Skip to main content
NCBI home page
The Western Journal of Medicine logoLink to The Western Journal of Medicine
. 1982 Apr;136(4):295–308.

Do Coronary Artery Bypass Operations Prolong Life?

Kenneth W Carr 1,2,3, Robert L Engler 1,2,3, John Ross Jr 1,2,3
PMCID: PMC1273712  PMID: 7046257

Abstract

Coronary artery bypass operations improve survival in patients with symptomatic left main coronary artery stenosis, but whether or not longevity is improved in other patients has been controversial. Small clinical studies, even when randomized, have not sufficiently controlled for the heterogeneous distribution of risk factors in patient cohorts treated medically and surgically. The first randomized study large enough to overcome such problems, the Veterans Administration Cooperative Study, showed that coronary artery bypass procedures prolonged survival only in the high-risk subgroup. The surgically treated patients suffered more perioperative morbidity and mortality and had worse long-term survival than similar patients operated on in more recent years. The European Coronary Surgery Study Group recently reported that the three-year to five-year survival of symptomatic patients with triple-vessel disease and normal left ventricular function was better if patients were randomly assigned to surgical therapy. The third and by far the largest randomized study, the Coronary Artery Surgery Study (CASS), has not yet reported long-term follow-up results.

Large clinical studies, both randomized and nonrandomized, that have subgrouped patients by the number of diseased coronary arteries and by the degree of left ventricular dysfunction all show that survival with single-vessel disease is excellent and not improved by operation. Medically treated patients with double- and triple-vessel disease who have good left ventricular function generally now have a five-year survival greater than 85 percent and only two of the major studies suggest that it is improved by operation. The results of most studies, however, suggest that bypass operation prolongs survival in symptomatic patients when left ventricular dysfunction coexists with double- and triple-vessel disease. Continually improving surgical techniques may potentiate the small survival differences that are now apparent, but until then, because the survival differences are so small, it is recommended that limiting anginal symptoms remain the primary indication for a coronary bypass procedure for an individual patient.

