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State ofthe Art Surgical
CoronaryRevascularization
State ofthe Art
Surgical Coronary
Revascularization
EDITED BY
David P Taggart
Professor of Cardiovascular Surgery, Nuffield Department of Surgical Sciences,
University of Oxford, John Radcliffe Hospital, Oxford, UK
John D Puskas
Professor of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai,
Chairman, Department of Cardiovascular Surgery, Mount Sinai Morningside, Mount Sinai Beth
Israel, and Mount Sinai West, New York, USA
Co- Editor
Mario Gaudino
Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery, Weill Cornell Medicine,
New York–Presbyterian Hospital
Section Editors
Section 1:Thomas F.Lüscher, Valentin Fuster, and Prashant Vaishnava
Section 2:Patrick W.Serruys, David R.Holmes, and Vasim Farooq
Section 3:Stephen E.Fremes and Michael E.Halkos
Section 4:John M.Murkin and Gregory Fischer
Section 5:John M.Murkin and Gregory Fischer
Section 6:Tristan D.Yan, Ki- Bong Kim, Paul G.Bannon, and Mario Gaudino
Section 7:Joseph F.Sabik, III, Stuart J.Head, and Vipin Zamvar
Section 8:Naresh Trehan and Yasir Abu- Omar
Section 9:Marc Ruel and David Glineur
1
3
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Great Clarendon Street, Oxford, OX2 6DP,
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© Oxford University Press 2021
e moral rights of the authors have been asserted
First Edition published in 2021
Impression:1
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and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number:2020939206
ISBN 978– 0– 19– 875878– 5
DOI: 10.1093/med/9780198758785.001.0001
Printed in Great Britain by
Bell & Bain Ltd., Glasgow
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
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Foreword
ere never has been an operation like coronary bypass surgery.
ere is more evidence, and more good evidence, from randomized
trials, large registries, and large observational studies that coronary
bypass surgery prolongs patient survival than there is for any other
operation or procedure in the history of medicine. ere may be
other operations that prolong survival, but the incredible volume of
data regarding coronary bypass surgery and the impact of coronary
bypass surgery on survival relative to other forms of treatment for
coronary artery disease is unmatched. e advent of coronary bypass surgery made possible a specialty of Adult Cardiac Surgery, and
despite the advances in many other areas of Cardiothoracic Surgery,
bypass surgery is still the underpinning of most such programs in
the world. It is the most common thoracic surgical operation—by far
the most economically productive—and allows most adult cardiac
programs to exist.
Experimentation with dierent concepts of myocardial revascularization was carried out throughout the rst half of the twentieth century, as it seemed logical to many that if some way to
increase and make more secure the blood supply to the heart could
be devised then the death and disability associated with coronary
atherosclerosis could be ameliorated. However, a number of parallel
intellectual and technical advances were necessary for coronary
surgery to ourish.
e rst step was understanding the pathology of coronary atherosclerosis. Two important principles became established. First
was the concept that the stenoses in the coronary arteries were responsible for causing the lack of myocardial blood ow (ischemia)
that produced angina and possibly myocardial infarction. Today
that idea is clear, but it was not always so. And second, in most situations those stenoses are not randomly distributed throughout the
coronary arteries, but tend to occur proximally more commonly
than distally. e recognition of these two principles made bypass
surgery logical. Developing in parallel with these principles was
anticoagulation, with heparin, and antibiotics that decreased the
risk of infection during procedures. Without these pharmacologic
advances, clinical bypass surgery would not have expanded the way
it did.
Many strategies for revascularization, both direct and indirect,
were investigated experimentally and clinically by numerous investigators, but the date usually accepted as the systematic beginning of
bypass surgery was 1967, when Favaloro and colleagues performed a
bypass gra to the right coronary artery. e essential contributions
of the Cleveland Clinic team were that this was a planned approach
to the treatment of coronary artery disease, the surgery was guided
by angiography, and they kept at it. It was not meant to be anecdotal,
but a widespread treatment. e potential value of bypass surgery
was readily apparent, and by the early 1970s it was being performed
in many centers in the United States and around the world.
