Pro: Standard CABG is the procedure of choice for myocardial revascularization

Abstract

The standard CABG operation, which was developed by Favalaro and colleagues in 1967,1 has today reached the stature of being regarded as one of the best tested, most proved interventions of any type in the history of medicine. The standard CABG represents the gold standard of the first order against which any new approaches to coronary revascularization need to be critically compared. It provides a completely controlled surgical field, permits complete revascularization, produces excellent relief of angina, in both the short and long term, prolongs life in important subgroups and can improve left ventricular function in patients with impaired baseline function.2 Thus, standard CABG meets the goals that could reasonably be set for the surgical treatment of coronary artery disease. It is today being accomplished with excellent, reproducible results in surgical centers all over the world. It can be performed by the average cardiac surgeon and has the lowest operative mortality and morbidity of any operation for ischemic heart disease. It goes without saying that a major surgical endeavor like CABG has some adverse effects. But over the decades it has become evident that cardiopulmonary bypass (CPB) is generally well tolerated. Devastating complications are rare and most adverse effects are mild and recoverable. The concept of off-pump CABG (OPCAB) is not new. It was described in 19673 and continued to be performed by a few surgeons. With CPB becoming more safe and refined, OPCAB became nearly obsolete. However, in recent years, there has been an upsurge of interest in OPCAB in an attempt to avoid the deleterious effects of CPB. Enthusiasts for OPCAB emphasize broad views on the systemic inflammatory response, neurologic and renal damage and cost benefits. This importance of cost control in medicine has become a driving force in the pursuit of alternatives to standard CABG. OPCAB is now possible. But is it better? There is no consensus. This article examines a number of pertinent issues regarding comparative merits and demerits of the standard CABG and OPCAB. For the purposes of the current discussion, standard CABG will be compared with the technique of performing CABG using a midline sternotomy but without the use of CPB.