What research is needed for future advances in coronary artery bypass grafting (CABG)?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Despite a steady increase in the proportion of older and higher risk patients being referred for surgery, major perioperative morbidity and mortality continues to be low, and long-term outcomes are excellent. With an operation that has stood the test of time, future advances in percutaneous coronary interventions (PCIs), molecular therapeutics, and novel surgical approaches must be rigorously compared to the gold standard of coronary artery bypass grafting (CABG).

Current mortality risk prediction models for CABG do not have a standardized approach to defining outcome and predictor variables, and they include problematic issues such as inadequate sample sizes, inappropriate handling of missing data, as well as suboptimal statistical techniques. [39] Future risk modelling will need to improve upon these factors to refine the quality of mortality risk prediction.

The surgical robot allows surgeons to remotely manipulate fully articulating videoscopic instruments by way of "master-slave" servos and microprocessor control. The improved video resolution is an advantage, but the added expense and time required as well as difficulty with learning this technique, in addition to the limited applications in CABG surgery, has limited the role of robotic-assisted CABG.

A relatively recent development is hybrid surgical and percutaneous revascularization. In this approach, patients undergo not only minimally invasive CABG, most often with the use of the left internal thoracic (mammary) artery graft to the left anterior descending coronary artery, but also undergo PCI of lesions in the circumflex and right coronary arteries. This strategy provides the benefits of CABG with a lower morbidity and could emerge as the new standard for patients with multivessel coronary artery disease (CAD). [40, 41]

CABG does not prevent the progression of native CAD, however, both disease progression and vein graft failure can be ameliorated by aggressive secondary prevention with medical therapy. [42] The American Heart Association recommends life-long antiplatelet therapy. [43]  Daily intake of low-dose (81 mg) aspirin may be preferable to minimize the risk of bleeding. Beta blockers should be used in patients with recent myocardial infarction, left ventricular systolic dysfunction, or in patients with non-revascularized CAD. All patients, regardless of their lipid values should receive life-long high-intensity statin therapy. Diet, exercise, and smoking cessation are well known adjuncts to promote improved cardiovascular health. [43]


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