Many versions of how bypass surgery was performed were explored by many surgeons, and it should be understood that many
of the varieties of surgery still being investigated today were present in the 1970s. O-pump surgery, alternative incision surgery,
internal mammary artery gras, single and bilateral, radial artery
gras, free arterial gras, upper extremity vein gras, sequential
gras, interrupted and continuous anastomotic techniques, and a
variety of medications to control bleeding were all explored during
the 1970s. We have spent the last y years trying to dene their role
and few of these strategies have been completely abandoned. But by
the 1990s the standard bypass operation had become the le internal
mammary artery as a gra to the le anterior descending coronary
artery (LITA-LAD) along with vein gras performed to other stenotic vessels.
Underappreciated has been the impact of bypass surgery on the
delivery of healthcare in general. Early randomized trials of bypass
surgery set the standard for how new treatment strategies and devices have been investigated, and the use of large bypass surgery
registries has brought scientic observation to bear on questions
that have been dicult to answer with randomization, sometimes
because of the lack of equipoise. e specialties of Cardiology and
of Interventional Cardiology were essentially created by bypass
surgery, in addition to the specialty of adult cardiac surgery. e
juxtaposition of the Medicare-Medicaid Act of 1965, along with the
initiation of bypass surgery in 1967, meant that not only was there a
potential treatment for the disease that was the most common cause
of death in Western society but also that doctors and hospitals could
get paid for doing it. Investments in hospital infrastructure could
be recouped by the economic productivity of the care of coronary
disease, partially from the income from bypass surgery and partially
from the income from other treatments, such as percutaneous coronary interventions (PCI), that developed in the wake of bypass surgery. e growth of hospitals and healthcare systems in the United
States and in many other countries in the world over the last y
years has been largely fueled by the hospital income from bypass
surgery.
e emphasis on quality in healthcare over the last twenty years
has been led, in large part, by analyses of bypass surgery. Bypass surgery has been the most common cardiac operation, occurring in
numbers large enough to allow statistical analysis. Many institutions
have kept data regarding short- and long-term outcomes, based in
part on professional pressure and in part on the public’s desire for information. Bypass surgery counts, the issue is life and death and the
public seems to understand this. Bypass surgery has become part of
vi
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Foreword
popular culture. e same has been true for PCI. Furthermore, data
monitoring has led to the establishment of clinical standards based
on those registry analyses. For example, to our knowledge the use
of the LITA-LAD as part of the bypass operation is the only surgical
technique to be mandated as a mark of quality in the performance
of any operation, despite the lack of randomized data supporting
this concept.
is new major textbook attempts to examine coronary bypass
surgery past, present, and future in all its many forms. A huge
volume of data exists regarding the comparisons of the outcomes
aer bypass surgery with that of alternative treatments and those
data are reviewed in detail. But to a very large extent those data
involve comparisons of alternative treatments with a standard bypass operation, LITA-LAD with SVGs to other vessels, complete
revascularization and performed on-pump. But bypass surgery has
become more varied. e dilemma many surgeons face is whether
or not modications in the operation—oen done in attempts to
decrease morbidity, improve cosmesis, or reduce hospital stay or
cost—can be done while consistently achieving the same positive
impact on survival documented for the standard operation. ese
questions are examined by experts in those areas and while all
predictions about the future are speculative, those speculations are
based on experience.
It is a good time for such a complete review of myocardial
revascularization and its many facets. Data continue to accumulate,
options have widened, and surgical skills become more varied. As
those data accumulate, it still is clear that bypass surgery is a unique
intervention compared with other treatment alternatives. e many
advances made in interventional cardiology have expanded the PCI
options and have made great progress in the control of restenosis,
but have not yet shown that in-line anatomic corrections have the
same impact on long-term patient survival that has been demonstrated for bypass surgery. Bypass surgery matters and uniquely prolongs survival for many patients as long as it is performed expertly.
is volume is a compendium of the current state of bypass surgery
and presents a future agenda.
