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(Circulation. 1999;100:1464-1480.)
© 1999 American Heart Association, Inc.
ACC/AHA Practice Guidelines |
ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)
Key Words: ACC/AHA Practice Guidelines • bypass • angioplasty • morbidity • mortality • revascularization • risk factors
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I. Introduction |
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Top
I. Introduction
II. OutcomesThe American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of diagnostic tests and therapies for patients with known or suspected cardiovascular disease. Coronary artery bypass graft (CABG) surgery is among the most common operations performed in the world and accounts for more resources expended in cardiovascular medicine than any other single procedure. Since the original Guidelines were published in 1991, there has been considerable evolution in the surgical approach to coronary disease, and at the same time there have been advances in preventive, medical, and percutaneous catheter approaches to therapy. These revised guidelines are based on a computerized search of the English literature since 1989, a manual search of final articles, and expert opinion.
As with other ACC/AHA guidelines, this document uses ACC/AHA classifications I, II, and III as summarized below:
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness or efficacy of a procedure.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.
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II. Outcomes |
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A. Hospital Outcomes
Seven core variables (priority of operation, age, prior heart surgery, sex, left ventricular [LV] ejection fraction [EF], percent stenosis of the left main coronary artery, and number of major coronary arteries with significant stenoses) are the most consistent predictors of mortality after coronary artery surgery. The greatest risk is correlated with the urgency of operation, advanced age, and 1 or more prior coronary bypass surgeries. Additional variables that are related to mortality include coronary angioplasty during index admission; recent myocardial infarction (MI); history of angina, ventricular arrhythmias, congestive heart failure, or mitral regurgitation; and comorbidities such as diabetes, cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal dysfunction. Table 1
shows a method by which key patient
variables can be used to predict an individual patient's operative
risk of death, stroke, or mediastinitis.
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B. Morbidity Associated With Bypass Surgery
1. Neurological Events
Neurological impairment after bypass surgery may be attributable
to hypoxia, emboli, hemorrhage, and/or
metabolic abnormalities. Postoperative neurological
deficits have been divided into 2 types: type 1, associated with major,
focal neurological deficits, stupor, or coma; and type 2, in which
deterioration in intellectual function is evident. Adverse cerebral
outcomes are observed in 
6% of patients after bypass surgery and
are equally divided between type 1 and type 2 deficits. Predictors of
cerebral complications after bypass surgery include advanced age and a
history of hypertension. Particular predictors of type 1 deficits
include proximal aortic atherosclerosis as defined by
the surgeon at operation, history of prior neurological disease, use of
the intra-aortic balloon pump, diabetes, hypertension, unstable angina,
and increased age. Predictors of type 2 deficits include a history of
excess alcohol consumption; dysrhythmias, including atrial
fibrillation; hypertension; prior bypass surgery;
peripheral vascular disease; and congestive heart failure.
Estimation of a patient's risk for postoperative stroke can be
calculated from Table 1
.
2. Mediastinitis
Deep sternal wound infection occurs in 1% to 4% of patients
after bypass surgery and carries a mortality of 25%. Predictors of
this complication include obesity, reoperation, use of both internal
mammary arteries at surgery, duration and complexity of surgery, and
diabetes. An individual patient's risk of postoperative mediastinitis
can be estimated from Table 1.
3. Renal Dysfunction
Postoperative renal dysfunction occurs in as many as 8% of
patients. Among patients who develop postoperative renal dysfunction
(defined as a postoperative serum creatinine level >2.0
mg/dL or an increase in baseline creatinine level of >0.7
mg/dL), 18% require dialysis. Overall mortality among patients who
develop postoperative renal dysfunction is 19% and approaches two
thirds among patients requiring dialysis. Predictors of renal
dysfunction include advanced age, a history of moderate or severe
congestive heart failure, prior bypass surgery, type 1 diabetes, and
prior renal disease. Table 2 can be used
to estimate the risk for an individual patient. Patients with advanced
preoperative renal dysfunction who undergo CABG surgery have an
extraordinarily high rate of requiring postoperative dialysis. Among
patients with a preoperative creatinine level >2.5 mg/dL,
40% to 50% require hemodialysis.
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C. Long-Term Outcomes
Predictors of poor long-term survival after bypass surgery include
advanced age, poor LVEF, diabetes, number of diseased vessels, and
female sex. In some studies, additional predictors include angina
class, hypertension, prior MI, renal dysfunction, and clinical
congestive heart failure. Predictors of the recurrence of
angina, late MI, or any cardiac event also include obesity and lack of
use of an internal mammary artery, as well as those factors identified
above. Of these events, the return of angina is the most common and is
primarily related to late vein-graft atherosclerosis
and occlusion.
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III. Comparison of Medical Therapy Versus Surgical Revascularization |
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The comparison of medical therapy with coronary surgical revascularization is primarily based on randomized, clinical trials and large registries. Although clinical trials have provided valuable insights, there are limitations to their interpretation in the current era. Patient selection had primarily included individuals
65 years of age, very few included large cohorts
of women, and for the most part, the studies evaluated patients at low
risk who were clinically stable. In addition, because the studies were
done in the late 1970s and early 1980s, only 1 of the trials used
arterial grafts, and even that trial had no
arterial grafts in 86% of patients. Newer modalities of
cardioprotection during cardiopulmonary bypass were not used,
nor were minimally invasive or off-bypass techniques. Finally, medical
therapy was not optimized in the trials. Lipid-lowering therapy had not
yet become standard, aspirin was not widely used, and ß-blockers were
used in just half of the patients. Angiotensin-converting
enzyme inhibitors were not being routinely used in patients
with congestive heart failure or dilated
cardiomyopathy. Accordingly, although the clinical
trials have provided important insights, their interpretation must be
viewed with caution, given the evolution in all types of
coronary therapies. For the most part, stratification of patients in the trials was based on the number of vessels with anatomically significant disease, whether or not the major epicardial obstruction was proximal, and the extent of LV dysfunction as determined by global EF. The end point of the trials was primarily survival.
Overview: Randomized Trials
There were 3 major, randomized trials and several smaller ones. A
collaborative meta-analysis of 7 trials with a total enrollment
of 2649 patients has allowed comparison of outcomes at 5 and 10 years
(Tables 3, 4, and 5
and the Figure). Among all patients, the
extension survival of CABG surgical patients compared with medically
treated patients was 4.3 months at 10 years of follow-up. The benefit
of CABG compared with medical therapy in various clinical subsets is
presented below.
