2011 CABG Guidelines

8/17/2019 2011 CABG Guidelines

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2011 ACCF/AHA Guidelines forCoronary Artery Bypass Graft

Surgery

Developed in Collaboration with and endorsed by the AmericanAssociation for Thoracic Surgery, Society of Cardiovascular

Anesthesiologists, and Society for Thoracic Surgeons

© American College of Cardiology Foundation and American Heart Association, Inc.


2/142

CitationThis slide set was adapted from the 20 ACCF!AHA

"uideline for Coronary Artery #ypass "raft $urgery.

%u&lished on 'o(em&er )th ahead of print, a(aila&le at* http*!!content.online+acc.org!cgi!content!full!+.+acc.20.0.00-

The fullte/t guidelines are also a(aila&le on the following e&

sites*

ACC 1www.cardiosource.org and AHA 1my.americanheart.org

http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.009http://www.cardiosource.org/http://www.my.americanheart.org/http://www.my.americanheart.org/http://www.cardiosource.org/http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.009


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Slide Set Editors3. 4a(id Hillis, 54, FACC, Chair and %eter 6. $mith, 54, FACC, 7ice Chair

CABG Guideline Writing Committee Members3. 4a(id Hillis, 54, FACC, Chair

%eter 6. $mith, 54, FACC, 7ice Chair

Special Thanks To

8ichard A. 3ange, 54, FACC, FAHA

5artin 9. 3ondon, 54

5ichael 9. 5ac:, 54, FACC

5anesh 8. %atel, 54, FACC

9ohn 4. %us:as, 54, FACC

9oseph F. $a&i:, 54, FACC

;la $elnes, %h4

4a(id 5. $hahian, 54, FACC, FAHA

9effrey C. Trost, 54, FACC

5ichael 4. inniford, 54, FACC

9effrey 3. Anderson, 54, FACC

9ohn A. #ittl, 54, FACC

Charles 8. #ridges, 54, $c4, FACC, FAHA

9ohn ". #yrne, 54, FACC

9oa:a, 54, FACC, FAHA

Adolph 5. Hutter, 9r., 54, 5ACC, FAHA

5ichael =. 9essen, 54, FACC

=llen C. 6eeley, 54, 5$

$tephen 9. 3ahey, 54


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ass cat on o eco""en at ons an e$e sof %$idence A recommendation with

3e(el of =(idence # or C

does not imply that the

recommendation is wea:.

5any important clinical

ed trials are

una(aila&le, there may &e

a (ery clear clinicalconsensus that a

particular test or therapy

is useful or effecti(e.

?4ata a(aila&le fromclinical trials or registries

a&out the

usefulness!efficacy in

different su&populations,

such as se/, age, historyof dia&etes, history of

prior myocardial

infarction, history of heart

failure, and prior aspirin

use.

@For comparati(e

effecti(eness

recommendations 1Class I

and IIa 3e(el of =(idence

A and # only, studies thatsupport the use of

comparator (er&s shouldin(ol(e direct

comparisons of the

treatments or strategies&eing e(aluated.


5/142

&roceduralConsiderations

Guideline for CABG


6/142

AnestheticConsiderations

'ntraoperati$e Considerations


7/142

Anesthetic management directed toward early

postoperati(e e/tu&ation and accelerated reco(ery

of low to mediumris: patients undergoing

uncomplicated CA#" is recommended.

5ultidisciplinary efforts are indicated to ensure an

optimal le(el of analgesia and patient comfort

throughout the perioperati(e period.

Anesthetic Considerations

I IIa IIb III

I IIa IIb III


8/142

Anesthetic Considerations(cont)*

=fforts are recommended to impro(e interdisciplinary

communication and patient safety in the perioperati(e

en(ironment 1e.g., formali>ed chec:listguided

multidisciplinary communication.

A fellowshiptrained cardiac anesthesiologist 1or

e/perienced &oardcertified practitioner credentialed in

the use of perioperati(e T== is recommended to pro(ide

or super(ise anesthetic care of patients who areconsidered to &e at high ris:.

I IIa IIb III

I IIa IIb III


9/142

AnestheticConsiderations (cont)*

7olatile anesthestic&ased regimens can &e useful in

facilitating early e/tu&ation and reducing patient recall.

The effecti(eness of high thoracic epidural

anesthesia!analgesia for routine analgesic use is uncertain.

I IIa IIb III

I IIa IIb III


10/142

Anesthetic Considerations(cont)*

Cycloo/ygenase2 inhi&itors are not recommended for pain relief

in the postoperati(e period after CA#".

8outine use of early e/tu&ation strategies in facilities with limited

&ac:up for airway emergencies or ad(anced respiratory support

is potentially harmful.

Harm

Harm

I IIa IIb III

I IIa IIb III


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Bypass Graft Conduit



12/142

Bypass Graft Conduit

If possi&le, the 3I5A should &e used to &ypass the 3A4

artery when &ypass of the 3A4 artery is indicated.

