Potential but unproven explanations for the adverse effects of PAD on long-term survival after CABG include: 1) The presence of PAD may lead to vascular events (ie, cerebrovascular events) that adversely affect post-CABG survival; 2) PAD may be a marker for more severe CAD, which may lead to an increased rate of post-CABG death from cardiac causes despite revascularization; and 3) PAD may contribute to noncardiovascular death in the long term. Revascularization of PAD before CABG is not known to improve post-CABG outcomes. 7. Economic Issues 7.1. Cost-Effectiveness of CABG and PCI In the United States, it is estimated that the annual hospital costs of CABG are approximately $10 billion.1242 Despite the increasing risk profile of CABG candidates, it nonetheless is becoming more cost-effective. Hospital charges from the Nationwide Inpatient Sample of nearly 5.5 million patients who had isolated CABG in the United States from 1988 to 2005 were examined.1243 A decrease in risk-adjusted mortal- ity rate, from 6.2% to 2.1% (P 0.0001), was noted. When hospital costs were corrected for inflation, they declined from $26 210 in 1988 to $19 196 in 2005 ($1988) (P 0.0001). Several factors tend to increase the cost of CABG, includ- ing advanced patient age, female sex, African-American ethnicity, postoperative complications, longer hospital stay, and multiple comorbidities, particularly CKD.1244 1247 The National Health Service Foundation Trust in Britain found that patients 75 years of age undergoing CABG had higher rates of postoperative complications and greater resource utilization than their younger counterparts.1244 Similarly, the Maryland Health Services Cost Review Commission reported an increased total cost and length of hospital stay with increasing age in patients undergoing CABG.1245 The same phenomenon was not present with PCI until the patients were 80 years old. In an examination of data from 12 016 subjects undergoing CABG in New York State in 2003, it was determined that older age, female sex, and African-American ethnicity were associated with higher costs.1247 Clinical char- acteristics, such as a lower LVEF, number of diseased vessels, previous open-heart operations, and numerous co- morbidities, further increased costs. Larger hospitals were associated with higher CABG discharge costs, whereas costs significantly decreased with higher CABG volumes. Not surprisingly, perioperative complications lead to in- creased costs. An examination of the Medicare Provider Analysis and Review file of data from 114 223 Medicare beneficiaries who survived CABG in 2005 showed the mean cost of hospitalization associated with CABG to be $32 201 $23 059 for a mean length of stay of 9.9 7.8 days. Those with complications (13.6% of patients) consumed significantly more hospital resources (incremental cost, $15 468) and had a longer length of stay (average additional Evidence for the role of off-pump versus on-pump CABG in decreasing costs is conflicting. In a randomized study comparing off-pump and on-pump CABG, the mean total hospitalization cost per patient was $2272 less for off-pump CABG at hospital discharge and $1955 less at 1 year.1248 Another study of 6665 patients who underwent CABG between 1999 and 2005 determined that off-pump CABG provided a small short-term gain,1249 although off-pump patients had increased long-term risks of repeat revascular- ization and major vascular events, especially if they were considered to be high risk. In the long run, in fact, off-pump patients utilized more resources. 7.1.1. Cost-Effectiveness of CABG Versus PCI Medical costs and quality of life were examined 10 to 12 years after patients were randomly assigned to receive angio- plasty or CABG in the BARI trial.1250 Although CABG costs initially were 53% higher, the gap closed to 5% by the end of 2 years. After 12 years, the average cost was $123 000 in CABG patients and $120 000 for PCI patients. Cumulative costs were significantly higher among patients with diabetes mellitus, heart failure, and comorbid conditions, and they were higher in women. CABG was deemed to be as cost- effective as PCI in patients with multivessel CAD. The cost of coronary artery revascularization in 6218 patients with and without CKD whose data were available in the Duke database was examined.1251 CABG was an economically attrac- tive alternative to PCI or medical therapy for all patients with left main or 3-vessel CAD without concomitant CKD as well as those with 2-vessel CAD with concomitant CKD. For subjects with 3-vessel CAD and concomitant CKD, 2-vessel CAD without CKD, and 1-vessel CAD regardless of renal function, medical therapy was an economically attractive strategy com- pared with CABG or PCI. This analysis concluded that CABG is most economically attractive compared with PCI and medical therapy in patients to whom it confers the greatest survival advantage and for whom the cost of alternative treatments is greatest (ie, those with the most severe CAD). Although CABG was more expensive than medical therapy for all patients, the survival benefits associated with it were of such magnitude in some subjects that it was economically attractive. The cost-effectiveness of CABG and PCI in high-risk patients was analyzed in the AWESOME (Angina With Extremely Serious Operative Mortality Evaluation) study,446 in which costs were assessed at 3 and 5 years. After 3 years, the average total cost was $63 896 for PCI and $84 364 for CABG, a difference of $20 468. After 5 years, the average total cost was $81 790 for PCI and $100 522 for CABG, a difference of $18 732. The authors concluded that PCI was less costly and at least as effective for urgent revasculariza- tion in high-risk patients with medically refractory angina. 