In the Twilight of Evidence: Is Bypass Surgery Still on the Table for Cardiac Allograft Vasculopathy?

<b>Background:</b> Cardiac allograft vasculopathy (CAV) is a major prognosis-limiting factor in patients undergoing orthotopic heart transplantation (HT). Due to the diffuse involvement of the coronary tree, CAV lesions are often not amenable to percutaneous coronary intervention (PCI), leaving coronary artery bypass grafting (CABG) and retransplantation as primary revascularization options. <b>Aim and Results</b>: The latest guidelines from the International Society for Heart and Lung Transplantation (ISHLT) recognize CABG as a viable option but with a downgraded strength of recommendation. The 2023 ISHLT guidelines now categorize CABG as a Class IIb recommendation (Level of Evidence: C) for highly selected CAV patients with anatomically suitable lesions, a downgrade from the Class IIa recommendation in the 2010 guidelines. This adjustment underscores the persisting reliance on limited, retrospective studies and the lack of substantial new data supporting CABG in CAV management. Our article examines the evidence collected since 2010 on this topic, highlighting key findings and assessing the role of CABG in contemporary transplant practice. This article calls for targeted investigations to better define the role of CABG as a therapeutic option, addressing the gaps in evidence for surgical revascularization in HT patients.