The right I5A is pro&a&ly indicated to &ypass the 3A4

artery when the 3I5A is una(aila&le or unsuita&le as a

&ypass conduit.

I IIa IIb III

I IIa IIb III


13/142


14/142

Bypass Graft Conduit(cont)*

Arterial grafting of the right coronary artery may &e reasona&le

when a critical 1D-0E stenosis is present.

se of a radial artery graft may &e reasona&le when grafting left

sided coronary arteries with se(ere stenoses 1G)0E diameter

and rightsided arteries with critical stenoses 1D-0E that perfuse

37 myocardium.

I IIa IIb III

I IIa IIb III


15/142

Bypass Graft Conduit(cont)*

An arterial graft should not &e used to &ypass the right

coronary artery with less than a critical stenosis 1-0E.

Harm

I IIa IIb III


16/142

'ntraoperati$e T%%



17/142

'ntraoperati$e T%%

Intraoperati(e T== should &e performed for e(aluation of

acute, persistent, and lifethreatening hemodynamic

distur&ances that ha(e not responded to treatment.

Intraoperati(e T== should &e performed in patients undergoing

concomitant (al(ular surgery.

I IIa IIb III

I IIa IIb III


18/142

'ntraoperati$e T%%(cont)*

Intraoperati(e T== is reasona&le for monitoring ofhemodynamic status, (entricular function, regional wall

motion, and (al(ular function in patients undergoing CA#".

I IIa IIb III


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&reconditioning/+anage"ent of +yocardial

'sche"ia



20/142

&reconditioning/+anage"ent of+yocardial 'sche"ia

5anagement targeted at optimi>ing the determinants of

coronary arterial perfusion 1e.g., heart rate, diastolic or mean

arterial pressure, and 87 or 37 enddiastolic pressure isrecommended to reduce the ris: of perioperati(e myocardial

ischemia and infarction.

I IIa IIb III


21/142

&reconditioning/+anage"ent of+yocardial 'sche"ia (cont)*

7olatile&ased anesthesia can &e useful in reducing the

ris: of perioperati(e myocardial ischemia and infarction.

The effecti(eness of prophylactic pharmacological

therapies or controlled reperfusion strategies aimed at

inducing preconditioning or attenuating the ad(erse

conse


22/142

&reconditioning/+anage"ent of+yocardial 'sche"ia (cont)*

5echanical preconditioning might &e considered to reduce

the ris: of perioperati(e myocardial ischemia and infarction

in patients undergoing offpump CA#".

8emote ischemic preconditioning strategies usingperipherale/tremity occlusion!reperfusion might &e

considered to attenuate the ad(erse conse


23/142

CABG in &atients ,ith Acute +'

Clinical Su-sets


24/142


25/142

CABG in &atients ,ith Acute +' (cont)*

=mergency CA#" is recommended in patients with

cardiogenic shoc: and who are suita&le for CA#"

irrespecti(e of the time inter(al from 5I to onset of shoc:

and time from 5I to CA#".

=mergency CA#" is recommended in patients with life

threatening (entricular arrhythmias 1&elie(ed to &e

ischemic in origin in the presence of a left main stenosis

DJ0E and!or (essel CA4.

I IIa IIb III

I IIa IIb III


26/142


The use of CA#" is reasona&le as a re(asculari>ation

strategy in patients with multi(essel CA4 with recurrent

angina or 5I within the first K hours of $T=5I

presentation as an alternati(e to a more delayed strategy.

=arly re(asculari>ation with %CI or CA#" is reasona&le

for selected patients G)J years of age with $Tsegment

ele(ation or left &undle &ranch &loc: who are suita&le forre(asculari>ation irrespecti(e of the time inter(al from 5I

to onset of shoc:.

I IIa IIb III

I IIa IIb III


27/142


=mergency CA#" should not &e performed in patients

with persistent angina and a small area of (ia&le

myocardium who are sta&le hemodynamically.

=mergency CA#" should not &e performed in patients

with noreflow 1successful epicardial reperfusion with

unsuccessful micro(ascular reperfusion.

Harm

Harm

I IIa IIb III

I IIa IIb III


28/142

#ife.Threatening entricular Arrhyth"ias

Clinical Su-sets


29/142

#ife.Threatening entricular Arrhyth"ias

CA#" is recommended in patients with resuscitated

sudden cardiac death or sustained (entricular tachycardia

thought to &e caused &y significant CA4 1DJ0E stenosis

of the left main coronary artery and!or D)0E stenosis of ,

2, or all epicardial coronary arteries and resultant

myocardial ischemia.

CA#" should not &e performed in patients with (entricular

tachycardia with scar and no e(idence of ischemia.I IIa II& IIII IIa II& IIII IIa II& IIIIIa II& III

Harm

I IIa IIb III

I IIa IIb III


30/142

%"ergency CABG AfterFailed &C'

Clinical Su-sets


31/142


=mergency CA#" is recommended after failed %CI in the

presence of ongoing ischemia or threatened occlusion

with su&stantial myocardium at ris:.

