Coronary artery bypass graft surgery (CABG)

Coronary artery bypass graftsurgery (CABG) Effective surgical treatment has had a profound effect onthe management of CHD in the developed world

. Coronaryartery bypass grafting can now be performed with anoverall operative mortality of under 1 %. Symptoms can beeradicated in 80-90% of patients and improved considerablyin a further 5-10%; a few are no better or, indeed,are worse following surgery. It might therefore be askedwhy this form of therapy, which aims to 'revascularize' theheart, is not offered to all patients with angina. Severalfactors are responsible, including:

Finite morbidity from surgery

Deterioration of grafts

Survival advantage for surgical treatment has beenproven for only moderate- and high-risk subgroups ofpatients

Benefit in symptoms has to outweigh the cost in wellbeingfor up to 12 weeks postoperatively.

Deterioration of grafts

Saphenous vein bypass grafts have an appreciable rate ofdeterioration: more than 90% are patent immediately aftersurgery, but then occlude at a rate of approximately 2% ofgrafts per year between 5 and 10 years, and at 4% per yearthereafter. About 60% of grafts are patent after 10 years.This implies that surgery is not a permanent cure, merelyanother method of symptom control in these patients.Improvements in early vein-patency rates have beenachieved by the use of antithrombotic agents, such asaspirin. Even more significant has been the use of theinternal mammary arteries (IMA) as grafts. This is moredemanding technically, but has been shown to providegreater than 90% patency rates at 10 years. Unfortunately,complete cardiac revascularization is not often possibleeven when both IMA are used.

Survival advantage

Survival is improved by surgery in those with left mainstem disease and those with three-vessel coronary diseaseand impaired left ventricular function. It isvery likely to improve survival in patients with severe angina, three vessel coronary disease and normal ventricular function.

The situation is less clear for patientswith less marked symptoms and those with little in the wayof symptoms but with a positive exercise test, althoughevidence is mounting that this group of patients alsobenefit from surgery.Surgery appears to be a more effective treatment for patients with continued symptoms not controlled by drugs.There is a diminution in fatal heart attacks, but probably not in non-fatal events. Randomized studies have failed toshow any differences between medical and surgical treatment in the numbers of patients who return to work, or inthe amount of recreational activity they take up. However,the sociological measures may not reflect the changes inperceived quality of life in the two groups of patients.

Thus, in general, patients are considered for coronaryartery surgery if medical therapy fails to control theirsymptoms adequately, or if they fall into the above higher risk groups. These broad guidelines conceal a large number of patients in a rather grey area, in whom individual assessments must be made. These might include young patients with severe stenoses causing highly positive exercise tests,in whom the consequences of occlusion might be a disabling infarction and in whom an internal mammary graftmight be expected to be a highly successful treatment.Patients with extensive left ventricular aneurysm mayoften improve, in terms of heart failure control and anginal symptoms, with plication or resection of the aneurysmal area.

Coronary artery bypass graft surgery (CABG)

By: Dr Izharul Hasan

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