The father of coronary artery bypass grafting: René Favaloro and the 50th anniversary of coronary artery bypass grafting
2018; Elsevier BV; Volume: 155; Issue: 6 Linguagem: Inglês
10.1016/j.jtcvs.2017.09.167
ISSN1097-685X
AutoresFaisal G. Bakaeen, Eugene H. Blackstone, Gösta Pettersson, A. Marc Gillinov, Lars G. Svensson,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoCentral MessageThis year represents the 50th anniversary of a revolutionary milestone in the evolution of CABG. We discuss its history, modern-day practice, and future prospects.See Editorial Commentary page 2329. This year represents the 50th anniversary of a revolutionary milestone in the evolution of CABG. We discuss its history, modern-day practice, and future prospects. See Editorial Commentary page 2329. Dr René Favaloro performed his first coronary bypass operation in May 1967 with an interposed saphenous vein graft (SVG) and shortly thereafter used aortocoronary bypasses sutured proximally to the ascending aorta. This milestone endured because of the development of routine and safe coronary bypass techniques by Favaloro and his colleagues and the demonstration of coronary artery bypass grafting (CABG) as a reproducible, lifesaving, and life-changing therapy for coronary artery disease (CAD). Its subsequent adoption worldwide has been sustained to this day. In the words of Dr Denton Cooley, “Although he [Favaloro] was always hesitant to carry the moniker of ‘father’ of coronary artery bypass surgery, he is the surgeon we should credit with introducing coronary bypass surgery into the clinical arena.”1Cooley D.A. In memoriam. Tribute to Rene Favaloro, pioneer of coronary bypass.Tex Heart Inst J. 2000; 27: 231-232PubMed Google Scholar The 50th anniversary of Favaloro's first CABG operation recognizes a long process of laboratory experimentation and pioneering isolated clinical cases in surgical myocardial revascularization.2Jones D.S. CABG at 50 (or 107?) – the complex course of therapeutic innovation.N Engl J Med. 2017; 376: 1809-1811Crossref PubMed Scopus (14) Google Scholar For this review, we have chosen to focus on technical aspects and challenges as they pertain to CABG and its evolution over time. We summarize the history of myocardial revascularization divided into 2 eras relative to Favaloro's first bypass operation. These eras are interrelated, with overlap in surgeons and techniques. In 1910, Dr Alexis Carrel3Carrel A. VIII. On the experimental surgery of the thoracic aorta and heart.Ann Surg. 1910; 52: 83-95Crossref PubMed Google Scholar described a series of canine experiments in which he devised means to treat CAD by creating a “complementary circulation” for the diseased native coronary arteries. No clinical translation occurred at the time, but he was awarded the Nobel Prize in Medicine. Experimental refinements of coronary arterial revascularization, including use of internal thoracic artery (ITA) grafts, were later reported by Murray and colleagues,4Murray G. Porcheron R. Hilario J. Roschlau W. Anastomosis of systemic artery to the coronary.Can Med Assoc J. 1954; 71: 594-597PubMed Google Scholar Demikhov,5Demikhov V. Experimental Transplantation of Vital Organs. Consultant's Bureau, New York1962Google Scholar and Goetz and colleagues6Goetz R.H. Rohman M. Haller J.D. Dee R. Rosenak S.S. Internal mammary-coronary artery anastomosis. A nonsuture method employing tantalum rings.J Thorac Cardiovasc Surg. 1961; 41: 378-386PubMed Google Scholar in the 1950s and early 1960s. Initial clinical interventions for ischemic heart disease were diverse and imaginative and included sympathectomy and indirect revascularization of the heart.2Jones D.S. CABG at 50 (or 107?) – the complex course of therapeutic innovation.N Engl J Med. 2017; 376: 1809-1811Crossref PubMed Scopus (14) Google Scholar The latter was attempted by Beck and Tichy,7Beck C.S. Tichy V.L. The production of a collateral circulation to the heart.Am Heart J. 1935; 10: 849-873Abstract Full Text PDF Scopus (28) Google Scholar who created vascular adhesions between the epicardium and the myocardium using mechanical abrasion, often supplemented by some form of poudrage, or use of muscle or omental grafts as a source for neovascularization.8O'Shaughnessy L. Surgical treatment of cardiac ischaemia.Lancet. 