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1. Left Main Coronary Artery Disease
The trials defined significant left main coronary
artery stenosis as a >50% reduction in lumen diameter. Median
survival for surgically treated patients was 13.3 years versus 6.6
years in medically treated patients. Left main equivalent disease
(
70% stenosis in both the proximal left anterior descending
[LAD] and proximal left circumflex arteries) appeared to behave
similarly to true left main coronary artery disease. Median
survival for surgical patients was 13.1 years versus 6.2 years for
medically assigned patients. The benefit of surgery for left main
coronary artery disease patients continued well beyond 10
years. By 15 years, it was estimated that two thirds of patients
originally assigned to medical therapy and who survived would have had
surgery. The 15-year cumulative survival for left main coronary
artery disease patients having CABG surgery was 44% versus 31% for
medical patients.
2. Three-Vessel Disease
If one defines 3-vessel disease as stenosis of 50%
or more in all 3 major coronary territories, the overall
extension of survival was 7 months in CABG patients compared with
medically treated patients. Patients with class III or IV angina, those
with more proximal and severe LAD stenosis, those with worse LV
function, and/or those with more positive stress tests derived more
benefit from surgery.
3. Proximal LAD Disease
In patients with severe, proximal LAD stenosis, the
relative risk reduction due to bypass surgery compared with medical
therapy was 42% at 5 years and 22% at 10 years. This was even more
striking in patients with depressed LV function.
4. LV Function
In patients with mildly to moderately depressed LV function, the
poorer the LV function, the greater was the potential advantage of CABG
surgery. Although the relative benefit was similar, the absolute
benefit was greater because of the high-risk profile of these
patients.
5. Symptoms and Quality of Life
Improvement in symptoms and quality of life after bypass surgery
parallels the outcome data regarding survival. Beyond survival, bypass
surgery may be indicated to alleviate symptoms of angina above and
beyond medical therapy or to reduce the incidence of nonfatal
complications like MI, congestive heart failure, and hospitalization.
Registry studies have shown a reduction in late MI among highest-risk
patients, such as those with 3-vessel disease, and/or those with severe
angina. In pooled analyses, a benefit on the incidence of MI
was not evident. This result likely reflected an early increase in MI
perioperatively after CABG, which was balanced by fewer
MIs over the long term among CABG recipients. Antianginal medications
were required less frequently after bypass surgery. At 5 years, two
thirds of bypass patients were symptom-free compared with 38% of
medically assigned patients. By 10 years, however, these differences
were no longer significant. This result is related to the attrition of
vein grafts in the bypass group as well as crossover of medically
assigned patients to bypass surgery.
6. Loss of Benefit of Surgery
After 10 to 12 years of follow-up, there was a tendency for the
bypass surgery and medical therapy curves to converge, in regard to
both survival as well as nonfatal outcomes. This convergence is due to
a number of factors. First, the reduced life expectancy of patients
with coronary disease (regardless of treatment) leads to a
steady attrition. Second, the increased event rate in the late
follow-up period of surgically assigned patients was likely related to
the progression of native coronary disease and graft disease
over time. Finally, medically assigned patients crossed over to surgery
late, thus allowing the highest-risk medically assigned patients to
gain from the benefit of surgery later in the course of follow-up. By
10 years, 37% to 50% of medically assigned patients had crossed over
to surgery. Tables 3, 4, and 5 and the Figure
provide estimates of long-term outcomes among patients
randomized in the trials. These tables and the Figure can be used to
estimate the general survival expectations in various anatomic
categories.
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IV. Comparison of Bypass Surgery With Percutaneous Revascularization |
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The results of a number of randomized, clinical trials comparing angioplasty and bypass surgery have been published. The trials excluded patients in whom survival had already been shown to be longer with bypass surgery than with medical therapy. Also, none of the trials was sufficiently large to detect relatively modest differences in survival between the 2 techniques. Most of the trials did not have a long-term follow-up, ie, 5 to 10 years, and therefore were unable to provide clear inferences regarding long-term benefit of the 2 techniques in similar populations. Also, and perhaps most notably, only
5% of
screened patients with multivessel disease at enrolling institutions
were included in the trials. Half of the patients approached were
ineligible owing to left main coronary artery disease,
insufficient symptoms, or other reasons. Even among a large group of
patients with multivessel disease suitable for enrollment, only half
were actually randomized. It appeared that physicians elected not to
enroll many patients with 3-vessel disease in the trials but rather
refer them for bypass surgery, whereas patients with 2-vessel disease
tended to be referred for angioplasty rather than be enrolled in the
trials.
Overall, procedural complications were low for both procedures but
tended to be higher with CABG surgery (Table 6). For patients randomized to
angioplasty, CABG was needed in 6% during the index hospitalization
and in nearly 20% by 1 year. The initial cost and length of stay were
lower for angioplasty than for CABG. Patients having angioplasty
returned to work sooner and were able to exercise more at 1 month. The
extent of revascularization achieved by bypass
surgery was generally higher than with angioplasty. Long-term survival
was difficult to evaluate owing to the short period of follow-up and
the small sample size of the trials. However, for the Bypass
Angioplasty Revascularization Investigation (BARI)
trial, bypass patients had a 5-year survival of 89.3% compared with
86.3% for angioplasty. Secondary analysis revealed that in
treated diabetic patients in the BARI trials, CABG led to significantly
superior survival compared with percutaneous
transluminal coronary angioplasty (PTCA). However, this finding
was not evident in other trials. In long-term follow-up, the most
striking difference was the 4- to 10-fold-higher likelihood of
reintervention after initial PTCA. Quality of life, physical activity,
employment, and cost were similar by 3 to 5 years after both
procedures. The BARI trial suggested higher mortality associated with
PTCA in several high-risk groups, including those with diabetes,
unstable angina, and/or non–Q wave MI, and in patients with heart
failure.
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An analysis of registries generally shows data similar to
those of the trials. However, a recent analysis of 60 000
patients who were treated in New York State in the early 1990s provides
a 3-year survival analysis of patients undergoing CABG and
PTCA. After adjustment for various covariates, bypass surgery in the
New York State registry experience was associated with longer survival
in patients with severe proximal LAD stenosis and/or 3-vessel
disease. Contrariwise, patients with 1-vessel disease not involving the
proximal LAD had improved survival with PTCA. Table 7 summarizes survival data from the New
York State registry with respect to various cohorts of patients
undergoing angioplasty or bypass surgery. These data can be used to
estimate 3-year survival expectations for patients with various
anatomic features.
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V. Management Strategies |
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Reduction of Perioperative Mortality and Morbidity
1. Reducing the Risk of Type 1 Brain Injury After CABG
Postoperative neurological complications represent 1 of the most devastating consequences of CABG surgery. Type 1 injury, in which a significant, permanent, neurological injury is sustained, occurs in
3% of patients overall and is responsible for a 21%
mortality.
Atherosclerotic Ascending Aorta
An important predictor of this complication is the surgeon's
identification of a severely atherosclerotic, ascending aorta before or
during the bypass operation. Perioperative
atheroembolism from aortic plaque is thought to be responsible for
approximately one third of strokes after CABG.