Full text

PDF
295

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adkins P. C., Orthner H. F. The Society of Thoracic Surgeons manpower survey for 1976: a summary. Ann Thorac Surg. 1979 Nov;28(5):407–412. doi: 10.1016/s0003-4975(10)63147-5. [DOI] [PubMed] [Google Scholar]
  2. Bruschke A. V., Proudfit W. L., Sones F. M., Jr Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. I. Arterographic correlations. Circulation. 1973 Jun;47(6):1147–1153. doi: 10.1161/01.cir.47.6.1147. [DOI] [PubMed] [Google Scholar]
  3. Bruschke A. V., Proudfit W. L., Sones F. M., Jr Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. II. Ventriculographic and other correlations. Circulation. 1973 Jun;47(6):1154–1163. doi: 10.1161/01.cir.47.6.1154. [DOI] [PubMed] [Google Scholar]
  4. Campeau L., Corbara F., Crochet D., Petitclerc R. Left main coronary artery stenosis: the influence of aortocoronary bypass surgery on survival. Circulation. 1978 Jun;57(6):1111–1115. doi: 10.1161/01.cir.57.6.1111. [DOI] [PubMed] [Google Scholar]
  5. Campeau L., Lespérance J., Hermann J., Corbara F., Grondin C. M., Bourassa M. G. Loss of the improvement of angina between 1 and 7 years after aortocoronary bypass surgery: correlations with changes in vein grafts and in coronary arteries. Circulation. 1979 Aug;60(2 Pt 2):1–5. doi: 10.1161/01.cir.60.2.1. [DOI] [PubMed] [Google Scholar]
  6. Carey J. S., Cukingnan R. A., Groner G. F. Veterans Administration cooperative study of surgery for coronary arterial occlusive disease: view from a noncooperating hospital. Circulation. 1979 Aug;60(2 Pt 2):30–33. doi: 10.1161/01.cir.60.2.30. [DOI] [PubMed] [Google Scholar]
  7. Chaitman B. R., Rogers W. J., Davis K., Tyras D. H., Berger R., Bourassa M. G., Fisher L., StoverHertzberg V., Judkins M. P., Mock M. B. Operative risk factors in patients with left main coronary-artery disease. N Engl J Med. 1980 Oct 23;303(17):953–957. doi: 10.1056/NEJM198010233031701. [DOI] [PubMed] [Google Scholar]
  8. Cohen M. V., Gorlin R. Main left coronary artery disease. Clinical experience from 1964-1974. Circulation. 1975 Aug;52(2):275–285. doi: 10.1161/01.cir.52.2.275. [DOI] [PubMed] [Google Scholar]
  9. Cohn L. H., Boyden C. M., Collins J. J., Jr Improved long-term survival after aortocoronary bypass for advanced coronary artery disease. Am J Surg. 1975 Apr;129(4):380–385. doi: 10.1016/0002-9610(75)90181-6. [DOI] [PubMed] [Google Scholar]
  10. Conley M. J., Ely R. L., Kisslo J., Lee K. L., McNeer J. F., Rosati R. A. The prognostic spectrum of left main stenosis. Circulation. 1978 May;57(5):947–952. doi: 10.1161/01.cir.57.5.947. [DOI] [PubMed] [Google Scholar]
  11. Davis K., Kennedy J. W., Kemp H. G., Jr, Judkins M. P., Gosselin A. J., Killip T. Complications of coronary arteriography from the Collaborative Study of Coronary Artery Surgery (CASS). Circulation. 1979 Jun;59(6):1105–1112. doi: 10.1161/01.cir.59.6.1105. [DOI] [PubMed] [Google Scholar]
  12. DeRouen T. A., Hammermeister K. E., Dodge H. T. Comparisons of the effects on survival after coronary artery surgery in subgroups of patients from the Seattle Heart Watch. Circulation. 1981 Mar;63(3):537–545. doi: 10.1161/01.cir.63.3.537. [DOI] [PubMed] [Google Scholar]
  13. Detre K. M., Wright E., Murphy M. L., Takaro T. Observer agreement in evaluating coronary angiograms. Circulation. 1975 Dec;52(6):979–986. doi: 10.1161/01.cir.52.6.979. [DOI] [PubMed] [Google Scholar]
  14. Detre K., Murphy M. L., Hultgren H. Effect of coronary bypass surgery on longevity in high and low risk patients. Report from the V.A. Cooperative Coronary Surgery Study. Lancet. 1977 Dec 17;2(8051):1243–1245. doi: 10.1016/s0140-6736(77)92659-9. [DOI] [PubMed] [Google Scholar]
  15. Epstein S. E., Kent K. M., Goldstein R. E., Borer J. S., Rosing D. R. Strategy for evaluation and surgical treatment of the asymptomatic or mildly symptomatic patient with coronary artery disease. Am J Cardiol. 1979 May;43(5):1015–1025. doi: 10.1016/0002-9149(79)90369-2. [DOI] [PubMed] [Google Scholar]
  16. Favaloro R. G. Direct myocardial revascularization: a 10 year journey. Myths and realities. Louis F. Bishop Lecture. Am J Cardiol. 1979 Jan;43(1):109–129. doi: 10.1016/0002-9149(79)90053-5. [DOI] [PubMed] [Google Scholar]
  17. FitzGibbon G. M., Burton J. R., Leach A. J. Coronary bypass graft fate: angiographic grading of 1400 consecutive grafts early after operation and of 1132 after one year. Circulation. 1978 Jun;57(6):1070–1074. doi: 10.1161/01.cir.57.6.1070. [DOI] [PubMed] [Google Scholar]