1937; 1: 185-194Abstract Scopus (51) Google Scholar, 9Vineberg A.M. Kato Y. Pirozynski W.J. Experimental revascularization of the entire heart. Evaluation of epicardiectomy, omental graft, and/or implantation of the internal mammary artery in preventing myocardial necrosis and death of the animal.Am Heart J. 1966; 72: 79-93Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 10Friedbacker K. Omentum as source of nutrition to experimentally produced myocardial ischemia.Surg Gynecol Obstet. 1942; 75: 110-113Google Scholar Multiple needle punctures of the left ventricular wall were also tried to create new channels between the left ventricular cavity and the ischemic myocardium.11Sen P.K. Udwadia T.E. Kinare S.G. Parulkar G.B. Transmyocardial acupuncture: a new approach to myocardial revascularization.J Thorac Cardiovasc Surg. 1965; 50: 181-189Abstract Full Text PDF PubMed Google Scholar None of these techniques was particularly effective or widely adopted. In 1945, Vineberg and Miller12Vineberg A. Miller G. Internal mammary coronary anastomosis in the surgical treatment of coronary artery insufficiency.Can Med Assoc J. 1951; 64: 204-210PubMed Google Scholar capitalized on the unique properties of the ITA, including that it is usually spared from atherosclerosis, and reasoned that its branches would form collaterals with myocardial arterioles. They developed an experimental model and tracked the surviving patients who later died of other causes. They injected contrast medium in postmortem specimens demonstrating connections between the implant and the coronary arteries, but few surgeons took their work seriously.13Effler D.B. Chapter 1: History.in: Green G.E. Singh R.N. Sosa J.A. Surgical Revascularization of the Heart: The Internal Thoracic Arteries. Igaku-Shoin, Tokyo1991: 1-17Google Scholar Dr Claude Schaeffer Beck decided by 1948 that direct revascularization of the heart could be accomplished by a graft between the descending aorta and the partially ligated coronary sinus.14Beck C.S. Stanton E. Batiuchok W. Leiter E. Revascularization of heart by graft of systemic artery into coronary sinus.J Am Med Assoc. 1948; 137: 436-442Crossref PubMed Scopus (95) Google Scholar, 15McAllister F.F. Leighninger D. Beck C.S. Revascularization of the heart by vein graft from aorta to coronary sinus.Ann Surg. 1951; 133: 153-165Crossref PubMed Scopus (8) Google Scholar Initially the entire brachial artery was used as the conduit, but this was later replaced by a reversed SVG. The results were disappointing and the procedure shelved, and Beck reverted back to his technique of epicardial abrasion. The advent of cardiopulmonary bypass and subsequent introduction of “elective cardiac arrest” in 1955, using the Melrose concept of injecting potassium citrate into the aortic root, made it possible to operate on a still heart with a bloodless field.13Effler D.B. Chapter 1: History.in: Green G.E. Singh R.N. Sosa J.A. Surgical Revascularization of the Heart: The Internal Thoracic Arteries. Igaku-Shoin, Tokyo1991: 1-17Google Scholar, 16Kolff W.J. Effler D.B. Groves L.K. Peereboom G. Aoyama S. Sones Jr., F.M. Elective cardiac arrest by the Melrose technic: potassium asystole for experimental cardiac surgery.Cleve Clin Q. 1956; 23: 98-104Crossref PubMed Scopus (5) Google Scholar This enhanced the feasibility and precision of cardiac operations, including CABG. At that time, however, all attempts at enhancing the blood supply to the heart were based on unproven concepts and were essentially “blind” interventions. What was missing was a diagnostic tool that could accurately locate and assess coronary artery lesions and prove the effectiveness of various revascularization procedures. The breakthrough was the accidental injection by trainee Dr Royston C. Lewis of dye into the coronary arterial system on October 30, 1958, arresting the heart.17Sones Jr., F.M. Shirey E.K. Proudfit W.L. Westcott R.N. Cine-coronary arteriography.Circulation. 1959; 20 ([abstract]): 773-774Google Scholar His supervisor, Dr F. Mason Sones, Jr, successfully resuscitated the patient by having him cough. With this serendipitous event, Sones recognized the potential value of selective coronary angiography.18Meyers M.A. “Cough, goddamn it!”.The Pharos. 