Bruce Lytle, MD
Department of Cardiac and oracic Surgery
Baylor Scott & White
e Heart Hospital
Plano, TX, USA
Foreword: Il megglio è l’inimico del bene
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Aristotle promoted the ‘golden mean’ as a middle road between the
extremes: bad and best. In the Renaissance, it was well expressed in
an Italian aphorism, ‘Il megglio è l’inimico del bene’, meaning ‘e
best is the enemy of good’. In modern economics one could translate
this into a statement that ever-increasing eorts will gradually result
in diminishing returns. is concept limits at a certain moment any
further research and investment into the improvement of a product
or a procedure.
Ferdinand Sauerbruch and Jan Mikulicz-Radecki explored in
1904 the opening of a chest without ventilatory collapse of the patient. Walt Lillehei in 1954 conceptualised cross-circulation as a
phenomenal rst step towards extra-corporeal circulation. is
opened the door towards correcting congenital as well as acquired
pathologies of the heart. ese geniuses explored outside the ‘golden
mean’ in a search to treat a patient. Indeed, a medical professional
receives from society the unique privilege to ‘damage’ the physical
and mental integrity of the patient, conditional on proof of benet
in quality and quantity of life. Walt Lillehei also repeated in each
lecture his internal ethical combat that drove his exploration beyond
the ‘golden mean’.
In coronary pathology, Robert Goetz (1960), Vasilii Kolesov
(1964), Dudley Johnson (1966), and René Favoloro (1967) opened
the doors for coronary revascularisation. e departmental, institutional, technical and ethical barriers they had to confront were immense. ey did not accept what was then good, but explored the
best as the ultimate respect for the individual patient. is extreme
exploration of the unknown became coronary bypass surgery, the
globally most frequently performed surgical procedure, as common
as an appendectomy.
Transforming a procedure from a rare exploration in the unknown
to a routine procedure demanded new leadership and confrontation
with translational concepts. John Kirklin and Eugene Blackstone,
with their exceptional vision, made us understand that the art (if
ever) of coronary surgery had to become a science with a need to
implement scientic and industrial processes. Procedural success
alone was not sucient, but late success was the ultimate ambition.
ey proposed standard operating procedures, even automation, for
every aspect of preoperative, operative, and postoperative care. ey
proposed quality control databases and patient-reported outcomes.
ey set the rules for complete follow-up of the patient and proposed mathematical modelling to understand the benets but also
the limitations of cardiac surgical interventions.
is complex mathematical modelling made us understand that
there was a price to be paid to obtain later benets. ere was an
early procedural risk, extending far beyond the immediate hospital
stay and dependent not only on patient factors, but also by procedural, institutional, and surgeon variability. While the late outcomes
of the surgical team improved with experience, certain individual
patients paid a heavy or the ultimate price. One could accept this
as the ‘golden mean’ and stop further exploration of the unknown.
But, let us not forget ‘Primum Non Nocere’ and our unique privilege, based on proof of benet in quality and quantity of life for the
individual patient, rather than for a group of patients. Every patient
that has a complication is arguably a failure for the surgeon versus
his unique obligation towards society.
Let us not blame the patient and his comorbidities but reect on
how we should, using the power of science and the visionary capabilities of certainty, adapt the procedure to the patient, eliminate
early risk and simultaneously optimize late results. Let us not accept
the good but search for the best for our coronary patient. Our personal eorts should not be measured, as they are irrelevant, but only
the positive returns for the patient.
is new major textbook edited by John Puskas and David
Taggart describes the exploratory pathways towards the best possible coronary procedure and the evidence obtained. Both medical
professionals have not just proven their surgical skills over the years,
but have explored unknown territories, studied the risks and benets in the most critical scientic manner, and have deposited this in
a brilliant book for all of us to participate in their previous and future
scientic expeditions for the benet of the patient.
Paul Sergeant, MD, PhD
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Foreword
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Coronary artery bypass graing (CABG) has saved the lives of enormous numbers of ischemic heart disease patients in the past half
century like a ‘bridge over troubled water’. Japan and many of other
Asian countries instituted CABG in the early 1970s inspired by the
Cleveland Clinic success in CABG using saphenous vein gra. In
the beginning, however, surgical results were not satisfactory in Asia
due to lack of surgical experience and the smaller body structure of
Asian people compared to those of Euro-Americans.
