91 - Coronary Artery Bypass Grafting

Abstract

Coronary artery bypass grafting (CABG) belongs to the most important surgical procedures in the history of medicine. Its development has generated a treatment perspective for millions of patients who were facing debilitating symptoms and possibly even death from coronary artery disease (CAD). With improvements in medical therapy and the development of less-invasive interventional alternatives (percutaneous coronary intervention [PCI]), the number of CABG procedures worldwide has been declining in recent years. Yet, CABG still represents the most common heart operation. Its value is currently most evident in patients with multivessel complex CAD. Its unique treatment mechanism, on top of symptomatic relief through improving blood supply, appears to lie in a collateralization effect of the bypass grafts, preventing new myocardial infarctions. Its conduct not only requires a thorough assessment of the patient’s coronary status but also a comprehensive work-up to assess (and if possible limit) operative risk. Contrary to expectations, mortality from CABG is often not higher than from PCI. Because a CABG treatment effect depends on the patency of bypass grafts, current efforts focus on factors improving long-term patency (e.g., multiarterial grafting, the role of fractional flow reserve, additional medical treatment, and technical training to improve surgical precision). Other activities address performance of classic CABG surgery through less- (off-pump) or minimally invasive (MIDCAB) approaches. This chapter outlines the history, anatomic considerations, and indications for CABG as well as details of the operative procedure and postoperative care.