Surgical outcome

Surgical outcome

Relief of symptoms If revascularisation is complete, CABG alleviates or improves anginal symptoms in more than 90% of patients at 1 year; this falls to 80% at 5 years and 60% at 10 years. This symptomatic deterioration usually reflects progression of atherosclerotic disease in vein grafts and native coronary arteries. Survival Studies have reported survival rates to be >95% at 1 year, 90% at 5 years, 75% at 10 years and 60% at 15 years. These results may improve in the future because of increased use of arterial conduits and widespread use of dual antiplatelet therapy , β -blockers and lipid-lowering agents. Summary box 59.8 Coronary artery bypass surgery outcome /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF CABG without the use of CPB is gaining popularity and may be combined with a minimally invasive approach or carried out through a conventional sternotomy . It avoids the potential physiological stress associated with CPB and, to some extent, - the aortic manipulation that can lead to neurological injury through atherosclerotic embolisation. Since the introduction of ® cardiac stabilising devices such as the Octopus ( Figure 59.8 ), - o ff -pump coronary artery bypass (OPCAB) grafting has become widespread in the UK and around the world. The advantages of o ff -pump surgery over on-pump have recently been questioned, especially with the development of mini-bypass pumps, which o ff er a closed circuit and minimal non-physiological surface area. This reduces proinflammatory activation but at the same time allows the surgeon to oper - ate on a still, bloodless heart. The disadvantages of OPCAB are mainly related to the quality and number of anastomoses. There is still no evidence to support the superiority of any of the above-mentioned techniques and the final decision is usu - ally based on the surgeon’s skills and the required operation. Minimal access surgery Minimally invasive direct coronary artery bypass (MIDCAB) grafting is performed through a small incision and avoids the invasive aspects of conventional CABG. Through an anterior submammary incision the LIMA can be dissected using a - thoracoscope and grafted to the LAD. More lateral incisions allow access to other coronary vessels, including branches of the circumflex artery . Although not yet evidence based, one approach is to combine MIDCAB (typically LIMA to LAD) with PCI to other less accessible coronary arteries (‘hybrid’ coronary revascularisation).

Mortality Survival 1–3%

95% at 1 year 90% at 5 years Perioperative infarct 75% at 10 years 2–3% 60% at 15 years Angina Improved in >90% at 1 year 80% at 5 years 60% at 10 years