7.1.2. CABG Versus PCI With DES The use of DES for PCI will require a reassessment of cost- effectiveness. Although the initial procedure is considerably more expensive than the use of balloon angioplasty or BMS, equaling the cost of CABG in many patients with multivessel CAD, the cost of reintervention for restenosis may be reduced. The cost-effectiveness will depend on the pricing of stents, utilization rates of the more expensive stents, and efficacy. In a 2010 study from Japan comparing the total costs at 2 years of CABG and DES implantation in patients with left main CAD, the total costs were significantly lower for those undergoing CABG than for those receiving a DES.1252 8. Future Research Directions With improvements in percutaneous techniques and medical therapy, on-pump CABG and off-pump CABG will increas- ingly be reserved for patients with extensive CAD, many of whom have had previous PCI. The future of CABG will be directed at improving its results in high-risk patients and making CABG less invasive for elective revascularization. Minimally invasive techniques, with the use of robotics and anastomotic connectors, intraoperative imaging, hybrid pro- cedures, and protein and gene therapy, appear promising. Robotic technology in minimally invasive CABG leads to less traumatic harvesting of the LIMA for minimally invasive direct coronary artery bypass procedures compared with nonrobotic techniques.1253 The ultimate goal of robotic CABG is totally endoscopic CABG, but its use has been limited, at least partly because of a substantial learning curve, cost considerations, and few data demonstrating noninferior graft patency and outcomes compared with standard CABG. Anastomotic connectors may enable more routine applica- tion of totally endoscopic anastomoses in subjects undergoing minimally invasive CABG. Because hand-sewn anastomoses are technically challenging when performed endoscopically, consideration has been given to the concept of anatomic connectors to facilitate more reproducible and less technically demanding procedures and ultimately to allow widespread use. Both proximal and distal connectors may be used. Several options are being developed, some only available outside the United States, and the evidence base supporting their use is evolving.1254 The PAS-Port proximal device has been associated with acceptable outcomes. In two prospective studies, its angiographic graft patency 9 months after CABG was similar to that of hand-sewn anastomoses.1255,1256 With this device, the proximal anastomoses must be constructed Hillis et al 2011 ACCF/AHA CABG Guideline e699 before the distal ones. At present, only 1 distal device, the Cardica C-Port, has been approved for use in the United States. The prospective studies1257,1258 demonstrated a 6-month overall patency of 96% in 102 subjects. These devices increase the cost of the operation. Over the past 20 years, the patency rate of all graft types has improved gradually, so that the present failure rate of LIMA grafts at 1 year is about 8% and of SVGs roughly 20%.1259 Many patients being referred for CABG nowadays have far advanced CAD, which is often diffuse and exhibits poor vessel runoff. Technical issues at the time of surgery may influence graft patency, and intraoperative imaging may help to delineate technical from nontechnical issues. Because coronary angiography is rarely available intraoperatively, other techniques have been developed to assess graft integrity at this time, most often the transit-time flow and intraopera- tive fluorescence imaging. The transit-time flow is a quanti- tative volume-flow technique that cannot define the severity of graft stenosis or discriminate between the influence of the graft conduit and the coronary arteriolar bed on the mean graft flow. Intraoperative fluorescence imaging, which is based on the fluorescent properties of indocyanine green, provides a semiquantitative assessment of graft patency with images that provide some details about the quality of coronary anastomoses.1260 Although both methods are valu- able in assessing graft patency, neither is sufficiently sensi- tive or specific to allow identification of more subtle abnor- malities.1260 It is hoped that such imaging may help to reduce the occurrence of technical errors. The hybrid suite can be used as an operating room and a catheterization laboratory. It allows the performance of an angiogram after CABG so that one can identify abnormal grafts, providing the opportunity to revise them (with PCI or surgery) before leaving the operating room. Until completion angiography becomes more routine (in a hybrid suite), cardiac surgeons must rely on reasonably accurate, albeit imperfect, methods to identify problems with a recently implanted graft. 