=mergency CA#" is recommended after failed %CI for

hemodynamic compromise in patients without impairment

of the coagulation system and without a pre(ious

sternotomy.

I IIa IIb III

I IIa IIb III


32/142


=mergency CA#" is reasona&le after failed %CI for

retrie(al of a foreign &ody 1most li:ely a fractured

guidewire or stent in a crucial anatomic location.

=mergency CA#" can &e &eneficial after failed %CI for

hemodynamic compromise in patients with impairment of

the coagulation system and without a pre(ious

sternotomy.

I IIa IIb III

I IIa IIb III


33/142

%"ergency CABG AfterFailed &C' (cont)*

=mergency CA#" might &e considered after failed

%CI for hemodynamic compromise in patients with a

pre(ious sternotomy.

I IIa IIb III


34/142

%"ergency CABG AfterFailed &C' (cont)*

=mergency CA#" should not &e performed after failed

%CI in the a&sence of ischemia or threatened occlusion.

=mergency CA#" should not &e performed after failed

%CI if re(asculari>ation is impossi&le &ecause of target

anatomy or a noreflow state.

Harm

Harm

I IIa IIb III

I IIa IIb III


35/142

CABG in Association ,ith ther Cardiac

&rocedures

Clinical Su-sets


36/142

CABG in Association ,ith ther Cardiac&rocedures

CA#" is recommended in patients undergoing noncoronary

cardiac surgery with DJ0E luminal diameter narrowing of

the left main coronary artery D)0E luminal diameter

narrowing of other ma+or coronary arteries.

The use of the 3I5A is reasona&le to &ypass a significantly

narrowed 3A4 artery in patients undergoing noncoronary

cardiac surgery.

CA#" of moderately diseased coronary arteries 1GJ0Eluminal diameter narrowing is reasona&le in patients

undergoing noncoronary cardiac surgery.

I IIa IIb III

I IIa IIb III

I IIa IIb III


37/142

CA !e$asculariation

Guideline for CABG


38/142

Heart Tea" Approach to!e$asculariation

ecisions

CA !e$asculariation

H t T A h t


39/142

A Heart Team approach to re(asculari>ation is

recommended in patients with unprotected left

main or comple/ CA4.

Calculation of the $T$ and $L'TAM scores is

reasona&le in patients with unprotected left main

and comple/ CA4.

Heart Tea" Approach to!e$asculariation ecisions

I IIa IIb III

I IIa IIb III


40/142

!e$asculariation to'"pro$e Sur$i$al

CA !e$asculariation

!e$asculariation to '"pro$e


41/142

CA#" to impro(e sur(i(al is recommended for patientswith significant 1DJ0E diameter stenosis left main CA4.

%CI to impro(e sur(i(al is reasona&le as an alternati(e toCA#" in selected sta&le patients with significant 1DJ0Ediameter stenosis unprotected left main CA4 with* anatomic conditions associated with a low ris: of %CIprocedural complications and a high li:elihood of a goodlongterm outcome 1e.g., a low $L'TAM score NB22O, ostial

or trun: left main CA4 and 2 clinical characteristics thatpredict a significantly increased ris: of ad(erse surgicaloutcomes 1e.g., $T$predicted ris: of operati(e mortalityDJE.

!e$asculariation to '"pro$eSur$i$al3 #eft +ain CA

!e$asculariation

I IIa IIb III

I IIa IIb III



42/142

%CI to impro(e sur(i(al is reasona&le in patientswith A!'$T=5I when an unprotected left maincoronary artery is the culprit lesion and the

patient is not a candidate for CA#".

%CI to impro(e sur(i(al is reasona&le in patientswith acute $T=5I when an unprotected left maincoronary artery is the culprit lesion, distalcoronary flow is TI5I 1Throm&olysis In5yocardial Infarction grade , and %CI can &eperformed more rapidly and safely than CA#".

!e$asculariation to '"pro$eSur$i$al3 #eft +ain CA!e$asculariation (cont)*

I IIa IIb III

I IIa IIb III



43/142

%CI to impro(e sur(i(al may &e reasona&le as analternati(e to CA#" in selected sta&le patients withsignificant 1DJ0E diameter stenosis unprotected left mainCA4 with* anatomic conditions associated with a low to

intermediate ris: of %CI procedural complications and anintermediate to high li:elihood of good longterm outcome1e.g., lowintermediate $L'TAM score of , &ifurcationleft main CA4 and 2 clinical characteristics that predictan increased ris: of ad(erse surgical outcomes 1e.g.,moderatese(ere chronic o&structi(e pulmonary disease,disa&ility from pre(ious stro:e, or pre(ious cardiacsurgery $T$predicted ris: of operati(e mortality G2E.


I IIa IIb III



44/142

%CI to impro(e sur(i(al should not &e performed

in sta&le patients with significant 1DJ0E diameter

stenosis unprotected left main CA4 who ha(eunfa(ora&le anatomy for %CI and who are good

candidates for CA#".