2016; 79: 27-30Google Scholar He subsequently demonstrated that this new procedure could precisely localize coronary lesions, creating the roadmap for revascularization.19Sones Jr., F.M. Shirey E.K. Cine coronary arteriography.Mod Concepts Cardiovasc Dis. 1962; 31: 735-738PubMed Google Scholar Favaloro remarked that without Sones' work, “all our efforts in myocardial revascularization would have been fruitless.”20Hall R.J. In memorium: F. Mason Sones, Jr, M.D.Tex Heart Inst J. 1985; 12: 356-358Google Scholar Encouraged by the favorable endarterectomy experience in treating carotid and peripheral vascular disease and experimental endarterectomy in dogs and human hearts obtained at autopsy, segmental occlusions of major coronary arteries were approached by endarterectomy by Bailey and colleagues (1957),21Bailey C.P. May A. Lemmon W.M. Survival after coronary endarterectomy in man.J Am Med Assoc. 1957; 164: 641-646Crossref PubMed Scopus (180) Google Scholar Longmire and colleagues (1958),22Longmire Jr., W.P. Cannon J.A. Kattus A.A. Direct-vision coronary endarterectomy for angina pectoris.N Engl J Med. 1958; 259: 993-999Crossref PubMed Scopus (88) Google Scholar Effler and colleagues (1964),23Effler D.B. Groves L.K. Sones Jr., F.M. Shirey E.K. Endarterectomy in the treatment of coronary artery disease.J Thorac Cardiovasc Surg. 1964; 47: 98-108Abstract Full Text PDF PubMed Google Scholar and others thereafter. Inspection of the epicardium and palpation of the coronaries guided placement of the incision. Endarterectomy was soon abandoned because of the shearing effect on the side branches and the often problematic distal dissection flap,23Effler D.B. Groves L.K. Sones Jr., F.M. Shirey E.K. Endarterectomy in the treatment of coronary artery disease.J Thorac Cardiovasc Surg. 1964; 47: 98-108Abstract Full Text PDF PubMed Google Scholar and patch coronary arterioplasty, a technique described by Dr Åke Senning, was adopted.24Senning A. Strip grafting in coronary arteries. Report of a case.J Thorac Cardiovasc Surg. 1961; 41: 542-549PubMed Google Scholar, 25Effler D.B. Sones Jr., F.M. Favaloro R. Groves L.K. Coronary endarterotomy with patch-graft reconstruction: clinical experience with 34 cases.Ann Surg. 1965; 162: 590-601Crossref PubMed Scopus (55) Google Scholar In 1962, the Vineberg procedure was validated by selective ITA angiography of 3 patients operated on by Dr Wilfred Bigelow at Toronto General Hospital and referred to Cleveland. Their angiograms demonstrated patent ITAs with communications to the left anterior descending (LAD) coronary artery. Subsequently, Vineberg himself referred patients for angiography, and the Vineberg procedure became the revascularization modality of choice.13Effler D.B. Chapter 1: History.in: Green G.E. Singh R.N. Sosa J.A. Surgical Revascularization of the Heart: The Internal Thoracic Arteries. Igaku-Shoin, Tokyo1991: 1-17Google Scholar By 1968, 2000 single and bilateral Vineberg procedures were performed at Cleveland Clinic, with 90% patency, half having a demonstrable connection with the obstructed coronary artery, and a substantial number demonstrating a contrast blush.26Fergusson D.J. Shirey E.K. Sheldon W.C. Effler D.B. Sones Jr., F.M. Left internal mammary artery implant–postoperative assessment.Circulation. 1968; 37: II24-II26Crossref PubMed Google Scholar Dr David Sabiston, Jr, performed the first CABG with venous grafting on April 4,1962, in a patient with an occluded right coronary artery (RCA). An SVG was taken from the leg and anastomosed from the ascending aorta to the RCA.27Sabiston Jr., D.C. The development of surgery of the coronary circulation: the Bigelow lecture.Ann Surg. 1997; 226: 153-161Crossref PubMed Scopus (3) Google Scholar, 28Sabiston Jr., D.C. The William F. Rienhoff, Jr. Lecture. The coronary circulation.Johns Hopkins Med J. 1974; 134: 314-329PubMed Google Scholar At the end of the procedure, a pulse was present in both the graft and the RCA distally, but the patient had a stroke and died shortly thereafter. No angiographic documentation of this bypass was available. In 1964, Drs Edward Garrett, Jimmy Howell, and Michael DeBakey performed the first successful vein bypass in a patient with coronary obstruction as a bailout procedure for a complicated endarterectomy and published their report 9 years later with angiographic confirmation of graft patency.29Garrett H.E. Dennis E.W. DeBakey M.E. Aortocoronary bypass with saphenous vein graft. Seven-year follow-up.JAMA. 1973; 223: 792-794Crossref PubMed Scopus (191) Google Scholar In 1967, an article by Dr Vasilii Kolesov “Mammary Artery–Coronary Artery Anastomosis as Method of Treatment for Angina Pectoris” was published in the Journal.30Kolessov V.I. