Why do UK cardiac surgeons not perform their first choice operation for coronary artery bypass graft? | Heart

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Why do UK cardiac surgeons not perform their first choice operation for coronary artery bypass graft?

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Re. Why do UK cardiac surgeons not perform their first choice operation
Hratch L Karamanoukian
Published on: 9 January 2022

Published on: 9 January 2022
Re. Why do UK cardiac surgeons not perform their first choice operation
- Hratch L Karamanoukian, Director
- Other Contributors:
  Hratch Karamanoukian, and Harry Donias
Dear Editor
We read with extreme interest the timely scientific letter which addresses "why …UK surgeons not perform their first choice operation [all arterial revascularization] for coronary artery bypass graft(ing)".[1]
The results are intriguing and confirm a related study recently published by our group following a survey of US surgeons called "Is hybrid coronary revascularization favored by cardiologists...
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Dear Editor
We read with extreme interest the timely scientific letter which addresses "why …UK surgeons not perform their first choice operation [all arterial revascularization] for coronary artery bypass graft(ing)".[1]
The results are intriguing and confirm a related study recently published by our group following a survey of US surgeons called "Is hybrid coronary revascularization favored by cardiologists or cardiac surgeons".[2] Hybrid revascularization, also called integrated coronary revascularization is a combined revascularization strategy. Typically, the left internal mammary artery (LIMA) to left anterior descending (LAD) artery anastomosis is performed via a minimally invasive approach (MIDCAB, minimally invasive direct coronary artery bypass, or its robotic equivalent) and non-LAD targets are revascularized percutaneously using stents.
In our survey, surgeons and cardiologists were asked what the optimal revascularization strategy was for the non-LAD target. As expected, 68% of cardiologists believed that their current stents had better patency rates than saphenous vein grafts anastomosed to non-LAD targets. 75% of surgeons, however, believe that vein grafts are better than stents for non-LAD targets. Both surgeons and cardiologists believe in the "all arterial revascularization" strategy, unanimously agreeing that almost every patient receive a LIMA anastomosis for LAD disease, 78% of cardiologists support arterial conduits over vein grafts to non-LAD targets.
Our study is similar to the study published by Mr Taggart and his colleagues, as US surgeons infrequently (25%) used an "all arterial revascularization" strategy beyond the LIMA to LAD anastomosis during CABG. In the UK study, a little more than 15% of surgeons used more than one arterial graft during CABG. Although the reasons are multifactorial, both reports highlight the importance of arterial revascularization but cite an increased learning curve with higher morbidity and mortality. The findings are intriguing, as the impact of drug-eluting stents may drastically change the practice of cardiac surgery. If indeed stents are believed to have better patency rates than vein grafts to non-LAD targets, we predict that cardiologists will soon extrapolate this to drug eluting stents. Cardiac surgeons must change their practices and use "all arterial revascularization" in order to provide a more durable and cost effective alternative to the deployment of 2-4 drug-eluting stents in patients with multivessel coronary artery disease.[3] This may limit the "full metal jacket" syndrome representing overstenting.
We salute Mr Taggart and his colleagues for reporting this important study which has significant implications for the practice of coronary artery surgery worldwide.
References
(1) Catarino PA, Black E, Taggart DP. Why do UK cardiac surgeons not perform their first choice operation for coronary artery bypass graft? Heart 2002; 88643-644.
(2) D'Ancona G, Boyd DW, Donias HW, Vassiliades TA Jr, Stahl K, Karamanoukian HL. Is hybrid revascularization favored by cardiologists or cardiac surgeons? Heart Surgery Forum [serial online]. Available at http://www.hsforum.com/vol5/issue4/2002-50132.html Accessed December 03, 2002.
(3) Karamanoukian HL, Aoukar PS. What will be the impact of drug- eluting stents on hybrid coronary revascularization? Heart Surgery Forum [serial online]. Available at http://www.hsforum.com/vol5/issue4/2002-01110.html Accessed December 03, 2002.
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Conflict of Interest:
None declared.
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