C o r o n a r y a r t e r y

bypass grafting, CABG

Major operation1

Alexis Carrel 1873

1 9 9 4 2

Left anter ior

descending artery , LAD

1912

1946

Arthur Vineberg 1903 1988

Left internal mammary

artery, LIMA

1958 William

Longmire 1913 2013

Endarterectomy

1960

1962 David Sabiston 1924

2009 Greater

saphenous vein, GSV

Vasilii Kolesov

1 2 3 1 2,3

1904 1992

LIMA-LAD 1968

1970 1980

Veterans Administration Cooperative Study

European Coronary Surgery Study Coronary

Artery Surgery Study

Multi-vessel coronary artery disease

1

2009 Lancet

7812

Percutaneous coronary intervention,

PCI Meta-analysis

5.9

15% 16% CABG

PCI3 2013

SYNTAX

Synergy between PCI with Taxus and Cardiac

2017 61 3 33

Surgery 2005 3 2007 4

1800

CAD 3vd +/- LM CABG

P C I d r u g -

eluting stent, DES

DES

4

CABG

Major adverse cardiac or

cerebrovascular events, MACCEs

Repeated revascularization PCI

CABG 5 SYNTAX

Low, SYNTAX score <22

Intermediate, 23< SYNTAX score <32

H i g h , S Y N TA X s c o r e > 3 2

SYNTAX score 22 PCI

CABG SYNTAX>23

CABG MACCEs repeated

revascularization PCI

2 0 1 6 P C I

C A B G

S Y N TA X B E S T R a n d o m i z e d

Comparison of Coronary Artery Bypass Surgery

and Everolimus Eluting Stent Implantation

in the Treatment of Patients With Multivessel

Coronary Artery Disease PRECOMBAT

P r e m i e r o f R a n d o m i z e d C o m p a r i s o n

of Bypass Surgery vs. Angioplasty Using

Sirolimus-Eluting Stent in Patients With Left

Main Coronary Artery Disease CABG

MACCEs PCI6

E X C E L E v a l u a t i o n o f X I E N C E

versus Coronary Artery Bypass Surgery for

Effectiveness of Left Main Revascularization

1905

CAD, LM Syntax score <32

DES CABG

Non-inferior CAD7

8

CABG

Pump or not ?

On-pump arrest CABG

Cardiopulmonary bypass,

CPB Aor t ic c ross

clamp

90 CABG

OPCAB Off-

pump CABG On-pump beating CABG

OPCAB

2017 61 3 34

OPCAB

OPCAB

CABG OPCAB

9 2008 17,764

OPCAB On-pump arrest CABG

On-pump beating CABG 63.2%

26.7% 10.1%

86.4% 84% 70%

11.7% 14.7% 26.9%

CABG10

CORONARY study CABG Off or On

Pump Revascularization Study 11 19

4752 OPCAB

On-pump arrest CABG

CABG 2016

NEJM

11 OPCAB

On-pump CABG

1%

33% 12

600 13

On-pump OPCAB

Median sternotomy

Thoracotomy

MIDCAB Minimally invasive direct coronary

artery bypass 5 8

Pericardial cavity

Off-pump

LIMA-LAD MIDCAB LAD

Diagonal branch

hybrid technique MIDCAB

PCI

TECAB Totally endoscopic

coronary artery bypass

Robot-

assisted Coronary Artery Bypass Grafting

14

2017 61 3 35

STITCH trial Surgical Treatment for

Ischemic Heart Failure 15 2002 7 2007

5 1212 LVEF

35

CABG 2011

5.8 CABG

primary outcome, death from

any cause secondary

outcome, death from cardiovascular causes

2016 10

CABG

16

Ischemic cardiomyopathy

2009 NEJM

FA M E s t u d y F r a c t i o n a l F l o w

Reserve versus Angiography for Multivessel

Evaluation PCI

FFR, fractional flow reserve 0.8

17

FFR 18

FAME 3 trial

FFR 19 FFR

anatomical base

physiological base

myocardial reperfusion

VEGF, bFGF, NO

pro-angiogenetic theory after myocardial

reperfusion

20

1. Alexander JH, Smith PK: Coronary-Artery

Bypass Grafting. N Engl J Med 2016; 374:

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2. Al-Atassi T, Toeg HD, Ruel VCaM: Coronary

Ar te ry Bypass Graf t ing . Sab is ton and

Spencer Surgery of the Chest, 9th edition

2016: 1551-88.

3. Hlatky M, Boothroyd D, Bravata D, et al:

Coronary artery bypass surgery compared

2017 61 3 36

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main coronary disease: 5-year follow-up

of the randomised, clinical SYNTAX trial.

Lancet 2013; 381: 629-38.

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Coronary Artery Bypass Surgery Versus

Drug-Eluting Stent Implantation for Left

Main o r Mul t ivesse l Coronary Ar te ry

Disease. JACC: Cardiovascular Interventions

2016; 9: 2481-9.

7. Stone GW, Sabik JF, Serruys PW, et al:

Everolimus-Eluting Stents or Bypass Surgery

for Left Main Coronary Artery Disease. N

Engl J Med 2016; 375: 2223-35.

8. Group TBDS: A Randomized Trial of Therapies

for Type 2 Diabetes and Coronary Artery

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Coronary Ar te ry Bypass Gra f t ing and

Transmyocardial Laser Revascularization.

Sabiston and Spencer Surgery of the Chest,

9th edition 2016: 1589-602.

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or On-Pump Beating CABG? Ann Thorac

Cardiovasc Surg 2011; 17: 218-20.

11. André Lamy, Devereaux PJ , Dora i ra j

Prabhakaran, et al: Five-Year Outcomes

after Off-Pump or On-Pump Coronary-

Artery Bypass Grafting. N Engl J Med

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experience on the rate of blood transfusion

in off-pump coronary artery bypass. J

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quality indicators in off-pump coronary

artery bypass. Ann Thorac Surg 2013; 96:

2069-74.

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Coronary-Artery Bypass Surgery in Patients

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with Left Ventricular Dysfunction. N Engl J

Med 2011; 364: 1607-16.

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Coronary-Artery Bypass Surgery in Patients

with Ischemic Cardiomyopathy. N Engl J

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17. P im AL Tonino , Bernard De Bruyne ,

Nico H.J. Pij ls , et al: Fractional Flow

Reserve versus Angiography for Guiding

Percutaneous Coronary Intervention. N Engl

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Fractional flow reserve-guided coronary

artery bypass grafting: can intraoperative

physiologic imaging guide decision making?

J Thorac Cardiovasc Surg 2013; 146: 824-

35 e1.

19. FM Z, Bruyne D, Pij ls NH DM, et al :

Rationale and design of the Fractional

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a comparison of fractional flow reserve-

guided percutaneous coronary intervention

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incomplete coronary revascularization? Int

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