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris.J Thorac Cardiovasc Surg. 1967; 54: 535-544Abstract Full Text PDF PubMed Google Scholar Dr Brian Blades, then Editor-in-Chief, wrote a foreword explaining that the procedure was at variance with prevailing concepts for treating ischemic heart disease in the United States and was therefore accompanied by an invited commentary by Dr Donald Brian Effler, Chairman of Thoracic and Cardiovascular Surgery at Cleveland Clinic, and a response by Kolesov. Interestingly, Dr George Green was finishing his cardiothoracic surgery residency under Dr Frank Spencer and had visited Effler that same year and shared radiographic images of his direct ITA-to-LAD bypass in dogs. Kolesov presented no angiographic data, and case selection was based on electrocardiography, stress testing, and direct inspection of the heart during surgery. Evaluation of the procedure was based on survival and symptom improvement. Kolesov's early operations used a left anterior thoracotomy and were performed on a beating heart. By 1969, he reported on 45 patients who had undergone single and bilateral ITA grafting, with a mortality of 15%. Kolesov might have performed the first direct thoracic-to-coronary sutured anastomosis. In that context, in May 1960, Dr Robert Goetz had performed a sutureless right ITA-to-RCA anastomosis using tantalum rings in a 38-year-old man.6Goetz R.H. Rohman M. Haller J.D. Dee R. Rosenak S.S. Internal mammary-coronary artery anastomosis. A nonsuture method employing tantalum rings.J Thorac Cardiovasc Surg. 1961; 41: 378-386PubMed Google Scholar After realizing the suboptimal results of patch coronary arterioplasty, Favaloro's first attempt at coronary vein grafting occurred on May 7, 1967,31Favaloro R.G. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique.Ann Thorac Surg. 1968; 5: 334-339Abstract Full Text PDF PubMed Scopus (451) Google Scholar, 32Favaloro R.G. The developmental phase of modern coronary artery surgery.Am J Cardiol. 1990; 66: 1496-1503Abstract Full Text PDF PubMed Scopus (4) Google Scholar with an interposed SVG, and shortly afterward with bypasses from the ascending aorta. In 1968, Favaloro33Favaloro R.G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture.Am J Cardiol. 1979; 43: 109-129Abstract Full Text PDF PubMed Scopus (28) Google Scholar performed CABG for acute myocardial infarction and in the same year succeeded in combining reconstruction of the left ventricle and valve replacement with CABG. Important publications followed, documenting the largest CABG experience at the time, with operative mortality of less than 5% by 197033Favaloro R.G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture.Am J Cardiol. 1979; 43: 109-129Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 34Sheldon W.C. Favaloro R.G. Sones Jr., F.M. Effler D.B. Reconstructive coronary artery surgery. Venous autograft technique.JAMA. 1970; 213: 78-82Crossref PubMed Scopus (34) Google Scholar and 2% or less by the late 1970s.33Favaloro R.G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture.Am J Cardiol. 1979; 43: 109-129Abstract Full Text PDF PubMed Scopus (28) Google Scholar The low mortality, reproducibility, and relative simplicity caught the attention of the cardiovascular community and marked the start of the CABG revolution. At the end of 1970, impressed by the pioneering work of Green and colleagues,35Green G.E. Stertzer S.H. Reppert E.H. Coronary arterial bypass grafts.Ann Thorac Surg. 1968; 5: 443-450Abstract Full Text PDF PubMed Scopus (151) Google Scholar Favaloro and his team began using ITA–coronary anastomoses. Green used a microscope to construct these anastomoses, but Favaloro thought this approach cumbersome. Rather, he dissected the left ITA and anastomosed it to the LAD with only the help of the conventional magnifying surgical loupes that he used in his daily work. After Favaloro's departure from Cleveland Clinic in 1971, Dr Floyd Loop and colleagues standardized this method and demonstrated its excellent long-term outcomes in a seminal publication in 198636Loop F.D. Lytle B.W. Cosgrove D.M. Stewart R.W. Goormastic M. Williams G.W. et al.Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.N Engl J Med. 1986; 314: 1-6Crossref PubMed Scopus (2286) Google Scholar that established ITA-to-LAD grafting as a standard of care for CAD. Favaloro's and Sone's deep understanding of CAD was reflected in numerous publications and was a product of the long hours they spent reviewing coronary angiograms at the Sones Library in the basement level of the Clinic.37Favaloro R.G. The present era of myocardial revascularization–some historical landmarks.Int J Cardiol. 1983; 4: 331-344Abstract Full Text PDF PubMed Scopus (10) Google Scholar, 38Captur G. Memento for Rene Favaloro.Tex Heart Inst J. 2004; 31: 47-60PubMed Google Scholar Their astute observations about the natural history of ischemic heart disease and its correlation with angiographic findings, size and significance of diseased vessels, severity of obstructive lesions, and the role of collateral circulation guided their and their colleagues' decisions about which patients might benefit from CABG. In addition, they put forth thoughtful explanations for the findings of early randomized trials that undervalued the benefit of CABG.33Favaloro R.G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture.Am J Cardiol. 1979; 43: 109-129Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 37Favaloro R.G. The present era of myocardial revascularization–some historical landmarks.Int J Cardiol. 1983; 4: 331-344Abstract Full Text PDF PubMed Scopus (10) Google Scholar, 39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar In the words of Favaloro, “The introduction of PTCA [percutaneous transluminal coronary angioplasty] in 1977 deepened our responsibilities. Now our patients can follow three different roads (CABG, PTCA, or medical treatment).”39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar He meticulously analyzed differences between patients who qualified for both transcatheter intervention and CABG and thus were eligible for enrollment in trials, and patients who ended up in registries of the “everyday” CABG population. He reasoned that single-, double-, and triple-vessel disease classifications was inadequate to stratify CAD severity and used a scoring system when reading coronary angiograms.33Favaloro R.G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture.Am J Cardiol. 1979; 43: 109-129Abstract Full Text PDF PubMed Scopus (28) Google Scholar Many years later, the SYNTAX trial confirmed the importance of granular assessment of coronary lesion complexity in choosing between CABG and percutaneous coronary intervention and affirmed the incremental benefit of CABG in patients with complex left main and 3-vessel CAD (apart from those with CAD-associated disease, such as diabetes).40Mohr F.W. Morice M.C. Kappetein A.P. Feldman T.E. Stahle E. Colombo A. et al.Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.Lancet. 2013; 381: 629-638Abstract Full Text Full Text PDF PubMed Scopus (1256) Google Scholar Today, additional physiologic and imaging modalities are further refining the prognostic importance of coronary lesions and patient selection for intervention.41Collet C. Onuma Y. Miyazaki Y. Morel M.A. Serruys P.W. Integration of non-invasive functional assessments with anatomical risk stratification in complex coronary artery disease: the non-invasive functional SYNTAX score.Cardiovasc Diagn Ther. 2017; 7: 151-158Crossref PubMed Scopus (16) Google Scholar In one of his last comprehensive reviews of CABG in 1998,39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar Favaloro skillfully summarized the CABG evolution from the refinements of instruments and sutures to improvements in perfusion, myocardial protection, and perioperative care. He touched on important developments, including arterial conduits, off-pump surgery, minimally invasive surgery, and risk-adjusted outcomes, that importantly relate to current-day practice. Favaloro42Favaloro R.G. Double internal mammary artery implants: operative technique.J Thorac Cardiovasc