TCTAP 2026
Six Decades of Coronary Revascularization: CABG’s Enduring Edge
David Paul Taggart, MD, PhD (University of Oxford, United Kingdom), recipient of the 16th TCTAP Master of the Masters Award, delivered a sweeping assessment of coronary revascularization spanning the field’s six-decade history-from Favaloro’s first bypass graft in 1967 to the latest generation of drug-eluting stents. His verdict: despite relentless advances in percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) retains a durable survival advantage in most patients with multivessel or left main disease, and wide geographic variation in PCI-to-CABG ratios reflects physician preference more than evidence. A Tale of Two Pioneers In 1967, René Favaloro-the ‘father of CABG’-reported the systematic use of reversed saphenous vein grafting to treat multivessel coronary artery disease. Almost a decade later, Andreas Grüntzig described the opening of stenosed coronary arteries with a balloon, laying the foundation for interventional cardiology. Despite this parallel evolution, he was unequivocal: the long-predicted demise of CABG has not occurred. The fundamental CABG operation has changed little in 60 years, with saphenous vein increasingly replaced by the internal mammary artery and other arterial conduits. In contrast, PCI has evolved through numerous stent generations. Yet even contemporary PCI, he stressed, does not match CABG outcomes in many patients with complex disease. The long-predicted demise of CABG has not occurred. Despite never-ending improvements in stent technology, PCI does not match the results of CABG in many patients with multivessel or left main disease. David Paul Taggart, MD, PhD Multivessel Disease: SYNTAX and FAME III Early trials comparing PCI and CABG were confounded by enrolling patients with low-complexity disease that poorly reflected real-world practice. The SYNTAX trial addressed this by adopting a relative “all-comers” design-though 40% of screened patients had disease so severe they were referred directly for CABG rather than randomized. At five years, CABG demonstrated a significant overall survival advantage of approximately 5% over PCI, accompanied by marked reductions in myocardial infarction (MI) and the need for repeat revascularization. Crucially, when patients were stratified by SYNTAX score, the survival benefit of CABG widened with increasing disease complexity-roughly 7% in the intermediate-score group and 9% in the highest-risk tier. More recently, the FAME III trial, using fractional flow reserve (FFR)-guided PCI with contemporary drug-eluting stents, still failed to match CABG outcomes. These advantages are further amplified in patients with diabetes and impaired ventricular function, he noted. Trial / Comparison Key Finding CABG Advantage SYNTAX (MVD, 5-yr) All-cause mortality, MI, repeat revasc. ~5% overall survival benefit SYNTAX (High SYNTAX Score) Survival by disease severity +9% survival vs PCI FAME III (FFR-guided PCI) Contemporary DES vs CABG CABG still superior EXCEL (LMD, 5-yr) SYNTAX score ≤32 Clear survival benefit; ↓MI Table: Selected landmark trials comparing CABG and PCI. MVD = multivessel disease; LMD = left main disease; DES = drug-eluting stent; MI = myocardial infarction. Left Main Disease: The EXCEL Controversy The left main (LM) coronary artery debate has proven more contentious. The EXCEL trial-the most definitive study in selected LM disease with SYNTAX scores below 32-demonstrated a clear and accelerating survival benefit for CABG at five years, along with a marked reduction in MI on conventional biochemical definitions. Yet the cardiology literature subsequently became flooded with meta-analyses combining EXCEL results with smaller, underpowered studies of less severe disease, effectively diluting the mortality signal until CABG’s benefit “disappeared” from pooled estimates. Today, there is broad consensus that LM disease with SYNTAX scores above 32 is an indication for CABG unless contraindicated. Lesser-severity LM disease remains debated. He acknowledged a notable exception: patients with true ostial or isolated mid-shaft LM stenosis may achieve excellent outcomes with PCI-possibly because competitive flow from bypass grafts reduces graft efficacy in anatomically favorable lesions. Why CABG Retains Its Edge: Three Fundamental Differences ending improvements in stent technology, and whose benefits grow ever more durable with longer follow-up-extending beyond 10 years. He emphasized the most important: 1. Bypass grafts protect the whole proximal coronary circulation-independent of the complexity of the proximal culprit lesion and from the progression of, or development of, further proximal disease. This is witnessed by the sustained reduction in subsequent myocardial infarction with CABG versus PCI in longer-term studies. 2. The internal thoracic artery exerts beneficial vasoactive effects that may actively promote long-term vessel health-a biological property no stent platform can replicate. 3. CABG more reliably achieves complete revascularization, a factor consistently associated with improved long-term outcomes across disease subsets. The PCI:CABG Ratio Gap—Evidence vs. Practice Perhaps the most provocative element of his lecture was his challenge to the global mismatch between evidence and practice. Despite more than two decades of trial data demonstrating CABG’s superiority for most patients with multivessel and left main disease, the ratio of PCI to CABG varies enormously among countries and even within regions of the same country—variations that cannot be explained by differences in patient populations alone. Both PCI and CABG are complementary therapies when used in appropriate patients, he acknowledged. But he was blunt about the evidence gap: best evidence has demonstrated the superiority of CABG for most patients with multivessel and left main disease for over two decades. Given the same evidence base, the enormous discrepancies in PCI-to-CABG ratios across countries—and within regions of the same country—have only one plausible explanation: “clinical practice is largely dictated by physician preference rather than evidence basis, and that may be detrimental to the best interests of the patient.” The Heart Team Imperative His prescription was clear: the only effective solution is properly constituted multidisciplinary heart teams empowered to make evidence-based recommendations—so that patients can then make a truly informed decision. Both procedures, he stressed, are complementary when deployed in the right patient. The gulf between evidence and practice, he implied, is a failure not of science but of how clinical decisions are made. The lecture offered a sweeping reminder that six decades of evidence consistently point in the same direction—and that the greatest remaining challenge may not be technological, but organizational. Taggart reports no relevant conflicts of interest. TCTAP Award 2026 16th TCTAP Master of the Masters Award Thursday, April 30, 11:25 AM ~ 11:55 AM Main Arena, Level 1 Check the Session
May 01, 2026 198