Atherosclerosis of the ascending aorta is strongly
related to increased age. Thus, stroke risk is particularly increased
in patients beyond 75 to 80 years of age. Preoperative, noninvasive
testing to identify high-risk patients has variable accuracy.
Computed tomography identifies the most severely involved aortas but
underestimates mild or moderate involvement.
Transesophageal echocardiography is
useful for aortic arch examination, but examination of the ascending
aorta may be limited by the intervening trachea. Intraoperative
assessment with epiaortic imaging is superior to both methods.
Intraoperative palpation underestimates the high-risk aorta. The
highest-risk aortic pattern is a protruding or mobile aortic arch
plaque. An aggressive approach to the management of patients with
severely diseased ascending aortas identified by intraoperative
echocardiographic imaging reduces the risk of
postoperative stroke. For patients with aortic walls 3 mm
thick, standard treatment is used. For aortas >3 mm thick,
the cannulation, clamp, or proximal anastomotic sites may be changed,
or a no-clamp, fibrillatory arrest strategy may be used. For high-risk
patients with multiple or circumferential involvement or those with
extensive middle ascending aortic involvement, replacement of the
ascending aorta under hypothermic circulatory arrest may be indicated.
Alternatively, a combined approach with off-bypass, in situ
internal mammary grafting to the LAD and percutaneous
coronary intervention to treat other vessel stenoses
has conceptual merit.
Atrial Fibrillation and Stroke
Chronic atrial fibrillation is a hazard for
perioperative stroke. Intraoperative surgical
manipulation or spontaneous resumption of sinus rhythm during the early
postoperative period may lead to embolism of a left atrial clot. One
approach to reduce this risk is the performance of
preoperative, transesophageal
echocardiography. The absence of a left atrial clot
would suggest that the operation may proceed with acceptable risk. For
elective patients, if a left atrial clot is identified, 3 to 4 weeks of
anticoagulation therapy followed by restudy and then subsequent surgery
is reasonable. Few clinical trial data are available to assist
clinicians in this circumstance.
New-onset postoperative atrial fibrillation occurs in 30% of
post-CABG patients, particularly on the second and third postoperative
days, and is associated with a 2- to 3-fold increased risk of
postoperative stroke. Risk factors include advanced age, chronic
obstructive pulmonary disease, proximal right coronary
disease, prolonged operation, atrial ischemia, and withdrawal
of ß-blockers. The role of anticoagulants in patients who develop
post-CABG atrial fibrillation is unclear. Aggressive anticoagulation
and cardioversion may reduce the neurological complications associated
with this arrhythmia. Early cardioversion within 24 hours of
the onset of atrial fibrillation can probably be performed safely
without anticoagulation. However, persistence of the arrhythmia
beyond this time argues for the use of oral anticoagulants to reduce
stroke risk in patients who remain in atrial fibrillation and/or in
those for whom later cardioversion is planned.
Recent MI, LV Thrombus, and Stroke
Patients with a recent, anterior MI and residual wall-motion
abnormality are at increased risk for the development of an LV mural
thrombus and its potential for embolization. For patients undergoing
surgical revascularization after sustaining an
anterior MI, preoperative screening with
echocardiography may be appropriate to identify the
presence of a clot. Detection of an acute LV mural thrombus may call
for long-term anticoagulation and reevaluation by
echocardiography to ensure resolution or
organization of the thrombus before coronary bypass surgery.
Additionally, 3 to 6 months of anticoagulation therapy is appropriate
for patients with persistent, anterior wall–motion abnormalities after
coronary bypass surgery.
Recent, Antecedent Cerebrovascular Event
A recent, preoperative cerebrovascular accident represents
a situation in which delaying surgery may reduce the
perioperative neurological risk. In particular,
evidence of a hemorrhagic component based on computed tomographic scan
identifies high risk for the extension of neurological damage with
cardiopulmonary bypass. It is generally believed that a delay
of 4 weeks or more after a cerebrovascular accident is prudent, if
coronary anatomy and symptoms permit, before proceeding
with CABG.
Carotid Disease and Neurological Risk Reduction
Hemodynamically significant carotid
stenoses are thought to be responsible for up to 30% of early
postoperative strokes. The trend for coronary surgery to be
performed in an increasingly elderly population and the increasing
prevalence of carotid disease in this same group of patients underscore
the importance of this issue. Perioperative stroke risk
is thought to be <2% when carotid stenoses are <50%, 10%
when stenoses are 50% to 80%, and 11% to 19% in patients
with stenoses >80%. Patients with untreated, bilateral,
high-grade stenoses and/or occlusions have a 20% chance of
stroke. Carotid endarterectomy for patients with
high-grade stenosis is generally done preceding or coincident
with coronary bypass surgery and, with proper teamwork in
high-volume centers, is associated with a low risk for both short- and
long-term neurological sequelae. Carotid
endarterectomy performed in this fashion carries a
low mortality (3.5%) and reduces early postoperative stroke risk to
<4%, with a concomitant 5-year freedom from stroke of 88% to
96%.
The decision about who should undergo preoperative carotid screening is controversial. Predictors of important carotid stenosis include advanced age, female sex, known peripheral vascular disease, previous transient ischemic attack or stroke, a history of smoking, and left main coronary artery disease. Many centers screen all patients >65 years old. Patients with left main coronary disease are often screened, as are those with a previous transient ischemic attack or stroke. Preoperative central nervous system symptoms suggestive of vertebral basilar insufficiency should lead to an evaluation before elective CABG.
When surgery of both carotid and coronary disease is planned,
the most common approach is to perform the operation in a staged
manner, in which the patient first has carotid surgery followed by
coronary bypass in 1 to 5 days. Alternatively, especially if
the patient has compelling cardiac symptoms or coronary
anatomy, the operations may be performed during a single period
of anesthesia, with the carotid
endarterectomy immediately preceding
coronary bypass. Neither strategy has been established as being
superior. Stroke risk is increased if a reversed-stage procedure is
used, in which the coronary bypass operation precedes the
carotid endarterectomy by 1 day.
2. Reducing the Risk of Type 2 Brain Injury
Type 2 neurological complications are seen in 3% of patients
and are correlated with a 10% risk of postoperative death, with 40%
of patients requiring additional care in a transitional facility after
hospital discharge. Microembolization is thought to be a major
contributor to the postoperative cerebral dysfunction after CABG. The
release of microemboli during extracorporeal circulation, involving
small gaseous or lipid emboli, may be responsible. The use of a 40-µm
arterial-line filter on the heart-lung machine circuit and
routine use of membrane oxygenators rather than bubble oxygenators may
reduce such neurological injury. Additional maneuvers to reduce type 2
neurological injury include the maintenance of steady, cerebral
blood flow during cardiopulmonary bypass, avoidance of cerebral
hyperthermia during and after cardiopulmonary bypass,
meticulous control of perioperative hyperglycemia, and
avoidance and limitation of postoperative cerebral edema.