I IIa IIb III

Harm



45/142

CA#" to impro(e sur(i(al is &eneficial in patients

with significant 1D)0E diameter stenoses in

ma+or coronary arteries 1with or withoutin(ol(ement of the pro/imal 3A4 artery or in the

pro/imal 3A4 plus other ma+or coronary artery.

!e$asculariation to '"pro$eSur$i$al3 4on.#eft +ain CA

!e$asculariation

I IIa IIb III



46/142

CA#" or %CI to impro(e sur(i(al is&eneficial in sur(i(ors of sudden cardiac

death with presumed ischemiamediated(entricular tachycardia caused &y asignificant 1D)0E diameter stenosis in ama+or coronary artery.


!e$asculariation (cont)*

CABG

PCI

I IIa IIb III

I IIa IIb III



47/142

CA#" to impro(e sur(i(al is reasona&le in patients withsignificant 1D)0E diameter stenoses in 2 ma+or coronaryarteries with se(ere or e/tensi(e myocardial ischemia 1e.g.,

highris: criteria on stress testing, a&normal intracoronaryhemodynamic e(aluation, or G20E perfusion defect &ymyocardial perfusion stress imaging or target (esselssupplying a large area of (ia&le myocardium.

CA#" to impro(e sur(i(al is reasona&le in patients with

mildmoderate left (entricular systolic dysfunction 1e+ectionfraction JE to J0E and significant 1D)0E diameterstenosis multi(essel CA4 or pro/imal 3A4 coronary arterystenosis, when (ia&le myocardium is present in the regionof intended re(asculari>ation.



I IIa IIb III

I IIa IIb III



48/142

CA#" with a 3I5A graft to impro(e sur(i(al isreasona&le in patients with a significant 1D)0Ediameter stenosis in the pro/imal 3A4 artery and

e(idence of e/tensi(e ischemia.

It is reasona&le to choose CA#" o(er %CI toimpro(e sur(i(al in patients with comple/ (essel CA4 1e.g., $L'TAM score G22 with or

without in(ol(ement of the pro/imal 3A4 arterywho are good candidates for CA#".



I IIa IIb III

I IIa IIb III



49/142

CA#" is pro&a&ly recommended in preference to %CI to impro(esur(i(al in patients with multi(essel CA4 and dia&etesmellitus, particularly if a 3I5A graft can &e anastomosed to the3A4 artery.

The usefulness of CA#" to impro(e sur(i(al is uncertain inpatients with significant 1D)0E stenoses in 2 ma+or coronaryarteries not in(ol(ing the pro/imal 3A4 artery and without

e/tensi(e ischemia.



I IIa IIb III

I IIa IIb III



50/142

The usefulness of %CI to impro(e sur(i(al is uncertain inpatients with 2 or (essel CA4 1with or withoutin(ol(ement of the pro/imal 3A4 artery or (esselpro/imal 3A4 disease.

CA#" might &e considered with the primary or sole intentof impro(ing sur(i(al in patients with $IH4 with se(ere 37systolic dysfunction 1=FJE whether or not (ia&lemyocardium is present.

The usefulness of CA#" or %CI to impro(e sur(i(al isuncertain in patients with pre(ious CA#" and e/tensi(eanterior wall ischemia on nonin(asi(e testing.



I IIa IIb III

I IIa IIb III

I IIa IIb III



51/142

CA#" or %CI should not &e performed with theprimary or sole intent to impro(e sur(i(al inpatients with $IH4 with or more coronary

stenoses that are not anatomically or functionallysignificant 1e.g., )0E diameter non−left maincoronary artery stenosis, fractional flow reser(eG0.0, no or only mild ischemia on nonin(asi(etesting, in(ol(e only the left circumfle/ or rightcoronary artery, or su&tend only a small area of

(ia&le myocardium.



I IIa IIb III

Harm

! l i i '


52/142

CA#" or %CI to impro(e symptoms is &eneficialin patients with or more significant 1D)0Ediameter coronary artery stenoses amena&le tore(asculari>ation and unaccepta&le angina

despite "45T.

CA#" or %CI to impro(e symptoms is reasona&lein patients with or more significant 1D)0Ediameter coronary artery stenoses and

unaccepta&le angina for whom "45T cannot &eimplemented &ecause of medicationcontraindications, ad(erse effects, or patientpreferences.

!e$asculariation to '"pro$eSy"pto"s

I IIa IIb III

I IIa IIb III


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%CI to impro(e symptoms is reasona&le inpatients with pre(ious CA#", or moresignificant 1D)0E diameter coronary arterystenoses associated with ischemia, and

unaccepta&le angina despite "45T.

It is reasona&le to choose CA#" o(er %CI toimpro(e symptoms in patients with comple/ (essel CA4 1e.g., $L'TAM score G22, with or

without in(ol(ement of the pro/imal 3A4 arterywho are good candidates for CA#".

!e$asculariation to '"pro$eSy"pto"s (cont)*

I IIa IIb III

I IIa IIb III


54/142

CA#" to impro(e symptoms might &e reasona&lefor patients with pre(ious CA#", or moresignificant 1D)0E diameter coronary arterystenoses not amena&le to %CI, and unaccepta&leangina despite "45T.