8.1. Hybrid CABG/PCI Advances in surgical techniques and the introduction of DES have provided a platform for a hybrid revascularization strategy that combines grafting the LAD artery with the LIMA and stenting the non-LAD arteries with DES (instead of bypassing them with SVGs). Although preliminary data1261 have indicated that a hybrid strategy may be a reasonable alternative in some patients with multivessel CAD, its real effect will not be known until results of RCTs are avail- able.1261 The primary purpose of performing hybrid CABG is to decrease the morbidity rate of traditional CABG in high-risk patients. Although hybrid revascularization is most often performed in a staged fashion, a simultaneous hybrid procedure can be performed in a hybrid suite, offering several potential advantages, including improving the efficiency and cost-effectiveness of therapy as well as condensing therapy into 1 patient encounter. If a staged approach is chosen, minimally invasive CABG performed first, followed days later by PCI, is probably preferable, so as to enable surgery without the unwanted effects of antiplatelet therapy as well as to enable complete angiography of the LIMA graft at the time of PCI. The major disadvantage of this approach is that if complications occur with PCI, a third procedure may be necessary. Even with a hybrid suite, one of the most substan- tive barriers to simultaneous minimally invasive CABG and PCI is the management of antiplatelet therapy. The role of hybrid CABG PCI compared with sole PCI and sole conven- tional CABG awaits the results of the ongoing observational study of hybrid coronary revascularization by the National Heart, Lung, and Blood Institute. 8.2. Protein and Gene Therapy Several proteins, such as vascular endothelial growth factor, acidic fibroblast growth factor, and basic fibroblast growth factor, induce angiogenesis1262; as a result, interest has grown in using these substances to stimulate myocardial perfusion. One RCT found that patients who were given 100 mcg of basic fibroblast growth factor became angina free, and nu- clear perfusion testing appeared to show improved perfu- sion.1262 Another RCT has suggested that the intracoronary injection of high-dose angiogenic molecules yields improve- ment in symptoms, exercise time, functional capacity, and myocardial perfusion.1263 Alternatively, gene therapy may be used to induce angiogenesis, but conceptual concerns with intravascular gene therapy, such as peripheral uptake into nontarget tissues and subsequent unintended effects, have been raised. 8.3. Teaching CABG to the Next Generation: Use of Surgical Simulators Over the past decade, pressure on hospitals and physicians to ensure high quality and safety has increased. Public reporting of outcomes, common in many states, has been endorsed by the STS. In addition, healthcare reform has placed great emphasis on the efficiency of care. These factors, coupled with the increased complexity of patients referred for CABG, the decreased number of qualified physicians specializing in cardiac surgery, and the restrictions on resident work hours, make the teaching of surgical techniques to the next genera- tion a substantial challenge. Given the success of simulator training of airline and military personnel, it has the potential to have a major impact on surgical training paradigms. With surgical simulators, a trainee s first distal anastomosis in an actual patient will occur only after mastering the technique on a simulator.1264 The mastery of basic skills will allow the trainee to focus on more complex tasks as well as to understand the conduct of the operation more thoroughly and quickly. The fundamentals of simulator training are based on the learning principle of deliberate practice, in which an individual practices a finite task until it is mastered. Still, before this method of training can be incorporated into a formal curriculum, several issues must be addressed. Trainees must have adequate supervision and instruction to ensure appropriate technique, which will require that attending surgeons have time away from clinical and academic duties to provide simulator training. This poses a considerable challenge under current reimbursement re- quirements, and a reimbursement system that provides an incentive to active surgeons to teach residents in the simula- tion laboratory will be required. As an alternative, training programs may opt to hire recently retired surgeons to teach in the simulation laboratory. Finally, simulators must become more robust, with perhaps computer-enhanced clinical sce- narios, before the residents who train on them are qualified to care for patients. Staff American College of Cardiology Foundation David R. Holmes, Jr, MD, FACC, President John C. Lewin, MD, Chief Executive Officer Janet Wright, MD, FACC, Senior Vice President, Science and Quality Charlene May, Senior Director, Science and Clinical Policy Erin A. 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