3. Reducing the Risk of Perioperative
Myocardial Dysfunction
Protection in Patients With Normal LV Function
There is no universally applicable myocardial protection
technique. Among patients with preserved preoperative cardiac function,
no strong argument can currently be made for warm versus cold and
crystalloid versus blood cardioplegia. However, certain techniques may
offer a wider margin of safety for special patient subsets.
Myocardial Protection for Acutely Depressed Cardiac Function
Several studies have suggested that blood cardioplegia (compared
with crystalloid) may offer a greater margin of safety during CABG
performed on patients with acute coronary occlusion, failed
angioplasty, urgent revascularization for unstable
angina, and/or chronically impaired LV function.
Protection for Chronically Depressed LV Function
The use of a prophylactic intra-aortic balloon pump as
an adjunct to myocardial protection may reduce mortality in patients
having CABG in the setting of severe LV dysfunction (eg, LVEF <0.25).
Placement of the intra-aortic balloon pump immediately before operation
appears to be as effective as placement on the day preceding
bypass surgery.
Adjuncts to Myocardial Protection
Although it is widely appreciated that use of the internal mammary
artery leads to improved long-term survival after coronary
bypass surgery, it has also been documented that use of the internal
mammary artery influences operative mortality itself. Thus, internal
mammary artery use should be encouraged in the elderly, emergent, or
acutely ischemic patient and other patient groups.
Inferior Infarct With Right Ventricular
Involvement
An acutely infarcted right ventricle is at great risk for severe,
postoperative dysfunction and predisposes the patient to a higher
postoperative mortality. During operation, loss of the pericardial
constraint may lead to acute dilatation of the dysfunctional right
ventricle, which then fails to recover even with optimal myocardial
protection and revascularization. The best defense
against right ventricular dysfunction is its recognition
during preoperative evaluation. When possible, CABG should be delayed
for 4 weeks to allow the right ventricle to recover.
4. Reducing the Systemic Consequences of Cardiopulmonary
Bypass
A variety of measures have been tried to reduce the systemic
consequences of cardiopulmonary bypass, which elicits a diffuse
inflammatory response that may cause transient or prolonged multisystem
organ dysfunction. Administration of corticosteroids
before cardiopulmonary bypass may reduce complement activation
and release of proinflammatory cytokines. Proper timing and
duration of corticosteroid application are incompletely
resolved. The administration of the serine protease
inhibitor aprotinin may attenuate complement activation and
cytokine release during extracorporeal circulation.
Unfortunately, aprotinin is relatively expensive. Another method to
reduce the inflammatory response is perioperative
leukocyte depletion through hematologic filtration.
5. Reducing the Risk of Perioperative Infections
Several methods exist to reduce the risk of wound infections in
patients undergoing CABG. These begin with interval reporting to
individual surgeons regarding their respective wound infection rates
and adherence to sterile operative techniques. Additional strategies
include skin preparation with topical antiseptics, clipping rather than
shaving the skin, avoidance of hair removal, reduction of operating
room traffic, laminar-flow ventilation, shorter operation, minimization
of electrocautery, avoidance of bone wax, use of double-glove barrier
techniques for the operating room team, and routine use of a pleural
pericardial flap. Aggressive, perioperative glucose
control in diabetics through the use of continuous,
intravenous insulin infusion reduces
perioperative hyperglycemia and its associated
infection risk. Avoidance of homologous blood transfusions after CABG
may reduce the risk of both viral and bacterial infections. This is due
to an immunosuppressive effect of transfusion. Leukodepletion of
transfused blood also reduces this effect. This can be accomplished by
regional blood blanks at the time of donation or at the bedside by use
of a transfusion filter.
Preoperative antibiotic administration reduces the risk of
postoperative infection 5-fold. Efficacy is dependent on adequate drug
tissue levels before microbial exposure. Cephalosporins are currently
the agents of choice. Table 8 identifies
appropriate choices, doses, and routes of therapy. A 1-day course of
intravenous antimicrobials is as effective as 48 hours or
more. Therapy should be administered within 30 minutes of incision and
again in the operating room if the operation exceeds 3 hours. Many
centers deliver antibiotics just before incision. One fail-safe method
is to have the anesthesiologist administer the cephalosporin after
induction but before skin incision. If deep sternal wound infection
does occur, aggressive surgical debridement and early vascularized
muscle flap coverage are the most effective methods for treatment,
along with long-term systemic antibiotics.
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6. Prevention of Postoperative Dysrhythmias
Postoperative atrial fibrillation increases the length of stay,
cost, and most important, the risk of stroke. Atrial fibrillation
occurs in up to 30% of patients, usually on the second or third
postoperative day. Methods to avoid atrial fibrillation are several.
First, withdrawal of preoperative ß-blockers in the postoperative
period doubles the risk of atrial fibrillation after CABG. Thus, early
reinitiation of ß-blockers is critical for avoidance of this
complication. Virtually every study of patients receiving ß-blockers
prophylactically has shown benefit in lowering the
frequency of atrial fibrillation. Most have used the drug in the
postoperative period, but greater benefit may occur if ß-blockade is
begun before the operation. More recently, small studies of
propafenone, sotalol, and amiodarone have also shown
effectiveness in reducing the risk of postoperative atrial
fibrillation. Table 9 provides a review
of pharmacological approaches in the randomized trials. Digoxin and
calcium channel blockers have no consistent benefit for
preventing atrial fibrillation after CABG, although they are frequently
used to control its rate after it does occur. Currently, the routine
preoperative or early postoperative administration of ß-blockers is
considered standard therapy to reduce the risk of atrial fibrillation
after CABG.
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7. Strategies to Reduce Perioperative Bleeding and
Transfusion Risk
Transfusion Risk
Despite the increasing safety of homologous blood transfusion,
concerns surrounding viral transmission during transfusion remain.
Currently, the risks are likely very low and have been estimated to be
1/493 000 for human immunodeficiency virus, 1/641 000 for human
T-cell lymphotrophic virus, 1/103 000 for hepatitis C virus, and
1/63 000 for hepatitis B virus.
Perioperative Bleeding
Risk factors for blood transfusion after CABG include advanced
age, low preoperative red blood cell volume, preoperative aspirin
therapy, urgent operation, duration of cardiopulmonary bypass,
recent thrombolytic therapy, reoperation, and
differences in heparin management. Institutional protocols that
establish minimum thresholds for transfusion lead to a reduced number
of units transfused and the percentage of patients requiring blood.
Additional strategies can reduce the transfusion requirement after
CABG. For stable patients, aspirin and other antiplatelet drugs may
be discontinued 7 days before elective CABG. Aprotinin, a serum
protease inhibitor with antifibrinolytic activity, also
decreases postoperative blood loss and transfusion requirements in
high-risk patients. Although there has been some concern that aprotinin
may reduce early graft patency, recent studies have failed to document
this effect. Routine use of aprotinin is limited by its high cost.
