Coronary artery surgery-beyond the crossroads?

When coronary artery surgery is well performed one can anticipate an operative mortality of +/- 1%, a perioperative infarction rate of +/- 4% and a graft patency rate of 5 years of 80-85%; about 90% of patients are likely to obtain relief from angina pectoris. Moreover, life expectancy is prolonged in patients with left main obstruction, triple- and double-vessel (when the left anterior descending (LAD) coronary artery is involved) disease, and isolated LAD artery disease above the first septal perforator. An extensive area of jeopardized myocardium is common to all these anatomical subgroups. In 1981, absolute indications for coronary angiography and coronary artery surgery in operable cases included medically refractory angina, unstable angina (non-responders, those whose condition was previously stable, and those with marked ST-segment depression during pain), unstable infarction (subendocardial infarction and infarct extension) and left ventricular failure with a demonstrably ischaemic myocardium. In all other patients with coronary artery disease, decision regarding surgery is based on coronary anatomy and the extent of viable, but jeopardized, myocardium. Although coronary angiography is the only technique that will unequivocally identify severe anatomical disease, selection of patients for this procedure is at present determined by the result of a stress exercise test. The 1980s will focus more sharply on additional subgroups of patients who will benefit from coronary artery surgery.