Coronary artery surgery: the end of the beginning

In each of the first three decades of myocardial revascularization, convent ional treatment has been revised completely. This lecture comments on three areas of discovery that have shaped the evolution of myocardial revascular ization: science, technology development, and revascularization. The discov eries in all three areas are inexorably interrelated. The single greatest l esson learned so far is that conduit performance carries more prognostic we ight than any other factor. We have observed that vein graft atherosclerosi s is predictable, and that the first-generation lipid lowering drugs have a favorable effect in patients who achieve marked LDL reduction. Biologicall y better revascularization begins with use of the internal thoracic artery for grafting to the anterior descending coronary artery. As the results of internal thoracic artery grafting are widely reported, arterial bypass reva scularization has expanded, notably by radial and gastroepiploic arteries. The results of bilateral internal thoracic artery grafting are discussed in cluding large-scale registry results of internal thoracic artery usage in t he United States. The internal thoracic artery is significantly underutiliz ed. Diabetes affects both endoluminal and surgical revascularization. The n ew pharmacology in cardiology interventions shows promise in diminishing re stenosis and thrombosis even in diabetic patients. Conversely, extended int ernal thoracic artery grafting may also benefit diabetic patients. Now we a re entering a new age of minimally invasive coronary surgery. We have passe d through the early stages of mini-thoracotomy, and we are moving on to acc ess through l-cm ports, intrathoracic cannulation, antegrade and retrograde myocardial protection, and computer guided three-dimensional vision and in strumentation. The potential for robotic control adds greater precision, ea se of use, and safety. This new technology will be integrated with diagnost ic information, intraoperative monitoring, anesthesia and perfusion data, c ost accounting, and surgical note transcription. The operating room of the future will package intraoperative information and is adaptable to all surg ical specialties. The future of coronary artery surgery will depend on mini mally invasive techniques, all-arterial grafting, and selective lipid modif ication to reduce progressive atherosclerosis. Te conclusion of this decade marks the end of the beginning. The new generation of cardiothoracic surge ons will share in an array of technology and research unmatched in previous decades. (C) 1998 Elsevier Science B.V. All rights reserved.