Advancing Coronary Surgery in India: The Rise of a Dedicated Subspecialty Society

Abstract

Coronary artery disease is the leading cause of mortality worldwide and presents with disproportionately severe patterns in the South Asian population. Coronary artery bypass grafting remains the most durable revascularization modality. Yet, its evolution in India has been inconsistent, perhaps in part due to the absence of a dedicated scientific body focused exclusively on coronary surgery. Following the successful completion of the PROMOTE Patency Trial, the first multicenter randomized clinical trial in Indian cardiac surgery, a motivated group of surgeons recognized the need for sustained collaboration, research, and subspecialty-driven progress. This realization led to the formation of the Society of Coronary Surgeons in December 2020 under the leadership of its Founder President, L. R. Sajja, during the unprecedented disruptions of the COVID-19 pandemic. The society’s creation marks a pivotal advance in India’s effort to cultivate indigenous coronary research, data collection, standardized training, and region-specific guidelines. This perspective outlines the origins of the Society of Coronary Surgeons, the evolution of coronary surgery, the need for a coronary subspecialty society in India, and the importance of establishing a national coronary surgery database tailored to Indian patient characteristics. The Society of Coronary Surgeons represents both a scientific necessity and a transformative opportunity for the future of coronary surgery in India.

Introduction

Coronary artery disease (CAD) remains the foremost cause of death globally, accounting for a substantial proportion of the global mortality burden, particularly in India, where patients often present at younger ages, with more diffuse disease, and with smaller caliber coronary arteries than Western counterparts.^{1, 2} Coronary artery bypass grafting (CABG) continues to be the gold standard for managing complex multivessel CAD; yet, the practice of coronary surgery has evolved unevenly in South Asian countries. Historically, India lacked a dedicated platform to unify coronary surgeons, promote focused scientific inquiry, or develop guidelines that reflect its unique anatomical and epidemiologic features. The establishment of the Society of Coronary Surgeons (SCS) in December 2020 represents a decisive step toward addressing these gaps, emerging from the collaborative spirit fostered during the PROMOTE Patency Trial and crystallizing the collective aspiration of Indian coronary surgeons to build a sustained, evidence-driven community in the field of coronary revascularization. ³

Origins of the Society of Coronary Surgeons (India)

The formation of SCS was directly influenced by the landmark PROMOTE Patency Trial, which brought together surgeons from across India in a shared scientific endeavor (Figures 1 and 2). The trial not only generated valuable clinical evidence but also created a strong professional network among participating surgeons, underscoring the need for an enduring organizational structure to sustain advances in coronary research in India. Motivated by this scientific momentum, a core group of coronary surgeons, led by Sajja, initiated the formation of a dedicated national society for coronary surgery (Figure 3). This group of surgeons is also actively involved in the ongoing Indian Council of Medical Research (ICMR)-sponsored multicenter randomized controlled PREDICT study. Remarkably, the society was conceived and launched during the height of the COVID-19 pandemic, a time marked by restricted travel, curtailed elective surgeries, and overloaded hospitals. Establishing SCS required repeated virtual coordination, persistent advocacy, and a shared belief that coronary surgery in India needed its own scientific identity. Despite these challenges, the society was formally inaugurated in December 2020, demonstrating the resilience and unity of Indian coronary surgeons amid unprecedented disruption.

Figure 1.

Source: Sajja Heart Foundation website (https://sajjaheartfoundation.org/gallery.php)

Figure 2.

Source: Sajja Heart Foundation website (https://sajjaheartfoundation.org/gallery.php)

Figure 3.

Source: Society of Coronary Surgeons website (https://www.thescs.net/)

The Need for a Coronary Subspecialty Society in India

Coronary surgery has become increasingly complex, particularly in India, where surgeons routinely manage patients with diffuse disease, diabetes, smaller vessels, and early-onset atherosclerosis. While CABG remains the most frequently performed adult cardiac operation globally, it continues to be treated as a generalist procedure in many centers rather than as a formal subspecialty. ⁴ This stands in marked contrast to other areas of cardiac surgery, mitral valve repair, aortic surgery, congenital heart surgery, and heart-failure surgery, each of which has developed distinct subspecialty frameworks and dedicated societies. Global models such as the International Society for Coronary Artery Surgery and the Japanese Association for Coronary Artery Surgery demonstrate that professional communities dedicated exclusively to coronary revascularization can foster improved training, research output, standardized practice, and guideline development. India, however, despite being home to one of the world’s largest volumes of CABG surgeries, lacked an equivalent until SCS’s creation.