Multidisciplinary approaches to conserve blood in single institutions
appear to be effective.
For patients without exclusions, such as low hemoglobin values, heart failure, unstable angina, left main coronary artery disease, or advanced anginal symptoms, self-donation of 1 to 3 units of red blood cells over 30 days before operation reduces the need for homologous transfusion during or after operation. Donation immediately before cardiopulmonary bypass yields a higher platelet and hemoglobin count compared with simple hemodilution without pre–cardiopulmonary bypass blood harvesting.
8. Antiplatelet Therapy for Saphenous Vein Graft
Patency
Aspirin significantly reduces vein graft closure during the first
postoperative year. The aspirin should be started within 24 hours after
surgery because its benefit on saphenous vein graft patency is lost
when begun later. Dosing regimens from as little as 100 mg/d to as much
as 325 mg TID appear to be efficacious. Ticlopidine offers no advantage
over aspirin but is an alternative in truly aspirin-allergic patients.
Life-threatening neutropenia is a rare but recognized side effect.
Clopidogrel offers the potential for fewer side effects compared with
ticlopidine as an alternative in aspirin-allergic patients. Its
incidence of severe leukopenia is rare.
9. Pharmacological Management of Hyperlipidemia
Aggressive treatment of
hypercholesterolemia reduces progression of
atherosclerotic vein graft disease in patients after bypass surgery.
Statin therapy has been shown to reduce saphenous vein graft disease
progression over the ensuing years after bypass. Patients with unknown
low-density lipoprotein (LDL) cholesterol levels after
bypass should have cholesterol levels determined and
treated pharmacologically if the LDL exceeds 100 mg/dL. Patients with
treated LDL cholesterol should have their low-fat diet and
cholesterol-lowering medications continued after bypass
surgery to reduce subsequent graft attrition. Data regarding the
benefit of cholesterol lowering after bypass surgery are
most supported by studies that have used HMG CoA
(3-hydroxy-3-methylglutaryl coenzyme A) reductase
inhibitors, particularly targeting LDL levels to <100
mg/dL.
10. Hormonal Manipulation
While observational studies have suggested that hormone
replacement therapy in postmenopausal women leads to a reduction in
all-cause mortality, a recent, randomized trial for secondary
coronary prevention failed to show a beneficial effect on the
overall rate of coronary events. Thus, hormone replacement
therapy should be considered in postmenopausal women after bypass when,
in the physician's judgment, the potential coronary benefit is
not offset by an increased risk of uterine or breast cancer.
11. Smoking Cessation
Smoking cessation is the single, most important
risk-modification goal after CABG in patients who smoke. Smoking
cessation leads to less recurrent angina, improved physical function,
fewer admissions, maintenance of employment, and improved
survival. Treatment individualized to the patient is crucial.
Depression may be an important complicating factor and should be
approached with behavioral and drug therapy. Nicotine replacement with
a transdermal patch, nasal spray, gum, or inhaler is beneficial. A
sustained-release form of bupropion, an antidepressant similar to
selective serotonin reuptake inhibitors,
reduces the nicotine craving and anxiety of smokers who quit. All
smokers should receive educational counseling and be offered smoking
cessation therapy after CABG (Table 10).
|
12. Cardiac Rehabilitation
Cardiac rehabilitation, including early ambulation during
hospitalization, outpatient prescriptive exercise, family education,
and dietary and sexual counseling, has been shown to improve outcomes
after CABG. The benefits include better physical mobility and perceived
health. A higher proportion of rehabilitated patients are working at 3
years after CABG. The benefits of rehabilitation extend to the elderly
and to women. Cardiac rehabilitation reinforces pharmacological therapy
and smoking cessation and should be offered to all eligible patients
after CABG.
13. Emotional Dysfunction and Psychosocial Considerations
Lack of social participation and low religious strength are
independent predictors of death in elderly patients undergoing CABG.
Although controversial, the high prevalence of depression after bypass
surgery may reflect a high prevalence preoperatively. Cardiac
rehabilitation has a highly beneficial effect in patients who are
moderately or severely depressed. Evaluation of social supports and
attempts to identify and treat underlying depression should be part of
routine post-CABG care.
14. Rapid Sustained Recovery After Operation
Rapid recovery and early discharge are standard goals after
CABG. The shortest in-hospital postoperative stays are followed by the
fewest rehospitalizations. Important components of "fast-track"
care are careful patient selection, patient and family education, early
extubation, prophylactic antiarrhythmic therapy, dietary
considerations, early ambulation, early outpatient telephone follow-up,
and careful coordination with other physicians and healthcare
providers.
15. Communication Between Caregivers
Maintenance of appropriate and timely communication
between treating physicians regarding care of the patient is crucial.
When possible, the primary care physician should follow up the patient
during the perioperative course. The referral physician
needs to provide clear, written reports of the findings and
recommendations to the primary care physician, including discharge
medications and dosages along with long-term goals.
|
VI. Impact of Evolving Technology |
|---|
A. Less-Invasive Coronary Bypass Surgery
Technical modifications of CABG have been developed to decrease the morbidity of the operation, either by using limited incision or by eliminating cardiopulmonary bypass. Currently, "less-invasive" CABG surgery can be divided into 3 categories: (1) off-bypass CABG performed through a median sternotomy with a smaller skin incision, (2) minimally invasive direct CABG (MID-CAB) performed through a left anterior thoracotomy without cardiopulmonary bypass, and (3) port-access CABG with femoral-to-femoral cardiopulmonary bypass and cardioplegic arrest with limited incision.
Off-bypass coronary surgery is performed on a beating heart after reduction of cardiac motion with a variety of pharmacological and mechanical devices. These include slowing the heart with ß-blockers and calcium channel blockers and use of a mechanical stabilizing device to isolate and stabilize the target vessel. Retraction techniques may elevate the heart to allow access to vessels on the lateral and inferior surfaces of the heart. Because this technique generally uses a median sternotomy, its primary benefit is the avoidance of cardiopulmonary bypass, not a less extensive incision.
MID-CAB refers to bypass surgery without median sternotomy and without the use of cardiopulmonary bypass. Generally, this is performed with a small left anterior thoracotomy, exposing the heart through the fourth intercostal interspace with access to the LAD and diagonal branches and occasionally, the anterior marginal vessels. The right coronary artery can be approached by using a right anterior thoracotomy. MID-CAB procedures are generally performed on only 1 or 2 coronary targets. Observational studies have suggested that MID-CAB is associated with a reduced average length of stay and an earlier return to work. Although initial reports of 2-year actuarial and event-free survival are encouraging, the data must be viewed with caution. Because the number of anastomoses performed on a beating heart is usually 1 or occasionally 2, the potential long-term effects of incomplete revascularization are unknown.
