CABG SURGERY

PHYSICIANS PERSPECTIVES
DR.R.MEENAKSHI SUNDARAM MS MCH
Consultant Cardiothoracic Surgeon
DEVADOSS HEART CENTRE
Senior ASSISTANT PROFESSOR DEPT OF CARDIOTHORACIC
SURGERY
GOVT RAJAJI HOSPITAL&MADURAI MEDICAL COLLEGE
WHAT THIS PRESENTATION IS ABOUT

CABG VS PCI
OFFPUMP VS ONPUMP
DAY TO DAY PRACTICE
ORIENTED PEARLS
FEW CLINICAL SCENARIOS
 HISTORICAL FACTS
The introduction of coronary artery bypass surgery (CABG) in 1968 resulted in a paradigm shift
in the management of coronary artery disease.
Percutaneous transluminal coronary angioplasty as a nonsurgical alternative in 1977 by
Gruntzig dramatically altered the landscape

1968 Favaloro 1st surgeon to perform bypass

surgery (SVG)

1957/8 Bailey/Longmire report successful coronary

revascularization on a beating heart
CURRENT SCENARIO OF REVASCULARISATION
CABG PCI/STENTING
• Angina relief
• Reduced reintervention Initially cost effective
• Complex anatomy Fast recovery
Reduced acute
• Complete
complications
revascularization
Least invasive
• Mortality benefit in Increased restenosis
selected patient groups Repeat revascularization
• Potential high costs
• Invasive
 IT WAS THE STORY THEN
In 2003/04.....Existing (and ongoing) trials did not address
real-world questions and were
MEDICAL MANAGEMENT OR INTERVENTION
SURGERY OR STENTING
BEATING HEART OR ON PUMP
ARTERIAL GRAFT OR VENOUS GRAFTS…
List was long…….
Though current, standard techniques for
CABG and PCI was followed there were no randomized trials data to compare
CABG and PCI
Practice of Evidence based medicine
The SYNTAX Trial
Synergy Between PCI With Taxus DES And Cardiac Surgery
Trial Design And Philosophy

With 1800 patients randomized from 85 centers in the Europe and the
United States, this has been the largest randomized controlled study of PCI
versus CABG.
Open Inclusion Criteria
3-vessel disease and/or left main disease
Renal and respiratory insufficiency
Decreased pump function
Patients with multiple comorbidities
 SYNTAX Randomized trial
5-year all-cause mortality was 14.2% for PCI with drug-eluting stents and
9.2% for CABG (P <.05)
CABG reduced all-cause mortality by 5.0% over 5 years, corresponding to a 5-
year NNT of 20 (=100/5.0).
LIMA grafting was done in 97% of patients in the CABG group.
In 2019, the 10-year results of the SYNTAX trial were reported.In patients
with 3-vessel disease, 10-year all-cause mortality was 28% for PCI and 21% for
CABG.
 CABG resulted in a LOWER all-cause mortality over 10 years, corresponding
to a 10-year NNT of 14.2 (= 100/ 7).
 Surgical revascularization resulted in
a more complete revascularization
 Lower rates of major cardiac or
cerebrovascular events in a long-term
follow-up.
 Also, grading the incompleteness of
revascularization through the
residual SYNTAX score was done.
 SYNTAXES The SYNTAX Extended Survival study
Ten-year survival after coronary artery bypass
grafting vs PCI