  18. Flemma R. J., Mullen D. C., Lepley D., Jr, Assa J. A comparative synchronous coronary surgery survival study. Ann Thorac Surg. 1979 Nov;28(5):423–428. doi: 10.1016/s0003-4975(10)63149-9. [DOI] [PubMed] [Google Scholar]
  19. Gazes P. C., Mobley E. M., Jr, Faris H. M., Jr, Duncan R. C., Humphries G. B. Preinfarctional (unstable) angina--a prospective study--ten year follow-up. Prognostic significance of electrocardiographic changes. Circulation. 1973 Aug;48(2):331–337. doi: 10.1161/01.cir.48.2.331. [DOI] [PubMed] [Google Scholar]
  20. Gifford R. H., Feinstein A. R. A critique of methodology in studies of anticoagulant therapy for acute myocardial infarction. N Engl J Med. 1969 Feb 13;280(7):351–357. doi: 10.1056/NEJM196902132800703. [DOI] [PubMed] [Google Scholar]
  21. Gross H., Vaid A. K., Cohen M. V. Prognosis in patients rejected for coronary revascularization surgery. Am J Med. 1978 Jan;64(1):9–20. doi: 10.1016/0002-9343(78)90174-2. [DOI] [PubMed] [Google Scholar]
  22. Hamby R. I., Aintablian A., Handler M., Voleti C., Weisz D., Garvey J. W., Wisoff G. Aortocoronary saphenous vein bypass grafts. Long-term patency, morphology and blood flow in patients with patent grafts early after surgery. Circulation. 1979 Oct;60(4):901–909. doi: 10.1161/01.cir.60.4.901. [DOI] [PubMed] [Google Scholar]
  23. Hammermeister K. E., DeRouen T. A., Dodge H. T. Effect of coronary surgery on survival in asymptomatic and minimally symptomatic patients. Circulation. 1980 Aug;62(2 Pt 2):I98–102. [PubMed] [Google Scholar]
  24. Hammermeister K. E., DeRouen T. A., Dodge H. T. Evidence from a nonrandomized study that coronary surgery prolongs survival in patients with two-vessel coronary disease. Circulation. 1979 Mar;59(3):430–435. doi: 10.1161/01.cir.59.3.430. [DOI] [PubMed] [Google Scholar]
  25. Hammermeister K. E., DeRouen T. A., Dodge H. T. Variables predictive of survival in patients with coronary disease. Selection by univariate and multivariate analyses from the clinical, electrocardiographic, exercise, arteriographic, and quantitative angiographic evaluations. Circulation. 1979 Mar;59(3):421–430. doi: 10.1161/01.cir.59.3.421. [DOI] [PubMed] [Google Scholar]
  26. Hammermeister K. E., DeRouen T. A., Murray J. A., Dodge H. T. Effect of aortocoronary saphenous vein bypass grafting on death and sudden death. Comparison of nonrandomized medically and surgically treated cohorts with comparable coronary disease and left ventricular function. Am J Cardiol. 1977 May 26;39(6):925–934. doi: 10.1016/s0002-9149(77)80048-9. [DOI] [PubMed] [Google Scholar]
  27. Harris P. J., Harrell F. E., Jr, Lee K. L., Behar V. S., Rosati R. A. Survival in medically treated coronary artery disease. Circulation. 1979 Dec;60(6):1259–1269. doi: 10.1161/01.cir.60.6.1259. [DOI] [PubMed] [Google Scholar]
  28. Hurst J. W., King S. B., 3rd, Logue R. B., Hatcher C. R., Jr, Jones E. L., Craver J. M., Douglas J. S., Jr, Franch R. H., Dorney E. R., Cobbs B. W., Jr Value of coronary bypass surgery. Controversies in cardiology: Part I. Am J Cardiol. 1978 Aug;42(2):308–329. doi: 10.1016/0002-9149(78)90917-7. [DOI] [PubMed] [Google Scholar]
  29. Hutchinson J. E., 3rd, Green G. E., Mekhjian H. A., Gallozzi E., Cameron A., Kemp H. G. Coronary bypass grafting in 476 patients consecutively operated on. Chest. 1973 Dec;64(6):706–710. doi: 10.1378/chest.64.6.706. [DOI] [PubMed] [Google Scholar]
  30. Hutter A. M., Jr Is there a left main equivalent? Circulation. 1980 Aug;62(2):207–211. doi: 10.1161/01.cir.62.2.207. [DOI] [PubMed] [Google Scholar]
  31. Kennedy J. W., Kaiser G. C., Fisher L. D., Fritz J. K., Myers W., Mudd J. G., Ryan T. J. Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation. 1981 Apr;63(4):793–802. doi: 10.1161/01.cir.63.4.793. [DOI] [PubMed] [Google Scholar]
  32. Kloster F. E., Kremkau E. L., Ritzmann L. W., Rahimtoola S. H., Rösch J., Kanarek P. H. Coronary bypass for stable angina: a prospective randomized study. N Engl J Med. 1979 Jan 25;300(4):149–157. doi: 10.1056/NEJM197901253000401. [DOI] [PubMed] [Google Scholar]
  33. Kouchoukos N. T., Oberman A., Karp R. B. Results of surgery for disabling angina pectoris. Cardiovasc Clin. 1977;8(2):157–166. [PubMed] [Google Scholar]
