A historical review: From standardized coronary bypass grafting to off-pump surgery

Abstract

The development of modern cardiac surgery was initiated by the development of the heart-lung machine by GIBBON in 1954 [11]. Extracorporeal circulation ensured the supply of oxygenated blood to all organs except the heart and allowed surgery to be performed on the inside of the heart, i.e., on the valves and septums. The development of protective procedures for the heart itself, which is not supplied with blood during this kind of surgery, led to increased safety and further standardization of these surgical procedures. We have to point out at this point that the origins of cardiac surgery lie in the treatment of congenital malformations and heart valve defects, in particular in the area of rheumatic valve alterations. Only much later, during the further development of this young surgical discipline the search began for a method to treat widespread coronary heart diseases. Between 1955 and 1964, there were only sporadic reports of operations on the coronary arteries by MURRAY, GARRETT, SABISTON and LONGMIRE [10, 17, 21, 24]. Only after the cardiological working group of EFFLER and SONES [8] at the Cleveland Clinic was able to determine coronary artery disease (CAD) by the systematic development of coronary angiography was it possible to standardize surgical strategies. It was left to FAVALORO [9] to introduce coronary bypass surgery as a therapy concept for the treatment of CAD in a standardized form. Within the scope of this kind of surgery, sternotomy as an access to the heart, the use of the heart-lung machine, moderate hypothermia for myocardial protection, and coronary revascularization by aorto-coronary vein bypasses became the standard. As late as 1970, this strategy was expanded by the use of the left internal mammary artery for revascularization of the left anterior descending artery (LAD) in the works of LOOP and coworkers [18]. With the further development of surgical techniques including extracorporeal perfusion, cardiac anesthesia and post-operative intensive care of the patients, the surgical revascularization concept of aorto-coronary bypass grafts for the revascularization of local coronary artery diseases was able to establish itself with high efficiency and safety. In the 1980s and 1990s, this surgical technique led to a boom, since systematic diagnostics using coronary angiography became a widespread tool. With the introduction of angioplasty by GRUENTZIG [12] in 1967, another pillar was formed for the treatment of coronary artery disease which has ever since competed with the surgical procedures. Especially due to the introduction of stents, several new methods for the treatment of in-stent stenoses which could not be removed previously and better drug treatments to avoid early occlusions, angioplasty was able to establish itself as the leading procedure for the treatment of coronary artery disease. Coronary bypass grafting has maintained its dominance only in patients with diffuse coronary artery disease, diabetes mellitus, left ventricular malfunction and main trunk stenoses. Several comparative studies have underlined the dominance of surgical therapy over angioplasty for the different patient subgroups.