The closed-chest, port-access, video-assisted CABG operation uses cardiopulmonary bypass and cardioplegia of a globally arrested heart. Vascular access for cardiopulmonary bypass is achieved via the femoral artery and vein. A triple-lumen catheter with an inflatable balloon at its distal end is used to achieve endovascular aortic occlusion, cardioplegia delivery, and LV decompression. With cardiopulmonary bypass and cardioplegic arrest, CABG can be performed with video assistance on a still and decompressed heart through several small ports. In comparison with the MID-CAB, port access allows access to different areas of the heart, thus facilitating more complete revascularization, and the motionless heart may allow a more accurate anastomosis. Compared with conventional CABG, median sternotomy is avoided. However, potential morbidity of the port-access operation includes multiple wounds at port sites, the limited thoracotomy, and the groin dissection for femoral-femoral bypass. Vigorous scrutiny of the long-term benefits versus risks of port access is required.
B. Arterial and Alternate Conduits
Another area of evolving technology is the use of
arterial and alternate conduits. The 5-year patency of
coronary artery–vein bypass grafts is 74%, and at 10 years,
just 41%. Contrariwise, patency rates of the internal mammary artery
implanted into the LAD are as high as 83% at 10 years. As a
consequence of improved patency, patients receiving an LAD graft with
an internal mammary artery have improved survival compared with
patients receiving only vein grafts. Currently, routine use of the left
internal mammary artery for LAD grafting with supplemental saphenous
vein grafts to other coronary lesions is generally accepted as
a standard grafting method. The use of bilateral internal mammary
arteries appears to be safe and efficacious. However, there is a higher
rate of deep sternal wound infection when both internal mammary
arteries are used. This is particularly true for patients with obesity
and diabetes and perhaps for those requiring prolonged ventilatory
support. The benefits of bilateral internal mammary artery use include
lower rates of recurrent angina, MI, and need for reoperation and a
trend for better survival. Recently, the radial artery has been used
more frequently as a conduit for coronary bypass surgery.
Five-year patency appears to be in the range of 85% (compared with
nearly 90% for the internal mammary graft). In patients for whom
mammary artery, radial artery, and standard vein conduits are
unavailable, the in situ right gastroepiploic artery, the
inferior epigastric free artery graft, and either lesser
saphenous or upper-extremity vein conduits have been used. Long-term
patency of these alternative grafts has not been extensively
studied.
C. Percutaneous Technology
Technological improvements in percutaneous
coronary angioplasty have included the introduction of new
devices and improved medical therapy of patients in whom angioplasty is
performed. The most notable improvement has been the introduction of
intracoronary stents that have reduced late restenosis
and the frequency with which emergency bypass surgery is required after
PTCA. Intracoronary stents have been used to treat saphenous
vein graft stenosis in patients with previous CABG. However,
stented patients still have an 25% combined rate of death, MI, need
for repeat CABG, or re-revascularization of the
target vessel. For some patients, hybrid procedures may be the best
choice, such as the combined use of CABG surgery and coronary
angioplasty. Such an approach is relevant to the patient whose
ascending aorta is involved with severe
atherosclerosis, for which the implantation of free
vein grafts or arterial grafts leads to risk for
atheroembolism. In such a patient, the use of in situ internal mammary
artery grafting without cardiopulmonary bypass combined with
additional coronary angioplasty in other diseased vessels
represents a strategy to provide complete
revascularization without the concomitant risks of
cardiopulmonary bypass and/or manipulation of the ascending
aorta.
D. Transmyocardial
Revascularization
A fourth area that is rapidly evolving is transmyocardial
revascularization. The use of transmyocardial laser
revascularization has generally been performed
surgically for patients with severe angina refractory to medical
therapy and who are not suitable candidates for standard surgical
revascularization, PTCA, or heart transplant. While
several studies have suggested improvement in angina severity with
transmyocardial laser revascularization, the
mechanism by which angina improves and the overall benefit on long-term
angina and/or survival await further clarification.
|
VII. Special Patient Subsets |
|---|
A. Elderly Patients
Elderly patients being considered for CABG have a higher average risk for mortality and morbidity in a direct relation to age, LV function, extent of coronary disease, and comorbid conditions and whether the procedure is urgent, emergent, or a reoperation. Nonetheless, functional recovery and sustained improvement in the quality of life can be achieved in the majority of such patients. The patient and physician together must explore the potential benefits of improved quality of life with the attendant risks of surgery versus alternative therapies that take into account baseline functional capacities and patient preferences. Age alone should not be a contraindication to CABG if it is thought that long-term benefits outweigh the procedural risk.
B. Women
A number of earlier reports had suggested that female sex
was an independent risk factor for mortality and morbidity after CABG.
More recent studies have suggested that women on average have a
disadvantageous, preoperative clinical profile that accounts for much
of this perceived difference. Thus, the issue is not necessarily
sex itself but the comorbid conditions that are particularly
associated with the later age at which women present for
coronary surgery. Thus, CABG should not be delayed in or denied
to women who have appropriate indications.
C. Diabetic Patients
Coronary heart disease is the leading cause of death
among adult diabetics and accounts for 3 times as many deaths among
diabetics as among nondiabetics. While CABG carries an increased
morbidity and mortality in diabetics, data suggest that in appropriate
candidates, the absolute risk reduction provided by successful
revascularization remains high. The BARI trial
suggested that diabetics with multivessel coronary disease
derived advantage from bypass surgery compared with angioplasty.
Several of the other randomized trials, albeit with smaller numbers of
patients, failed to show this trend. Diabetics who are candidates for
renal transplantation have a particularly high incidence of
coronary artery disease, even in the absence of symptoms or
signs. In appropriate candidates, CABG appears to offer morbidity and
mortality benefit in such patients.
D. Patients With Chronic Obstructive Pulmonary Disease
Because CABG is associated with variable degrees of
postoperative respiratory insufficiency, it is important to identify
patients at particular risk for pulmonary complications. The
intent is to treat reversible problems that may contribute to
respiratory insufficiency in high-risk patients, with the hope of
avoiding prolonged periods of mechanical ventilation after CABG.
High-risk patients often benefit from preoperative antibiotics,
bronchodilator therapy, a period of cessation from smoking,
perioperative incentive spirometry, deep-breathing
exercises, and chest physiotherapy. If pulmonary venous
congestion or pleural effusions are identified, diuresis often
improves lung performance.
Although preoperative spirometry directed to identifying patients with a low (eg, <1 L) 1-second forced expiratory volume has been used by some to qualify or disqualify candidates for CABG, clinical evaluation of lung function is likely as important if not more so. Patients with advanced chronic obstructive pulmonary disease are at particular risk for postoperative arrhythmias that may be fatal. While moderate to severe degrees of obstructive pulmonary disease represent a significant risk factor for early mortality and morbidity after CABG, it is also true that with careful preoperative assessment and treatment of the underlying pulmonary abnormality, many such patients are successfully carried through the operative procedure.