Surg. 1968; 55: 457-465PubMed Google Scholar is credited with the evolution of bilateral ITA grafting, starting with the Vineberg procedure. His innovative ITA retractor facilitated exposure and harvesting.43Favaloro R.G. Unilateral self-retaining retractor for use in internal mammary artery dissection.J Thorac Cardiovasc Surg. 1967; 53: 864-865PubMed Google Scholar He challenged the prevailing dogma that bilateral ITA harvesting resulted in sternal necrosis and popularized its use. In 2004, his successors associated bilateral ITA grafting with improved long-term survival compared with single ITA grafting.44Lytle B.W. Blackstone E.H. Sabik J.F. Houghtaling P. Loop F.D. Cosgrove D.M. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.Ann Thorac Surg. 2004; 78: 2005-2014Abstract Full Text Full Text PDF PubMed Scopus (413) Google Scholar The Achilles heel of CABG is the suboptimal patency of SVGs. Favaloro39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar and others understood that and incorporated additional arteries to supplement the ITA-to-LAD anastomosis in multivessel CABG. Furthermore, recent guidelines encourage multiarterial grafting.45Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar Despite the potential long-term benefits, only 5% of bypass operations in the United States are done with bilateral ITAs,45Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar and less than 5% include radial artery grafting. Technical difficulties and lack of financial incentives are partly to blame. The absence of high-level evidence from randomized trials confirming a clear advantage of multiarterial grafting is unlikely to change the prevailing practice of left ITA-to-LAD grafting and vein grafts to the remaining targets. With regard to off-pump CABG, Favaloro39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar reminded us that CABG was performed on the beating heart during the early days by Kolesov.30Kolessov V.I. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris.J Thorac Cardiovasc Surg. 1967; 54: 535-544Abstract Full Text PDF PubMed Google Scholar He believed it would be extremely difficult to obtain the best possible results with this approach, especially with multiarterial grafting off-pump. Contrary to the findings of observational studies, randomized studies have not shown an advantage of the off-pump strategy in clinical outcomes. Nationally, use of off-pump procedures peaked in 2002 at 23%, then declined to 17% by 2012.46Bakaeen F.G. Shroyer A.L. Gammie J.S. Sabik J.F. Cornwell L.D. Coselli J.S. et al.Trends in use of off-pump coronary artery bypass grafting: results from the Society of Thoracic Surgeons adult cardiac surgery database.J Thorac Cardiovasc Surg. 2014; 148: 856-864Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Favaloro commented on Calafiore and colleagues' large series47Calafiore A.M. Giammarco G.D. Teodori G. Bosco G. D'Annunzio E. Barsotti A. et al.Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass.Ann Thorac Surg. 1996; 61: 1658-1665Abstract Full Text PDF PubMed Scopus (560) Google Scholar of minimally invasive direct coronary artery bypass procedures. He speculated that minimally invasive direct coronary artery bypass may be combined with transcatheter interventions for non-LAD territories, adding that future development of thoracoscopic and other technologies to harvest conduits and create anastomoses may be in the pipeline. In essence, he foresaw the emergence of hybrid revascularization with or without robotic assistance. It is too early to pass judgment on these new modalities, and their use has been limited to niche practices thus far.48Hiesinger W. Atluri P. Hybrid coronary revascularization: ready for prime time, but who should star?.J Thorac Cardiovasc Surg. 2016; 151: 1090-1091Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In addition, lack of robust clinical and angiographic data and a number of technical, logistic, and cost-related barriers have hindered popularization of robotic CABG.49Cao C. Indraratna P. Doyle M. Tian D.H. Liou K. Munkholm-Larsen S. et al.A systematic review on robotic coronary artery bypass graft surgery.Ann Cardiothorac Surg. 2016; 5: 530-543Crossref PubMed Scopus (34) Google Scholar Favaloro, Sones, and their colleagues embodied one of the earliest examples of the heart team. Favaloro explicitly remarked: “…for I have always believed in teamwork. ‘We’ is more important than ‘I’. In medicine, the advances are always the result of many efforts accumulated over the years.”50Favaloro R.G. Landmarks in the development of coronary artery bypass surgery.Circulation. 