Transmyocardial laser re(asculari>ationperformed as an ad+unct to CA#" to impro(esymptoms may &e reasona&le in patients with(ia&le ischemic myocardium that is perfused &yarteries that are not amena&le to grafting.


I IIa IIb III

I IIa IIb III


55/142

CA#" or %CI to impro(e symptoms should not&e performed in patients who do not meetanatomic 1DJ0E left main or D)0E non−left main

stenosis or physiologic 1e.g., a&normal fractionalflow reser(e criteria for re(asculari>ation.


I IIa II& IIII IIa II& IIII IIa II& IIIIIa II& III

Harm

I IIa IIb III


56/142

ual Antiplatelet

Therapy Co"plianceand Stent Thro"-osis

CA !e$asculariation

ual Antiplatelet Therapy


57/142

%CI with coronary stenting 1#5$ or 4=$ shouldnot &e performed if the patient is not li:ely to &e

a&le to tolerate and comply with dual antiplatelettherapy for the appropriate duration of treatment&ased on the type of stent implanted.

ual Antiplatelet TherapyCo"pliance and Stent

Thro"-osis

Harm

I IIa IIb III


58/142

Hy-rid Coronary

!e$asculariation

CA !e$asculariation

Hy-rid Coronary


59/142

Hy&rid coronary re(asculari>ation 1defined as the planned

com&ination of left internal mammary arteryto3A4 artery

grafting and %CI of D non3A4 coronary arteries is

reasona&le in patients with or more of the following*

a.3imitations to traditional CA#", such as a hea(ily calcified

pro/imal aorta or poor target (essels for CA#" 1&ut

amena&le to %CI

&.3ac: of suita&le graft conduits

c.nfa(ora&le 3A4 artery for %CI 1i.e., e/cessi(e (esseltortuosity or chronic total occlusion.

Hy-rid Coronary!e$asculariation

I IIa IIb III

Hy-rid Coronary


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Hy&rid coronary re(asculari>ation 1defined as

the planned com&ination of 3I5Ato3A4 artery

grafting and %CI of D non3A4 coronary

arteries may &e reasona&le as an alternati(eto multi(essel %CI or CA#" in an attempt to

impro(e the o(erall ris:&enefit ratio of the

procedures.

Hy-rid Coronary!e$asculariation (cont)*

I IIa IIb III


61/142


62/142

&reoperati$e Antiplatelet

Therapy

&erioperati$e +anage"ent


63/142


64/142

&reoperati$e Antiplatelet


65/142

&reoperati$e AntiplateletTherapy (cont)*

In patients referred for urgent CA#", it may &e reasona&le

to perform surgery J days after clopidogrel or ticagrelor

has &een discontinued and ) days after prasugrel has

&een discontinued.

I IIa IIb III

i i


66/142

&ostoperati$e Antiplatelet

Therapy


&ostoperati$e Antiplatelet


67/142

&ostoperati$e AntiplateletTherapy

If aspirin 100 mg to 2J mg daily was not initiated

preoperati(ely, it should &e initiated within hours

postoperati(ely and then continued indefinitely to

reduce the occurrence of $7" closure and ad(erse

cardio(ascular e(ents.

For patients undergoing CA#", clopidogrel )J mg daily

is a reasona&le alternati(e in patients who are

intolerant of or allergic to aspirin.

I IIa IIb III

I IIa IIb III

& i i +


68/142

+anage"ent ofHyperlipide"ia


+anage"ent of


69/142

+anage"ent ofHyperlipide"ia

All patients undergoing CA#" should recei(e statin

therapy, unless contraindicated.

In patients undergoing CA#", an ade


70/142

+anage"ent ofHyperlipide"ia (cont)*

In patients undergoing CA#", it is reasona&le to treat

with statin therapy to lower the 343 cholesterol to )0

mg!d3 in (ery highris: patients.

For patients undergoing urgent or emergency CA#"

who are not ta:ing a statin, it is reasona&le to initiate

highdose statin therapy immediately.

I IIa IIb III

I IIa IIb III

+anage"ent of


71/142

+anage"ent ofHyperlipide"ia (cont)*

4iscontinuation of statin or other dyslipidemic

therapy is not recommended &efore or after CA#"

in patients without ad(erse reactions to therapy.

Harm

I IIa IIb III


72/142


73/142

Hor"onal +anipulation

se of continuous I7 insulin to achie(e and maintain anearly postoperati(e &lood glucose concentration B0

mg!d3 while a(oiding hypoglycemia is indicated to

reduce the incidence of ad(erse e(ents, including 4$I,

after CA#".

The use of continuous I7 insulin designed to achie(e a

target intraoperati(e &lood glucose concentration K0

mg!d3 has uncertain effecti(eness.

I IIa IIb III

I IIa IIb III

Hor"onal +anipulation


74/142

Hor"onal +anipulation(cont)*

%ostmenopausal hormonal therapy 1estrogen!

progesterone should not &e administered to women

undergoing CA#".