Furthermore, Indian patients possess distinct anatomical and metabolic profiles, smaller coronary arteries, earlier onset of disease, higher prevalence of metabolic syndrome, and diffuse atherosclerosis, which significantly influence conduit selection, graft patency, and surgical strategy. International guidelines derived from Western cohorts with different demographics cannot be applied without adaptation. Therefore, the establishment of SCS meets a critical requirement: to generate India-specific data and develop tailored guidelines for Indian patients. Echoing the perspective of Mack and Taggart, SCS embraces the principle that coronary revascularization warrants subspecialty status to ensure consistently high-quality outcomes. ⁴

Evolution of Coronary Surgery and Its Implications for India

Over the last 50 years, coronary surgery has evolved significantly from early saphenous-vein grafting to the adoption of arterial conduits, multi-arterial grafting (MAG), off-pump CABG (OPCAB), no-touch aortic technique, minimally invasive CABG, and hybrid revascularization. Despite robust evidence supporting bilateral internal thoracic artery grafting and MAG, global adoption remains low (around 5%) and is also lower in India (10%).^{4, 5} This gap underscores the need for structured coronary-specific training and high-volume practice, which a subspecialty society can deliver.

India has one of the world’s largest experiences with OPCAB, yet variations in technique, training, and outcome measurement persist. A dedicated coronary society can harmonize training standards, disseminate best practices, promote consistent documentation, and facilitate multicenter studies like the long-term PROMOTE follow-up and national surveys quantifying practice variation. ⁶

Emerging strategies such as minimally invasive and hybrid coronary procedures reflect the future direction of the field. ⁷ To ensure India remains aligned with global progress, coordinated training pathways and multicenter research frameworks are essential core responsibilities of a subspecialty organization such as SCS.

The Critical Role of a National Coronary Surgery Database

One of the most transformative advances in modern cardiac surgery has been the creation of the Society of Thoracic Surgeons (STS) National Database, which revolutionized outcome measurement, transparency, and risk modeling in cardiac care. ⁸ By establishing standardized data elements, outcomes reporting, and benchmarking systems, the STS database catalyzed quality improvement and scientific research in adult cardiac surgery. India currently lacks a comparable national registry of coronary surgery despite high procedural volumes and unique patient phenotypes. Without a comprehensive data infrastructure, it is impossible to measure true national outcomes, identify practice variation, or generate reliable evidence for guideline development. The SCS is ideally positioned to lead the establishment of an Indian Coronary Surgery Registry, defining uniform data definitions, coordinating multicenter enrollment, ensuring data quality, and enabling collaborative research. A unified national database will enable benchmarking, quality improvement, generation of India-specific risk models, and guideline development, thereby transforming Indian coronary surgery much like STS transformed practice in the USA.

Conclusion

The establishment of the SCS (India) marks a pivotal evolution in Indian cardiovascular surgery. Emerging from the collaborative energy of the PROMOTE Patency Trial and founded during the extraordinary adversity of the COVID-19 pandemic, the society reflects the shared commitment of Indian coronary surgeons to unify their scientific efforts and advance coronary surgery through subspecialization, research innovation, and collaborative excellence. SCS is not merely an academic group; it is the catalyst for subspecialty development, indigenous research, the creation of India-specific guidelines, international collaboration, and the establishment of a national coronary surgery database. As coronary surgery continues to evolve globally, the SCS positions India not only to keep pace but also to contribute meaningfully to global coronary science. The society’s continued growth and success will be essential to shaping the future of coronary revascularization in India and improving outcomes for millions of patients with CAD.