1998; 98: 466-478Crossref PubMed Scopus (41) Google Scholar Favaloro's humanitarianism was reflected throughout his professional career and lives to this day through a foundation he established in Argentina dedicated to research, teaching, and treatment. He was also especially proud of his educational endeavors, as expressed in his 1994 memoir: “I have said on many occasions that when I am gone I would prefer to be remembered for my teaching rather than my surgical activities.”51Favaloro R.G. The Challenging Dream of Heart Surgery. Little, Brown and Company, Boston1994Google Scholar Of note, despite his surgical prowess, Favaloro emphasized from the beginning that CABG was “only a palliative treatment” for CAD. He was a believer in secondary prevention and comprehensive risk-factor identification and management in combination with medical therapy to slow and possibly reverse atherosclerosis.39Favaloro R.G. Critical analysis of coronary artery bypass graft surgery: a 30-year journey.J Am Coll Cardiol. 1998; 31: 1B-63BCrossref PubMed Scopus (113) Google Scholar Favaloro emphasized the improved outcomes of CABG over time despite operating on older and sicker patients. He touted the risk-adjusted outcomes in the Society of Thoracic Surgeons database, but cautioned about the unintended consequences of risk aversion and denial of care. The star rankings of CABG quality and public reporting have added an extra layer of scrutiny, but were deemed a necessary evolution to keep cardiac surgeons ahead of the game in the current healthcare environment. Indeed, the concept of risk-adjusted public reporting of results of therapy across medicine had its origin in the reporting of outcomes for CABG. The proposed implementation of episode payment models will usher in a new era of CABG care that not only emphasizes high-quality outcomes but also holds hospitals and clinicians financially responsible for expenses incurred during index hospitalizations and 90 days after discharge. Although improved care coordination is the stated rationale, cost reduction is the driving motivation. However, concerns regarding access, quality, and effectiveness of treatment are real.52Bakaeen F.G. Rich J. Svensson L.G. Episode payment model for CABG–opportunities and challenges.JAMA Surg. 2018; 153: 20Crossref PubMed Scopus (1) Google Scholar Risk-adjusted outcomes based on claims data will be used, and it will be difficult to adjust for extreme-risk patients; thus, hospitals willing to care for such patients may be at greatest financial risk. In addition, factoring in the quality of CABG itself and its long-term effectiveness is not part of the CABG episode payment models. For example, using guideline-directed multiarterial revascularization45Aldea G.S. Bakaeen F.G. Pal J. Fremes S. Head S.J. Sabik J. et al.The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar in appropriately selected patients may be more expensive in the short term but more cost-effective in the long term. To handle these challenges, a more sophisticated risk-scoring and anticipated-benefit algorithm is required. As we celebrate the 50th anniversary of Favaloro's first bypass operation, we are reminded of his innovative and brave spirit, as well as others who contributed to the advancement of CABG. Their thorough and meticulous work documenting the safety, effectiveness, and durability of CABG has secured its important role in the treatment of CAD to this day and for the foreseeable future. Over the years, CABG has survived the closest scrutiny of quality and clinical effectiveness, as well as the challenges posed by percutaneous coronary intervention and diminishing reimbursement. Advancements in CABG techniques have been incremental and steady but not disruptive. Unless new medical therapies can reverse coronary atherosclerosis, we are likely to still celebrate CABG (in some form or another) 50 years from now.
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