COMPLETE REVASCULARISATION VS
10 YEAR ALL CAUSE
INCOMPLETE REVASCULARISATION
MORTALITY

 PCI versus CABG (56.6% versus 36.8%) 10-year all-cause mortality was
 Surgery had lower IR more so for LMCA
disease 28% for PCI and 21% for
CABG
 FREEDOM TRIAL For Diabetics
The Future Revascularization Evaluation in Patients with Diabetes Mellitus:
Optimal Management of Multivessel Disease (FREEDOM) trial was reported
in 2021.
The 5-year mortality rate was 10.9% in the CABG group and 16.3% in the PCI
group (P =.049)
CABG reduced all-cause mortality by 5.4% over 5 years, corresponding to a 5-
year NTT of 18.5 (=100/5.4).
A concept called “number needed to treat” (NNT); the number of patients
who must undergo CABG during a specific time to prevent 1 adverse outcome
is used. It is the reverse of the absolute risk reduction (ARR).
THE LOWER THE NNT THE BETTER IS OUTCOME
NNT FAVORS THE CABG
 STICH TRIAL For LOW EF
The Surgical Treatment for Ischemic Heart Failure (STICH) trial was a
randomized trial of patients with low cardiac function with an ejection
fraction of 35%.
CABG reduced all-cause mortality by 7.2% over 10 years, corresponding to a
10-year NNT of 13.9 (= 100/7.2)
Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure
in Patients With Reduced Ejection Fraction and Coronary Artery Disease A
Meta-Analysis(Circ Heart Fail. 2017;10:e003255. DOI:
10.1161/CIRCHEARTFAILURE.116.003255.)
CABG scores better with survival benefit and reduction in 5 year mortality
EXCEL TRIAL For LMCA LEFT MAIN DISEASE
XIENCE versus Coronary Artery Bypass Surgery for
Effectiveness of Left Main Revascularization (EXCEL) trial
of patients with LMCA disease
The reduction in all-cause mortality with CABG 3.1% at 5
years (13.0% PCI vs 9.9% CABG) (P = <0.05)
 Evidence Based Medicine
To summarise the current durability of CABG is Superior,
particularly in patients with
• Complex Multivessel Disease
• Diabetes
• Left Main Disease
• Low EF
• Renal Failure
 Consensus Off-Pump versus on pump
RCTs have reported similar operative risk for off- and on-pump CABG
Meta-analysis of 35 propensity-matched studies OPCAB to be superior to on-pump
surgery for all short-term outcomes including mortality
OPCAB can be associated with better outcomes in high-risk patents. Elderly patients,
patients with low EF, those with high neurological risk, and patients with end-organ
failure.
Off-pump was associated with
Less stroke,renal failure
Less pulmonary complication ( P = 0.01),
Infection
Postoperative transfusion (P = 0.02)
Off-PumpCoronaryArteryBypassGrafting:30YearsofDebateMario Gaudino MD et al J Am Heart Assoc. 2018
MULTIPLE ARTERIAL GRAFTS VS SINGLE ARTERIAL
GRAFTING
Subgroup Analysis Of Syntax Patients
At the longest follow-up of 12 years, all-cause death occurred in 23.6% of
MAG and 40.0% of SAG patients( P = 0.038 ).
MAG resulted in markedly lower all-cause death at 12-years follow-up
compared to a SAG strategy. Hence, this striking long-term survival benefit
of MAG over SAG encourages more extensive use of multiple arterial
grafting in selected patients with reasonable life expectancy.
MAG may be bilateral Mammary or Radial
 RECENT ADVANCES
 Minimally invasive CABG(MIDCAB) in which all areas of the heart are bypassed via a
small left anterolateral thoracotomy, usually without the use of the heart–lung
machine.
 Robotic total endoscopic coronary bypass grafting in which robotic techniques are
used not only for internal mammary artery harvest but also for the performance of all
graft anastomoses
 HCR, which combines the performance of a single LIMA-LAD graft via a small
anterolateral thoracotomy, with PCI to the other myocardial territories of the heart
that require revascularization.
 CLINICAL SCENARIO 1

 A 40-year-old male,smoker with hypertension, presents with recurrent chest pain

radiating to the back. ECG and enzymes reveal recent anterior myocardial
infarction .ECHO shows 32 % EF with hypokinesia of AW/apex/IVS.
 CAG reveals non stentable TVD
 CABG done with grafts LIMA to LAD.SVG grafts to Diagonal/Large OM/PDA
 This scenario depicts completeness of revascularisation in a young individual
 CLINICAL SCENARIO 2
  A 60-year-old woman with hypertension/uncontrolled diabetes/obesity and atypical chest pain and
breathlessness on ECG shows old AWMI and Echo reveals dilated chambers with RWMA involving anterior
and inferior walls with severe MR
 Patient taken up surgery .She underwent CABG onpump LIMA to LAD/SVG to OM/PDA followed by Mitral
Valve Replacement single stage.
 Patient discharged on tenth postoperative day with oral anticoagulants and aspirin.

Concomitant procedures can be done safely even in elderly with multiple comorbidities
 CLINICAL SCENARIO 3
 A 55 year old man diabetic/hypertensive/admitted with acute onset of chestpain/severe
breathlessness and cardiogenic shock.He was resuscitated with inotropes and elective
ventilation.Echo revealed hypokinetic LV AW and EF 28%.he had already underwent
PCI 8 years back.CAG revealed TVD with INSTENT RESTENOSIS.Patient had elevated
renal parameters with urea 65 AND CREATININE 2.1 .
 Patient taken up for CABG OFFPUMP with IABP support /with grafts to LAD/OM/PDA.
After obtaining high risk consent and need for dialysis.In view of poor target LAD SVG
graft was used.Fortunately patient recovered without dialysis and was weaned from IABP
and ventilator on second POD and discharged on twelvth POD.
 CABG ends up as a life savingprocedure in select high risk individuals
 experience

 AROUND 900 OPEN HEART SURGERIES OVER 12 YEARS

 70% CABGS
 90% OFFPUMP/SELECTIVE ONPUMP
 SEVERE LV DYSFUNCTION IABP SUPPORT
 COMBINED PROCEDURES CABG+AVR/ CABG +MVR
 FAST TRACKING IN ICU EXTUBATION ON TABLE/< 2HRS
• Advances in Anaesthesiology and Surgical fields have
made CABG surgeries very safe with very low mortality
• CABG is the gold standard treatment for Coronary artery
disease with multi vessel disease/left main trunk
involvement/diabetics/renal disease
• Offpump surgery can be done safely with good long term
outcomes
• Arterial grafts provide long term patency
• Complete revascularization ensures survival benefit
• Minimally invasive /Robotic/Hybrid procedures may
make CABG more acceptable in future