What are the changes in Coronary Artery Bypass Graft (CABG) outcomes?

From the Guidelines

Coronary artery bypass graft (CABG) outcomes have significantly improved over the past several decades, with mortality rates decreasing from 4-5% in the 1980s to approximately 1-2% today for isolated CABG procedures, as a result of advancements in patient selection, surgical techniques, and perioperative care 1. The improvement in CABG outcomes can be attributed to various factors, including:

• Better patient selection, which allows for more accurate identification of patients who will benefit from CABG
• Refined surgical techniques, such as off-pump CABG and minimally invasive approaches, which reduce surgical trauma and complications in appropriate candidates
• Improved myocardial protection methods, which help to reduce cardiac damage during surgery
• Enhanced perioperative care, including modern perioperative medication regimens and comprehensive cardiac rehabilitation programs These advancements have not only reduced mortality but also decreased major complications like stroke, wound infections, and renal failure. The use of arterial conduits, particularly the left internal mammary artery, has improved long-term graft patency, with 90% patency at 10 years versus 50-60% for saphenous vein grafts 1. In terms of the choice between on-pump and off-pump CABG, the evidence suggests that both techniques have excellent outcomes, but on-pump CABG may be associated with better 1-year composite outcomes and 1-year graft patency rates, with no difference in neuropsychological outcomes or resource utilization 1. However, off-pump CABG may be beneficial in patients with extensive disease of the ascending aorta, as it avoids manipulation of the aorta and reduces the risk of neurological complications. Ultimately, the choice between on-pump and off-pump CABG should be individualized based on patient characteristics and surgeon preference, with the goal of optimizing outcomes and minimizing complications 1.

From the Research

Changes in Coronary Artery Bypass Graft Outcomes

• Coronary artery bypass grafting (CABG) has seen significant advancements in recent years, leading to improved patient outcomes and treatment paradigms 2.
• The development of minimally invasive CABG techniques, such as robotic-assisted surgery and small thoracotomy methods, has resulted in reduced invasiveness, shorter recovery times, and improved patient satisfaction 2.
• The integration of CABG with percutaneous coronary intervention (PCI) has emerged as a versatile strategy, providing tailored treatment solutions for complex coronary anatomies 2.

Impact of Medications on CABG Outcomes

• Statin medications and aspirin have been shown to be essential for post-CABG patients, with statins reducing low-density lipoprotein (LDL) levels and aspirin preventing graft occlusion 3.
• The use of beta-blockers has been associated with improved outcomes after CABG, including reduced mortality and major adverse cardiovascular events (MACEs) 4, 5.
• The combination of statins and beta-blockers has been shown to have a synergistic effect on overall mortality outcomes, with a significant reduction in MACEs 4.

Quality Improvement Efforts

• Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade, with a focus on identifying and addressing root causes for mortality 6.
• Phase of care mortality analysis (POCMA) and failure to rescue (FTR) metrics have been used to identify institutional factors responsible for poor perioperative outcomes and improve quality of care 6.
• Ongoing quality improvement efforts, including POCMA and FTR analysis, have the potential to significantly improve outcomes after cardiac surgery 6.

Long-term Outcomes

• Long-term results after CABG have significantly improved, with patients experiencing higher survival rates, less angina, and better quality of life 2.
• The use of cardioselective beta-blockers has been associated with a reduction in MACEs, mainly due to a reduced risk of myocardial infarction (MI) 5.
• The development of more resilient grafts through tissue engineering and the use of bioresorbable materials in graft fabrication are exciting future research directions 2.