In the mid-1980s, the Cleveland clinic published a very important
message once again regarding the superiority of the internal thoracic artery gra on patient survival aer CABG. Most Asian cardiovascular surgeons, however, were reluctant to adopt the internal
thoracic artery graing because of the small caliber and fragile wall
of the artery in Asians. Nevertheless, Dr Soichiro Kitamura and I
started an aggressive use of the le internal thoracic artery gra
to the le anterior descending coronary artery in 1985 in Japan.
Inspired by our favourable early surgical results, Japanese and other
Asian surgeons then accepted this strategy as a standard procedure
and conrmed that the internal thoracic artery can be used safely
even in patients with a small body stature. Along with more liberal
use of the internal thoracic artery as double, free, and a sequential
gra, the search for an alternative arterial conduit became a central
interest for cardiac surgeons all over the world.
In 1986, I introduced the right gastroepiploic artery as a potentially suitable conduit for CABG based on basic scientic studies
and clinical application. Many Japanese and South Korean surgeons learned how to use it successfully and a cumulative number
of CABG with the gastroepiploic artery has increased until now. e
right gastroepiploic artery gra was used in 1,049 cases in 2018, as
reported by a national survey of CABG practice in Japan. On the
other hand, the radial artery gra has become the most frequent
gra next to the internal thoracic artery in Australia.
As a next technical aspect in CABG, an o-pump beating heart
anastomosis evolved in the late 1990s. While this particular procedure became common in South America due to a lack of the
availability of extracorporeal circulation during the early period
of CABG, sophisticated developments in surgical instruments and
pharmacological support to suppress the heart beat during anastomoses made the results satisfactory. In Japan in 2018, the total
number of CABG was 20,271, and isolated CABG was performed
in 13,390 patients with an overall 2.5% operative mortality and 1.3%
in 10,847 patients when redo and emergency operations were excluded. Among initial elective CABG procedures, the o-pump
CABG ratio was 56% and operative mortality of o-pump cases was
slightly better than in patients with on pump procedure.
Concerning the number of annual CABG in Asian countries,
it is variable depending on their population. In Japan, the annual
number of CABG has been steady around 18,000 to 20,000 from
2017 through 2019. On the other hand, the number of percutaneous
coronary intervention (PCI) was around 270,000 per year; therefore, PCI is 14 times more common than CABG in Japan. In South
Korea, CABG was performed consistently in around 4,000 patients
while PCI was slowly increasing to over 60,000 cases per year from
2017 through 2019 (personal communication by Dr Kim Ki-Bong).
erefore, their PCI/CABG ratio of 15 is similar to that of Japan.
Looking at UK practice, reported in the British Journal of Cardiology
in April 2020, the number of CABG was around 15,000 and PCI was
about 100,000 per year; therefore, the current PCI/CABG ratio is
6.7. In the United States, the annual number of CABG was around
150,000 to 160,000 and PCI was 600,000 to 630,000, based on the
STS database, giving a PCI/CABG ratio of around 4.0, signicantly
lower than that reported in Japanese and Korean practice.
In April 2019, updated results of ISCHEMIA TRIAL were published in the New England Journal of Medicine. ey demonstrated
that a surgical or catheter coronary intervention failed to reveal
signicant superiority on the prognosis of ischemic heart patients
compared with a conservative (non-invasive) approach, pharmacological treatment, diet, and exercise at 3.2 years follow-up. While the
impact of a conservative approach on the choice of initial treatment
is striking, the importance of patient selection and a relatively short
period of follow up is still debatable.
In 2020, the global human population has been seriously damaged by COVID-19, an epidemic that is still on-going. In our medical world, every surgical practice has been suppressed because of
fear of infection and shortage of manpower. Consequently, conservative therapy might be favored until successful viral control can be
established.
In summary, Asian CABG practice has steadily progressed in the
last half century. Despite a small body stature and relatively fragile
arterial wall compared with the Euro-American population, surgical
results are excellent and many innovative contributions have been
made from Asia in the history of CABG.
Finally, I truly believe that this new CABG textbook gives a comprehensive update of the latest knowledge and treatment recommendations to cardiac surgeons, cardiologists and all those involved
in the treatment of ischaemic heart disease across the world.
Hisayoshi Suma, MD
Suma Square Clinic
Tokyo, Jap an
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