Coronary artery bypass surgery (CABG) is the most common heart operation. Over 300,000 of this operation is done each year in this country alone. Until the recent advances in angioplasty, CABG was the most common operation in most major university hospital. Because of the enormous number of cases, this is the operation that has allowed university programs such as ours at Downstate over the last two decades to standardize the techniques of heart surgery and the conduct of the peri-operative care of patients. In short, this is the operation that has allowed field of heart surgery which comprises the most difficult and complex surgery done on the human body to mature into a stage where a high level of efficacy and safety is expected in its current practice.

In New York State, the average mortality (chance of death) from CABG is currently less than 2%, which is an astounding achievement in light of the seriousness of the operation. The 10 year patency (or the chance of having the bypass graft to stay open and functioning well) of an internal mammary graft to the left anterior descending coronary artery is in excess of 95%. CABG has developed into a routinely safe and long lasting operation.

The largest comprehensive data is from a study compiled by the New York State Department of Health, Cardiac Surgery / Angioplasty Advisory Committee published in New England Journal of Medicine in 20081. This study demonstrates superior survival benefit advantage of CABG over angioplasty-stent placement in patients with two or three vessel coronary artery disease. Patients with this condition lived longer after surgery than having stents placed in their coronary arteries. This study compiled the entire New York State experience of 17,000 consecutive patients who underwent surgery or stent over 15 months and followed their outcome over the next two years. Although this was not a prospective randomized study that may reduce the biases of the treatment choices, the reporting from the surgeons and cardiologists are mandatory and all inclusive in New York State. Therefore, this is probably the most important study that delineates the results of the current practice in the state of New York.

With angioplasty-stent placement as a more common treatment option than CABG, the surgeons are presented with increasingly higher risk patients for surgery. At the present, it is more important to choose a program that is equipped and trained to handle the complex needs of the patients presenting in the more advance age group and with multiple medical problems. These issues concern with patients in the most advance ages,2, 3, 4, 5, 6, 7 with end staged kidney disease and on dialysis8, with advance liver disease,9 with bleeding10 and other hematologic disorders.11

References: 1. E. Hannan, C Wu, G Walford, A Culliford, J Gold, C Smith, R Higgins, R Carlson, R Jones. Drug-Eluting Stents Vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease. New England Journal of Medicine 2008; 358:331-41. 2. Wilson Ko, Jeffrey P. Gold, Richard Lazzaro, John A. Zelano, O. Wayne Isom, Karl H. Krieger. Survival Analysis of Octogenarian Patients with Coronary Artery Disease Managed by Elective Coronary Artery Bypass Surgery Versus Conventional Medical Treatment. Circulation 1992; 86:[suppl II]:II-191 - II-197. 3. Wilson Ko, Karl H. Krieger, W. Douglas Lazenby, Yong T. Shin, Richard Lazzaro, Marjorie Goldstein, John A. Zelano, O. Wayne Isom. Isolated Coronary Artery Bypass Grafting in One Hundred Consecutive Octogenarian Patients: A Multivariate Analysis. Journal of Thoracic Cardiovascular Surgery 1991; 102(no. 4):532-538. 4. Anita Chiu, Daniel Lee, Wilson Ko. Off-pump versus conventional coronary artery bypass surgery for 97 consecutive octogenarian patients: an analysis of short term outcome and five year survival. Manuscript in preparation. 5. Wilson Ko. Coronary Artery Bypass Surgery in Elderly Patients. Facts, Research and Intervention in Geriatrics. 1997, 217-221. 6. Todd Rosengart, Eileen Finnin, David Kim, Sanjay Sami, Yvette Tanhekco, Wilson Ko, Samuel Lang, Karl H. Krieger, O. Wayne Isom, MD. Open Heart Surgery in the elderly: Results from a Consecutive series of 100 patients aged 85 years or older. American Journal of Medicine. February 2002, 112(2) p 143-7 7. Matthew Bacchetta, Wilson Ko, Leonard Girardi, Charles Mack, Karl Krieger, O. Wayne Isom, Leonard Lee. Outcomes of Cardiac Surgery in Nonagenarians: A 10-Year Experience. Annals of Thoracic Surgery. Annals of Thoracic Surgery 2005 Apr; 75(4):1215-20. Review. 8. Wilson Ko, Karl H. Krieger, O. Wayne Isom. Cardiopulmonary Bypass Procedures in Dialysis Patients. Annals of Thoracic Surgery 1993;55:677-84. 9. JD Klemperer, Wilson Ko, Karl Krieger, M. Connolly, TK Rosengart, N. Altorki, S. Lang, OW Isom. Cardiac Operations in Patients with Cirrhosis. Annals of Thoracic Surgery. January 1998; 65:85-87. 10. Ramesh Kumar, Daniel Lee, Joshua Burack, Vinay Tak, Peter Terry, Elizabeth Gloster, Wilson Ko. The use of recombinant activated factor VIIa as a rescue for profound coagulopathy immediately after cardiopulmonary bypass for cardiac surgery. Submitted to Journal of Cardiothoracic Surgery 11. Wilson Ko, O. Wayne Isom. Cardiopulmonary bypass procedures in patients with cold-reactive hemagglutination. A Case Report and a Literature Review. Journal of Cardiovascular Surgery 1996; 37:623-626.

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