Harm

I IIa IIb III

& i ti + t


75/142

&erioperati$e Beta

Blockers


&erioperati$e Beta


76/142

&erioperati$e BetaBlockers

#eta &loc:ers should &e administered for at least 2K

hours &efore CA#" to all patients without

contraindications to reduce the incidence or clinical

se


77/142

&erioperati$e BetaBlockers (cont)*

#eta &loc:ers should &e prescri&ed to all CA#" patients

without contraindications at the time of hospital

discharge.

I IIa IIb III


78/142

&erioperati$e Beta


79/142

&erioperati$e BetaBlockers (cont)*

Intra(enous administration of &eta &loc:ers in clinically sta&le

patients una&le to ta:e oral medications is reasona&le in the

early postoperati(e period.

The effecti(eness of preoperati(e &eta &loc:ers in reducing in

hospital mortality rates in patients with 37=F 0E is uncertain.

I IIa IIb III

I IIa IIb III



80/142

Angiotensin.Con$erting

%ny"e 'nhi-itorsand Angiotensin.

!eceptor Blockers


ng otens n. on$ert ng ny"e'nhi-itors


81/142

'nhi-itorsand Angiotensin.!eceptor

Blockers AC= inhi&itors and A8#s gi(en &efore CA#" should &e

reinstituted postoperati(ely once the patient is sta&le,

unless contraindicated.

AC= inhi&itors or A8#s should &e initiated

postoperati(ely and continued indefinitely in CA#"

patients who were not recei(ing them preoperati(ely,

who are sta&le, and who ha(e an 37=F BK0E,

hypertension, dia&etes mellitus, or chronic :idney

disease, unless contraindicated.

I IIa IIb III

I IIa IIb III



82/142


Blockers (cont)*It is reasona&le to initiate AC= inhi&itors or A8#s

postoperati(ely and to continue them indefinitely in all

CA#" patients who were not recei(ing them

preoperati(ely and are considered to &e at low ris: 1i.e.,

those with a normal 37=F in whom cardio(ascular ris:

factors are well controlled, unless contraindicated.

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83/142


Blockers (cont)*The safety of the preoperati(e administration of AC= inhi&itors

or A8#s in patients on chronic therapy is uncertain.

The safety of initiating AC= inhi&itors or A8#s &efore hospital

discharge is not well esta&lished.

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84/142

S"oking Cessation


S ki C ti


85/142

S"oking Cessation

All smo:ers should recei(e inhospital educational

counseling and &e offered smo:ing cessation therapy

during CA#" hospitali>ation.

The effecti(eness of pharmacological therapy for

smo:ing cessation offered to patients &efore hospital

discharge is uncertain.

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86/142

%"otional ysfunction

and &sychosocialConsiderations


"ot ona ys unct ond & h i l


87/142

and &sychosocial

Considerations

Cogniti(e &eha(ior therapy or colla&orati(e care for

patients with clinical depression after CA#" can &e

&eneficial to reduce o&+ecti(e measures of depression.

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88/142

Cardiac !eha-ilitation


C di ! h -ilit ti


89/142

Cardiac !eha-ilitation

Cardiac reha&ilitation is recommended for all eligi&le

patients after CA#".

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90/142

&erioperati$e

+onitoring




91/142

%lectrocardiographic

+onitoring




92/142

g p+onitoring

Continuous monitoring of the electrocardiogram for

arrhythmias should &e performed for at least K hours in

all patients after CA#".

Continuous $Tsegment monitoring for detection of

ischemia is reasona&le in the intraoperati(e period for

patients undergoing CA#".

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93/142

g p+onitoring (cont)*

Continuous $Tsegment monitoring for

detection of ischemia may &e considered in theearly postoperati(e period after CA#".

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94/142

&ul"onary Artery

Catheteriation


&ul"onary Artery


95/142

y yCatheteriation

%lacement of a %AC is indicated, prefera&ly &efore the

induction of anesthesia or surgical incision, in patients in

cardiogenic shoc: undergoing CA#".

%lacement of a %AC can &e useful in the intraoperati(e or

early postoperati(e period in patients with acute

hemodynamic insta&ility.

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&ul"onary Artery


96/142

y yCatheteriation (cont)*

%lacement of a %AC may &e reasona&le in

clinically sta&le patients undergoing CA#" after

consideration of &aseline patient ris:, theplanned surgical procedure, and the practice

setting.

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97/142

Central 4er$ous Syste"

+onitoring


Central 4er$ous Syste"


98/142

y+onitoring

The effecti(eness of intraoperati(e monitoring of the

processed electroencephalogram to reduce the possi&ility of

ad(erse recall of clinical e(ents or for detection of cere&ral

hypoperfusion in CA#" patients is uncertain.

The effecti(eness of routine use of intraoperati(e or early

postoperati(e monitoring of cere&ral o/ygen saturation (ia

nearinfrared spectroscopy to detect cere&ral hypoperfusion

in patients undergoing CA#" is uncertain.

