Ischemic Disease: Coronary Artery Bypass Grafting Large trials such as the Coronary Artery Surgery Study (CASS) established that patients with extensive coronary artery disease and systolic ventricular
dysfunction have better survival after revascularization. Unfortunately, these large, prospective, randomized trials which established the importance of coronary revascularization excluded patients with symptoms of heart failure and with left ventricular ejection fractions less than 35% (among seven randomized trials only 7% had an EF<40%, and only 4% had symptoms of heart failure). The STICH trial is an ongoing multiinstitutional, international, prospective, randomized trial comparing surgical revascularization with medical therapy for patients with heart failure or low left ventricular ejection fraction. The trial will finish enrollment in late 2006 and will be able to report medium term outcomes in the next few years. Awaiting the results of this trial and potential identification of subgroups of patients that will benefit from surgery, current decisions are based on smaller reports and retrospective reviews. A manuscript published in the Journal of the American Medical Association in 1994 reviewed 7 publications which reported on outcomes after CABG in patients with an EF between 25% and 40%. Six of the seven papers found that survival was best in the patients who had CABG. Since that time, in might be argued, medical therapy has improved for patients with heart failure, but surgical care including myocardial protection has also improved.