and Myocardial Infarction Weaknesses of RCT’s: Atypical populations, small numbers of patients, Crossovers, and short duration of follow-up

5. CABG: The Gold Standard Registries: Large number of patients, propensity matched, represent “real world” conditions, but fatal flaw is treatment bias

6. CABG: The Gold Standard 3 important clinical Trials: SYNTAX, FREEDOM, and ASCERT SYNTAX: (NEJM 2005)  Landmark trial  “all comers”  5 year outcomes  Absolute decrease in mortality, cardiac death, myocardial infarction, and need for repeat revascularization in CABG group  Survival curves for PCI and CABG continuing to diverge

7. CABG: The Gold Standard FREEDOM (NEJM 2012): Multivessel disease with Diabetes Superiority of CABG demonstrated again with absolute increase in survival rate and decreased rate of Myocardial infarction

8. CABG: The Gold Standard FUNDAMENTAL QUESTION WHY DOES CABG HAVE A SURVIVAL BENEFIT OVER PCI?

9. CABG: The Gold Standard  Anatomically, atheroma is located in the proximal portion of the coronary arteries.  CABG places grafts to the mid portion of the vessels, giving benefit against the recurrence of the culprit lesion and development of future atheroma  Future PCI strategies unlikely to approach the benefits of CABG in complex CAD