E. Patients With End-Stage Renal Disease
Coronary artery disease is the most important cause of
mortality in patients with end-stage renal disease. Many of such
patients have diabetes and other coronary risk factors,
including hypertension, myocardial dysfunction, abnormal lipids,
anemia, and increased plasma homocysteine levels. Although patients on
chronic dialysis are at higher risk when undergoing coronary
angioplasty or bypass, they are at even higher risk with conservative
medical management. Thus, in patients with modest reductions in LV
function, significant left main or 3-vessel disease, and/or unstable
angina, coronary revascularization can lead
to relief of coronary symptoms, improvement in overall
functional status, and improved long-term survival in this select
high-risk patient population.
F. Reoperative Patients
Operative survival and long-term benefit of reoperative CABG
are distinctly inferior to first-time operations. Patients
undergoing repeated CABG have higher rates of postoperative bleeding,
perioperative MI, and neurological and
pulmonary complications. Nevertheless, reasonable 5- and
10-year survival rates after reoperation for coronary disease
can be achieved, and the operation is appropriate if the severity of
symptoms and anticipated benefit justify the immediate risk. Data
suggest that the need for reoperation is less common in patients
undergoing internal mammary artery grafting to the LAD. More recently,
short-term follow-up studies suggest that patients undergoing multiple
arterial grafts have even lower rates of reoperation. These
early results are consistent with the known superior graft
patency of arterial conduits compared with vein grafts.
G. Concomitant Peripheral Vascular Disease
The presence of clinical and subclinical
peripheral vascular disease is a strong predictor of
increased hospital and long-term mortality rates in patients undergoing
CABG. However, the absolute benefit offered by coronary
revascularization is elevated in patients with
peripheral vascular disease, particularly those with
3-vessel coronary disease, more advanced angina, and/or a
depressed LVEF. Excess perioperative mortality in such
patients is related to an increased incidence of heart failure and
dysrhythmias rather than peripheral arterial
complications.
H. Poor LV Function
Patients with severe LV dysfunction have increased
perioperative and long-term mortality compared with
patients with normal LV function. However, studies suggest that the
beneficial effects of myocardial revascularization
in patients with ischemic heart disease and severe LV
dysfunction are sizeable when compared with medically treated patients
of similar status in terms of symptom relief, exercise tolerance, and
survival.
I. CABG in Acute Coronary Syndromes
Coronary bypass surgery offers a survival advantage
compared with medical therapy in patients with unstable angina and LV
dysfunction, particularly in the presence of 3-vessel disease. However,
the risk of bypass surgery in patients with unstable or postinfarction
angina or early after non–Q wave infarction and during acute MI is
increased severalfold compared with patients with stable angina.
Although this risk is not necessarily higher than that with medical
therapy, it has led to the argument to consider angioplasty or to delay
CABG in such patients if medical stabilization can be easily
accomplished.
|
VIII. Institutional and Operator Competence |
|---|
Studies suggest that mortality after CABG is higher when carried out in institutions that annually perform fewer than a minimum number of cases. Similar conclusions have been drawn regarding individual surgeons' volumes. This observation strengthens the argument for careful outcome tracking and supports the monitoring of institutions or individuals who annually perform <100 cases. It is also true that there is a wide variation in risk-adjusted mortality rates in low-volume situations. Thus, some institutions and practitioners maintain excellent outcomes despite relatively low volumes.
Outcome reporting in the form of risk-adjusted mortality rates after bypass has been effective in reducing mortality rates nationwide. Public release of hospital and physician-specific mortality rates has not been shown to drive this improvement and has failed to effectively guide consumers or alter physician referral patterns.
|
IX. Cost-Effectiveness of Bypass Surgery |
|---|
A variety of studies of CABG have found the technique to be cost-effective in patients for whom survival and/or symptomatic benefit is demonstrable. Within these subsets, the cost-effectiveness of CABG compares favorably with that of other accepted medical therapies.
When compared with PTCA, the initial hospital cost of CABG is significantly higher. However, by 5 years, the cumulative cost of PTCA compared with initial surgical therapy is within 5% of CABG, or a difference of <$3000. Observational studies showing a poorer survival effect of PTCA in patients with more advanced disease suggest that there may be a significant cost gradient for PTCA as the extent of disease increases, which is not apparent for coronary bypass surgery.
|
X. Indications |
|---|
A. Indications for CABG in Asymptomatic or Mild Angina
Class I
1. Significant left main coronary artery stenosis.
2. Left main equivalent: significant (70%)
stenosis of proximal LAD and proximal left circumflex
artery.
3. Three-vessel disease. (Survival benefit is greater in patients with abnormal LV function; eg, with an EF <0.50.)
Class IIa
1. Proximal LAD stenosis with 1- or 2-vessel
disease.*1
Class IIb
1. One- or 2-vessel disease not involving the proximal
LAD.
2
Class III
See text.
B. Indications for CABG in Stable Angina
Class I
1. Significant left main coronary artery
stenosis.
2. Left main equivalent: significant (70%)
stenosis of proximal LAD and proximal left circumflex
artery.
3. Three-vessel disease. (Survival benefit is greater when LVEF is <0.50.)
4. Two-vessel disease with significant proximal LAD stenosis and either EF <0.50 or demonstrable ischemia on noninvasive testing.
5. One- or 2-vessel coronary artery disease without significant proximal LAD stenosis, but with a large area of viable myocardium and high-risk criteria on noninvasive testing.
6. Disabling angina despite maximal medical therapy, when surgery can be performed with acceptable risk. If angina is not typical, objective evidence of ischemia should be obtained.
Class IIa
1. Proximal LAD stenosis with 1-vessel
disease.*1
2. One- or 2-vessel coronary artery disease without significant proximal LAD stenosis, but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing.
Class III
1. One- or 2-vessel disease not involving significant
proximal LAD stenosis, in patients (1) who have mild symptoms
that are unlikely due to myocardial ischemia or have not
received an adequate trial of medical therapy and (A) have only a small
area of viable myocardium or (B) have no demonstrable
ischemia on noninvasive testing.
2. Borderline coronary stenoses (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing.
3. Insignificant (<50% diameter) coronary stenosis.
C. Indications for CABG in Unstable Angina/Non–Q Wave MI
Class I
1. Significant left main coronary artery
stenosis.
2. Left main equivalent: significant (70%)
stenosis of proximal LAD and proximal left circumflex
artery.
3. Ongoing ischemia not responsive to maximal nonsurgical therapy.
Class IIa
1. Proximal LAD stenosis with 1- or 2-vessel
disease.*1
Class IIb
2. One- or 2-vessel disease not involving the proximal
LAD.2
Class III
See text.
D. Indications for CABG in ST-Segment Elevation (Q-Wave)
MI
Class I
None.
Class IIa
1. Ongoing ischemia/infarction not responsive
to maximal nonsurgical therapy.