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Guideline for CABG


99/142

CABG.Associated

+or-idity and +ortality3ccurrence and&re$ention

Guideline for CABG


100/142

&u-lic !eporting of Cardiac


101/142

gSurgery utco"es

%u&lic reporting of cardiac surgery outcomes

should use ris:ad+usted results &ased on

clinical data.

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102/142

se o utco"es orolu"e as CABG 6uality


103/142

olu"e as CABG 6uality

+easures All cardiac surgery programs should participate in a state,regional, or national clinical data registry and should

recei(e periodic reports of their ris:ad+usted outcomes.

hen credi&le ris:ad+usted outcomes data are not

a(aila&le, (olume can &e useful as a structural metric of

CA#"


104/142

olu"e as CABG 6uality

+easures (cont)*

Affiliation with a high(olume tertiary center

might &e considered &y cardiac surgery

programs that perform fewer than 2J CA#"

procedures annually.

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105/142

5se of %piaortic 5ltrasound '"agingto


106/142

!educe Stroke !ates

8outine epiaortic ultrasound scanning is

reasona&le to e(aluate the presence, location,

and se(erity of pla


107/142

4onin$asi$e Screening in CABG &atients

A multidisciplinary team approach 1consisting of acardiologist, cardiac surgeon, (ascular surgeon, and

neurologist is recommended for patients with clinically

significant carotid artery disease for whom CA#" is

planned.

Carotid artery duple/ scanning is reasona&le in selected

patients who are considered to ha(e highris: features

1i.e., age GJ years, left main coronary stenosis, %A4,

history of cere&ro(ascular disease NTIA, stro:e, etc.O,hypertension, smo:ing, and dia&etes mellitus.

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The !ole of &reoperati$e Carotid Artery4onin$asi$e Screening in CABG &atients


108/142

4onin$asi$e Screening in CABG &atients(cont)*

In the CA#" patient with a pre(ious TIA or stro:e and a significant1J0E to --E carotid artery stenosis, it is reasona&le to consider

carotid re(asculari>ation in con+unction with CA#". In such an

indi(idual, the seation may &e considered in the

presence of &ilateral se(ere 1)0E to --E carotid stenoses or a

unilateral se(ere carotid stenosis with a contralateral occlusion.

I IIa IIb III

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CABG.Associated +or-idity


109/142

+ediastinitis/&erioperat

i$e 'nfection

CABG Associated +or-idityand +ortality3 ccurrence and

&re$ention

+ediastinitis/&erioperati$e


110/142

'nfection

%reoperati(e anti&iotics should &e administered to all patients to

reduce the ris: of postoperati(e infection.

A first or secondgeneration cephalosporin is recommended for

prophyla/is in patients without methicillinresistant

Staphylococcus aureus coloni>ation.

I IIa IIb III

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111/142

'nfection (cont)*

7ancomycin alone or in com&ination with other anti&iotics to

achie(e &roader co(erage is recommended for prophyla/is in

patients with pro(en or suspected methicillinresistant S.

aureus coloni>ation.

A 4$I should &e treated with aggressi(e surgical

de&ridement in the a&sence of complicating circumstances.

%rimary or secondary closure with a muscle or omental flap

is recommended. 7acuum therapy in con+unction with early

and aggressi(e de&ridement is an effecti(e ad+uncti(etherapy.

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112/142

'nfection (cont)*

se of a continuous I7 insulin protocol to achie(e and

maintain an early postoperati(e &lood glucose

concentrationB0 mg!d3 while a(oiding hypoglycemia isindicated to reduce the ris: of 4$I.

I IIa IIb III

+ediastinitis/&erioperati$ef i ( *


113/142

'nfection (cont)*

hen &lood transfusions are needed, leu:ocyte

filtered &lood can &e useful to reduce the rate of

o(erall perioperati(e infection and inhospital

death.

The use of intranasal mupirocin is reasona&le in

nasal carriers of S. aureus.

I IIa IIb III

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114/142



115/142

!enal ysfunction

yand +ortality3 ccurrence and

&re$ention

!enal ysfunction


116/142

In patients with preoperati(e renal dysfunction 1creatinineclearance 0 m3!min, offpump CA#" may &e

reasona&le to reduce the ris: of A6I.

In patients with pree/isting renal dysfunction undergoing

onpump CA#", maintenance of a perioperati(e

hematocrit G-E and mean arterial pressure G0 mm Hg

may &e reasona&le.

I IIa IIb III

I IIa IIb III

!enal ysfunction( t *


117/142

(cont)*

In patients with pree/isting renal dysfunction, a

delay of surgery after coronary angiography may

&e reasona&le until the effect of radiographic

contrast material on renal function is assessed.

The effecti(eness of pharmacological agents to

pro(ide renal protection during cardiac surgery

is uncertain.

