What are the indications for Coronary Artery Bypass Grafting (CABG)?

From the Guidelines

Coronary artery bypass grafting (CABG) is indicated for patients with significant left main disease, multivessel coronary artery disease, especially those with reduced left ventricular function, and patients with diabetes mellitus and complex coronary anatomy. The primary indications for CABG include [ 1 ]:

• Left main coronary artery stenosis
• Multivessel coronary artery disease, especially with reduced left ventricular function (ejection fraction <50%)
• Significant left main stenosis and high anatomic complexity coronary artery disease
• Patients with ischemic cardiomyopathy and ejection fraction <50%
• Patients with refractory angina on medical therapy

The decision to perform CABG should be individualized based on the patient's clinical presentation, coronary anatomy, comorbidities, and the expertise of the heart team, which typically includes cardiologists and cardiac surgeons [ 1 ]. Some of the key considerations for CABG include:

• The presence of viable myocardium in the region of intended revascularization
• The severity of coronary artery stenosis
• The extent of myocardial ischemia
• The patient's overall health status and comorbidities

According to the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization [ 1 ], CABG is recommended for patients with:

• Left main disease
• Multivessel coronary artery disease with significant stenosis and high anatomic complexity
• Ischemic cardiomyopathy with ejection fraction <50%
• Refractory angina on medical therapy

In contrast, an older study [ 1 ] suggested that CABG may be indicated for patients with significant coronary artery disease and severe or extensive myocardial ischemia, but this is not supported by more recent evidence [ 1 ].

Overall, the indications for CABG are based on the patient's individual clinical presentation and coronary anatomy, and the decision to perform CABG should be made in consultation with a heart team [ 1 ].

From the Research

Indications for Coronary Artery Bypass Grafting (CABG)

The indications for CABG are as follows:

• Patients with unprotected left main disease (ULMD), multivessel coronary artery disease (CAD), or left ventricular dysfunction (LVD) are recommended to undergo CABG surgery, especially if the severity of coronary disease is deemed to be complex 2
• Patients with diabetes and multivessel CAD should be recommended for CABG surgery as standard therapy, given improved long-term survival and lower cardiac events 2
• CABG is superior to percutaneous coronary intervention (PCI) in reducing mortality in certain patients and improving the composite end points of angina, recurrent myocardial infarction, and repeat revascularization procedures 3
• CABG remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates 4
• CABG is the standard of care for patients with three-vessel or left main coronary artery disease, since it resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year compared to PCI 5

Patient Selection for CABG

Patient selection for CABG depends on various factors, including:

• Coronary anatomy: patients with complex coronary lesions and anatomy are recommended for CABG surgery 2, 3
• Patient comorbidities: patients with diabetes, LVD, and other comorbidities should be evaluated by a heart team to determine the best revascularization option 2, 3
• Local expertise: the choice of revascularization option should also consider local expertise in CABG and PCI 2

Graft Selection for CABG

Graft selection for CABG is also an important consideration:

• The use of multiple arterial grafts, especially if associated with anaortic techniques, might provide the best longer-term outcomes 4
• The left internal thoracic artery is considered the "golden standard" for bypassing the left anterior descending artery 6