Coronary artery surgery.

1 doubt that there has ever been a time in medicine where a field of surgery has grown so rapidly as in the area of direct coronary revascularization. Virtually within two years following the introduction of saphenous vem bypass grafting by Favalero and Johnson the procedure was adopted across the United States and the number of coronary bypasses performed has swelled during each additional ye~r. It is estimated that last year over 80,000 coronas~y révascularizations were performed and 1 suspect that the number will exceed that this year. The reasons for that growth are many, but prime among them is population demand. Last year over one million deaths were attributed to coronary artery disease and it is estimated that over twelve million patients per year are symptomatically affected. In addition, the ranks of cardiac surgeons have markedly swelled over the past few years and with the limited population of congenital and valvular heart disease, nearly 70% of these new surgeons found themselves engaged in noncardiac work. As a result of these two factors, the volume of saphenous vem bypass procedures increased rapidly. Added to these considerations, of course, is the fact that the procedure produced generally good results and the mortality, at least reported by the major instutions, was low. This produced confidence in the cardiologists to refer their patients to surgery since but a few years ago they had little to offer their patients in medical management. However over the last decade, many new developments have occurred which have caused us to te-examine the procedure and to more critically assess its application. One of these was fostered by some of the cardiac surgeons who themselves were prime in the development of the procedure and who advocated that revascularization should virtually be carried out even in the smallest private hospital. In many situations this was an unfortunate attitude since we ali realize that it takes more than a skillful surgeon to perform an open-heart procedure — it takes angiographic and laborarory support, good anesthesia, a well trained pump team, and a good postoperative facility and care. Unfortunately figures on mortality for these small programs were never reported until 1977 when the combined Veterans Administration report revealed their mortality which ranged between 1 and 16% virtualiy dependent upon the number of cases performed (Carey and Cukingnan 1979). Similar figures are available from Great Bri tain in their national registry of 1977 …