Class IIb
1. Progressive LV pump failure with coronary
stenosis compromising viable myocardium outside the
initial infarct area.
2. Primary reperfusion in the early hours (6 to 12 hours)
of an evolving ST-segment elevation MI.
Class III
1. Primary reperfusion late (12 hours) in evolving
ST-segment elevation MI without ongoing ischemia.
E. Indications for CABG in Poor LV Function
Class I
1. Significant left main coronary artery
stenosis.
2. Left main equivalent: significant (70%)
stenosis of proximal LAD and proximal left circumflex
artery.
3. Proximal LAD stenosis with 2- or 3-vessel disease.
Class IIa
1. Poor LV function with significant viable,
noncontracting, revascularizable myocardium without any of
the aforementioned anatomic patterns.
Class III
1. Poor LV function without evidence of intermittent
ischemia and without evidence of significant revascularizable,
viable myocardium.
F. Indications for CABG in Life-Threatening Ventricular
Arrhythmias
Class I
1. Left main coronary artery
stenosis.
2. Three-vessel coronary disease.
Class IIa
1. Bypassable 1- or 2-vessel disease causing
life-threatening ventricular arrhythmias.
3
2. Proximal LAD disease with 1- or 2-vessel
disease.3
Class III
1. Ventricular tachycardia with scar
and no evidence of ischemia.
G. Indications for CABG After Failed PTCA
Class I
1. Ongoing ischemia or threatened occlusion
with significant myocardium at risk.
2. Hemodynamic compromise.
Class IIa
1. Foreign body in crucial anatomic position.
2. Hemodynamic compromise in patients with impairment of coagulation system and without previous sternotomy.
Class IIb
1. Hemodynamic compromise in patients
with impairment of coagulation system and with previous sternotomy.
Class III
1. Absence of ischemia.
2. Inability to revascularize owing to target anatomy or no-reflow state.
H. Indications for CABG in Patients With Previous CABG
Class I
1. Disabling angina despite maximal noninvasive
therapy. (If angina is not typical, then objective evidence of
ischemia should be obtained.)
Class IIa
1. Bypassable distal vessel(s) with a large area of
threatened myocardium on noninvasive studies.
Class IIb
1. Ischemia in the non-LAD distribution
with a patent internal mammary graft to the LAD supplying functioning
myocardium and without an aggressive attempt at medical
management and/or percutaneous
revascularization.
Class III
See text.
|
Footnotes |
|---|
"ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)" was approved by the American College of Cardiology Board of Trustees in March 1999 and by the American Heart Association Science Advisory and Coordinating Committee in July 1999.
When citing this document, the American College of Cardiology and the American Heart Association request that the following citation format be used: Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent W, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 1999;100:1464-1480.
This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org). A single reprint of the executive summary and recommendations is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0173. To obtain a reprint of the complete guidelines published in the October 1999 issue of the Journal of the American College of Cardiology, ask for reprint No. 71-0174. To purchase additional reprints (specify version and reprint number): up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or . To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
1 Becomes Class I if extensive ischemia documented by noninvasive study and/or an LVEF <0.50. 
2 If a large area of viable myocardium and high-risk criteria on noninvasive testing, becomes Class I.
3 Becomes Class I if arrhythmia is resuscitated sudden cardiac death or sustained ventricular tachycardia.
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B. F. Buxton Invited commentary Ann. Thorac. Surg., February 1, 2006; 81(2): 589 - 590. [Full Text] [PDF]
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J. C.Y. Lu, A. D. Grayson, and D. M. Pullan On-Pump Versus Off-Pump Surgical Revascularization for Left Main Stem Stenosis: Risk Adjusted Outcomes Ann. Thorac. Surg., July 1, 2005; 80(1): 136 - 142. [Abstract] [Full Text] [PDF]
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C. Kubal, A. K. Srinivasan, A. D. Grayson, B. M. Fabri, and J. A.C. Chalmers Effect of Risk-Adjusted Diabetes on Mortality and Morbidity After Coronary Artery Bypass Surgery Ann. Thorac. Surg., May 1, 2005; 79(5): 1570 - 1576. [Abstract] [Full Text] [PDF]
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P. Kaul, B. L. Lytle, J. A. Spertus, E. R. DeLong, and E. D. Peterson Influence of Racial Disparities in Procedure Use on Functional Status Outcomes Among Patients With Coronary Artery Disease Circulation, March 15, 2005; 111(10): 1284 - 1290. [Abstract] [Full Text] [PDF]
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L. J. Dacey, D. S. Likosky, B. J. Leavitt, S. J. Lahey, R. D. Quinn, F. Hernandez Jr, H. B. Quinton, J. P. Desimone, C. S. Ross, G. T. O'Connor, et al. Perioperative Stroke and Long-Term Survival After Coronary Bypass Graft Surgery Ann. Thorac. Surg., February 1, 2005; 79(2): 532 - 536. [Abstract] [Full Text] [PDF]
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A. K. Srinivasan, A. D. Grayson, and B. M. Fabri On-Pump Versus Off-Pump Coronary Artery Bypass Grafting in Diabetic Patients: A Propensity Score Analysis Ann. Thorac. Surg., November 1, 2004; 78(5): 1604 - 1609. [Abstract] [Full Text] [PDF]
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A. H. Lindhout, C. W. Wouters, and L. Noyez Influence of obesity on in-hospital and early mortality and morbidity after myocardial revascularization Eur. J. Cardiothorac. Surg., September 1, 2004; 26(3): 535 - 541. [Abstract] [Full Text] [PDF]
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J. A. Bittl and A. T. Hirsch Concomitant Peripheral Arterial Disease and Coronary Artery Disease: Therapeutic Opportunities Circulation, June 29, 2004; 109(25): 3136 - 3144. [Full Text] [PDF]
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N. Svorkdal Treatment of Inoperable Coronary Disease and Refractory Angina: Spinal Stimulators, Epidurals, Gene Therapy, Transmyocardial Laser, and Counterpulsation Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2004; 8(1): 43 - 58. [Abstract] [PDF]
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W. E. McGregor, M. Payne, D. R. Trumble, K. M. Farkas, and J. A. Magovern Improvement of sternal closure stability with reinforced steel wires Ann. Thorac. Surg., November 1, 2003; 76(5): 1631 - 1634. [Abstract] [Full Text] [PDF]
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C. A. Estrada, J. A. Young, L. W. Nifong, and W.R. Chitwood Jr Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting Ann. Thorac. Surg., May 1, 2003; 75(5): 1392 - 1399. [Abstract] [Full Text] [PDF]
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M. Kuduvalli, A. D. Grayson, A. Y. Oo, B. M. Fabri, and A. Rashid The effect of obesity on mid-term survival following coronary artery bypass surgery Eur. J. Cardiothorac. Surg., March 1, 2003; 23(3): 368 - 373. [Abstract] [Full Text] [PDF]
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