I. The Coronary Arteries
II. Indications
III. Types of Grafts
IV. Outcomes
V. Complications
VI. Surgery in the Elderly
VII. Contraindications
VIII. Medications
IX. Coronary Bypass Surgery versus PCI
GLOSSARY
angina chest pain caused by temporary lack of blood to an area
of heart muscle cells, usually caused by severe obstruction of
the artery supplying blood to the segment of the cells. atheroma same as atherosclerosis, raised plaques filled with
cholesterol, calcium, and other substances on the inner wall
of arteries that obstruct the lumen and the flow of blood;
the plaque of atheroma hardens the artery, hence the term
atherosclerosis (sclerosis ¼ hardening). atrial fibrillation the most common, persistent arrhythmia that
is seen in medical practice; it may precipitate thromboembolic
stroke. ejection fraction the fraction of blood ejected from the heart
into the arteries, normally this ranges from 60 to 75%; a low
ejection fraction is less than 40%; often used as a marker of
left ventricular contractility. embolism, embolus a blood clot that forms in an artery, a vein,
or the heart that breaks off and is carried by the circulating
blood, finally lodging and blocking the artery that supplies

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• I. THE CORONARY ARTERIES
  Dr. Rene Favoloro of Argentina performed the first coro¬nary artery bypass graft (CABG) in 1967 at the Cleveland Clinic. He used a vein from a patient’s leg to bypass the obstruction in the coronary artery. Since that time, several million bypass operations have been performed worldwide. Coronary artery bypass grafting is a simple procedure: A vein from the patient’s leg is removed and inserted into the aorta as it leaves the heart and the other end of the vein is joined to the coronary artery below the blockage. Blood then flows from the aorta through the vein graft beyond the blockage to the coronary artery and to the heart muscle (see Fig. 1). When possible, surgeons prefer to use the internal mammary artery instead of using a vein graft to bypass the blockage in the important left anterior descending (LAD) artery.
• II. INDICATIONS
  A. Stable Angina
• III. TYPES OF GRAFTS
  A. Saphenous Vein
• IV. OUTCOMES A. Survival
  Overall mortality of bypass surgery is approximately 3%. The operative mortality in patients over age 70, especially in women, is high — 6.3% versus 3.8% for men. Low-risk patients may have a mortality as low as 1%, but in patients with left ventricular dysfunction and an EF of 30% or less, mortality is as high as 9%. Survival at one month and 1, 5, 10, and 15 years is 97, 95, 87, 76, and 60%, respectively (see Table 1).
• V. COMPLICATIONS
  A. Acute Myocardial Infarction
• VI. SURGERY IN THE ELDERLY
  Surgery in relatively healthy patients between the age of 70 to 80 in the absence of diabetes, left ventricular dysfunction, and other cardiovascular atherothrombotic disease undergo bypass surgery with a small added risk compared to younger patients. In a large series of patients intraoperative mortality was 3.8% in men versus 6.2% in women. The presence of the above conditions and other comorbid conditions increases the risk considerably to more than 7%.
• VII. CONTRAINDICATIONS
  Severe damage to the heart muscle as manifested by recurrent heart failure or other indications of left ven¬tricular dysfunction and an EF of less than 30% is a major contraindication for bypass graft surgery. Such patients are very short of breath and often have fluid in the lungs. Shortness of breath cannot be relieved by surgery, and the heart muscle is not significantly strengthened for surgery.
• VIII. MEDICATIONS
  A. Perioperative
• IX. CORONARY BYPASS SURGERY VERSUS PCI
  Coronary artery bypass surgery is not in competition with PCI (coronary angioplasty with intracoronary stent). The two methods of treatment are complimentary. Many of the surgical studies listed were done without the use of internal mammary artery grafts. Also, the PCI studies consist mainly of coronary angioplasty with only some patients receiving stents. Most important, the new drug-eluting stents are superior to older stents and produce up to 90% reduction in stent stenosis (a restenosis rate of
• BIBLIOGRAPHY
  Abizaid, A., Costa, M. A., Centemero, M. et al. Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: Insights from the arterial revascularization therapy study (ARTS) trial. Circulation, 104: 533–3821 2001.