  34. Lawrie G. M., Morris G. C., Jr, Howell J. F., Hines M., Chapman D. W. Improved survival beyond 5 years after coronary bypass surgery in patients with left main coronary artery disease. Am J Cardiol. 1979 Oct;44(4):612–615. doi: 10.1016/0002-9149(79)90277-7. [DOI] [PubMed] [Google Scholar]
  35. Lawrie G. M., Morris G. C., Jr, Howell J. F., Tredici T. D., Chapman D. W. Improved survival after 5 years in 1,144 patients after coronary bypass surgery. Am J Cardiol. 1978 Nov;42(5):709–715. doi: 10.1016/0002-9149(78)90088-7. [DOI] [PubMed] [Google Scholar]
  36. Lee K. L., McNeer J. F., Starmer C. F., Harris P. J., Rosati R. A. Clinical judgment and statistics. Lessons from a simulated randomized trial in coronary artery disease. Circulation. 1980 Mar;61(3):508–515. doi: 10.1161/01.cir.61.3.508. [DOI] [PubMed] [Google Scholar]
  37. Lim J. S., Proudfit W. L., Sones F. M., Jr Left main coronary arterial obstruction: Long-term follow-up of 141 nonsurgical cases. Am J Cardiol. 1975 Aug;36(2):131–135. doi: 10.1016/0002-9149(75)90515-9. [DOI] [PubMed] [Google Scholar]
  38. Loeb H. S., Pifarre R., Sullivan H., Palac R., Croke R. P., Gunnar R. M. Improved survival after surgical therapy for chronic angina pectoris: one hospital's experience in a randomized trial. Circulation. 1979 Aug;60(2 Pt 2):22–30. doi: 10.1161/01.cir.60.2.22. [DOI] [PubMed] [Google Scholar]
  39. Loop F. D., Lytle B. W., Cosgrove D. M., Sheldon W. C., Irarrazaval M., Taylor P. C., Groves L. K., Pichard A. D. Atherosclerosis of the left main coronary artery: 5 years results of surgical treatment. Am J Cardiol. 1979 Aug;44(2):195–201. doi: 10.1016/0002-9149(79)90304-7. [DOI] [PubMed] [Google Scholar]
  40. Mathur V. S., Guinn G. A., Anastassiades L. C., Chahine R. A., Korompai F. L., Montero A. C., Luchi R. J. Surgical treatment for stable angina pectoris. Prospective randomized study. N Engl J Med. 1975 Apr 3;292(14):709–713. doi: 10.1056/NEJM197504032921401. [DOI] [PubMed] [Google Scholar]
  41. McNeer J. F., Starmer C. F., Bartel A. G., Behar V. S., Kong Y., Peter R. H., Rosati R. A. The nature of treatment selection in coronary artery disease. Experience with medical and surgical treatment of a chronic disease. Circulation. 1974 Apr;49(4):606–614. doi: 10.1161/01.cir.49.4.606. [DOI] [PubMed] [Google Scholar]
  42. Murphy M. L., Hultgren H. N., Detre K., Thomsen J., Takaro T. Treatment of chronic stable angina. A preliminary report of survival data of the randomized Veterans Administration cooperative study. N Engl J Med. 1977 Sep 22;297(12):621–627. doi: 10.1056/NEJM197709222971201. [DOI] [PubMed] [Google Scholar]
  43. Peduzzi P., Hultgren H. N. Effect of medical vs surgical treatment on symptoms in stable angina pectoris. The Veterans Administration Cooperative Study of surgery for coronary arterial occlusive disease. Circulation. 1979 Oct;60(4):888–900. doi: 10.1161/01.cir.60.4.888. [DOI] [PubMed] [Google Scholar]
  44. Proudfit W. L., Bruschke A. V., Sones F. M., Jr Natural history of obstructive coronary artery disease: ten-year study of 601 nonsurgical cases. Prog Cardiovasc Dis. 1978 Jul-Aug;21(1):53–78. doi: 10.1016/s0033-0620(78)80004-8. [DOI] [PubMed] [Google Scholar]
  45. Read R. C., Murphy M. L., Hultgren H. N., Takaro T. Survival of men treated for chronic stable angina pectoris. A cooperative randomized study. J Thorac Cardiovasc Surg. 1978 Jan;75(1):1–16. [PubMed] [Google Scholar]
  46. Rosati R. A., Lee K. L., Mittler B. S., McNeer J. F., Behar V. S., Margolis J. R. Does coronary surgery prolong life in comparison with medical management? Postgrad Med J. 1976 Dec;52(614):749–756. doi: 10.1136/pgmj.52.614.749. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Sabiston D. C., Jr The William F. Rienhoff, Jr. lecture. The coronary circulation. Johns Hopkins Med J. 1974 Jun;134(6):314–329. [PubMed] [Google Scholar]
  48. Vismara L. A., Miller R. R., Price J. E., Karem R., DeMaria A. N., Mason D. T. Improved longevity due to reduction of sudden death by aortocoronary bypass in coronary atherosclerosis. Am J Cardiol. 1977 May 26;39(6):919–924. doi: 10.1016/s0002-9149(77)80047-7. [DOI] [PubMed] [Google Scholar]
  49. Vlietstra R. E., Assad-Morell J. L., Frye R. L., Elveback L. R., Connolly D. C., Ritman E. L., Pluth J. R., Barnhorst D. A., Danielson G. K., Wallace R. B. Survival predictors in coronary artery disease. Medical and surgical comparisons. Mayo Clin Proc. 1977 Feb;52(2):85–90. [PubMed] [Google Scholar]

Articles from Western Journal of Medicine are provided here courtesy of BMJ Publishing Group

RESOURCES