I IIa IIb III

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118/142

&erioperati$e

+yocardial ysfunction


&re$ention

&erioperati$e +yocardial f ti


119/142

ysfunction

In the a&sence of se(ere, symptomatic aortoiliacocclusi(e disease or %A4, the insertion of an

intraaortic &alloon is reasona&le to reduce the

mortality rate in CA#" patients who are considered to

&e at high ris: 1e.g., those who are undergoing

reoperation or ha(e 37=F 0E or left main CA4.

5easurement of &iomar:ers of myonecrosis 1e.g.,

creatine :inase5#, troponin is reasona&le in the first

2K hours after CA#".

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120/142

Transfusion


&re$ention

Transfusion


121/142

Transfusion

Aggressi(e attempts at &lood

conser(ation are indicated to limit

hemodilutional anemia and the need forintraoperati(e and perioperati(e

allogeneic red &lood cell transfusion in

CA#" patients.

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122/142

&erioperati$e

ysrhyth"ias


&re$ention

&erioperati$e h th i


123/142

ysrhyth"ias

#eta &loc:ers should &e administered for at least 2K

hours &efore CA#" to all patients without

contraindications to reduce the incidence or clinical

se


124/142

ysrhyth"ias (cont)*

4igo/in and nondihydropyridine calcium

channel &loc:ers can &e useful to control the

(entricular rate in the setting of AF &ut are

not indicated for prophyla/is.

I IIa IIb III

CABG.Associated +or-idityd + li d


125/142

&erioperati$e

Bleeding/Transfusion

and +ortality3 ccurrence and

&re$ention

&erioperati$eBleeding/Transfusion


126/142

Bleeding/Transfusion

3ysine analogues are useful intraoperati(ely andpostoperati(ely in patients undergoing onpump CA#" to

reduce perioperati(e &lood loss and transfusion

re


127/142

Bleeding/Transfusion (cont)*

In patients ta:ing thienopyridines 1clopidogrel or prasugrel or

ticagrelor in whom electi(e CA#" is planned, clopidogrel and

ticagrelor should &e withheld for at least J days and prasugrel for

at least ) days &efore surgery.

It is recommended that surgery &e delayed after the

administration of strepto:inase, uro:inase, and tissuetype

plasminogen acti(ators until hemostatic capacity is restored, if

possi&le. The timing of the recommended delay should &e guided&y the pharmacodynamic halflife of the in(ol(ed agent.

Clopidogrel P Ticagrelor

%rasugrel

I IIa IIb III

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128/142

Guideline for CABG


129/142

Specic &atient Su-sets



130/142

Ano"alous Coronary

Arteries

Ano"alous CoronaryArteries


131/142

ArteriesCoronary re(asculari>ation should &e performed in patientswith*

a. A left main coronary artery that arises anomalously

and then courses &etween the aorta and pulmonary

artery.

&. A right coronary artery that arises anomalously andthen courses &etween the aorta and pulmonary

artery with e(idence of myocardial ischemia.

Coronary re(asculari>ation may &e reasona&le in patients

with a 3A4 coronary artery that arises anomalously andthen courses &etween the aorta and pulmonary artery.

I IIa IIb III

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132/142

&atients ,ith Chronic

-structi$e &ul"onaryisease/!espiratory

'nsu7iciency

&atients ,ith Chronic -structi$e&ul"onary isease/!espiratory


133/142

'nsu7iciency

%reoperati(e intensi(e inspiratory muscle training is

reasona&le to reduce the incidence of pulmonary

complications in patients at high ris: for respiratory

complications after CA#".

After CA#", nonin(asi(e positi(e pressure (entilation may

&e reasona&le to impro(e pulmonary mechanics and to

reduce the need for reintu&ation.

I IIa IIb III

I IIa IIb III

&atients ,ith Chronic -structi$e&ul"onary isease/!espiratory


134/142

'nsu7iciency (cont)*

High thoracic epidural analgesia may &e

considered to impro(e lung function after

CA#".

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135/142

&atients ,ith %nd.Stage

!enal isease onialysis

&atients ,ith %nd.Stage!enal isease on ialysis


136/142

!enal isease on ialysis

CA#" to impro(e sur(i(al may &e reasona&le in patients

with endstage renal disease undergoing CA#" for left

main coronary artery stenosis of DJ0E.

CA#" to impro(e sur(i(al or to relie(e angina despite

"45T may &e reasona&le for patients with endstage

renal disease with significant stenoses 1D)0E diameter in

ma+or (essels or in the pro/imal 3A4 artery plus other

ma+or (essel, regardless of 37 systolic function.

I IIa IIb III

I IIa IIb III

&atients ,ith %nd.Stage!enal isease on ialysis


137/142

(cont)*

CA#" should not &e performed in patients

with endstage renal disease whose life

e/pectancy is limited &y noncardiac issues.

I IIa IIb III

Harm


138/142

&atients ,ith Conco"itantal$ular isease


139/142

al$ular isease

%atients undergoing CA#" who ha(e at least

moderate aortic stenosis should ha(e

concomitant aortic (al(e replacement.

%atients undergoing CA#" who ha(e se(ere

ischemic mitral regurgitation not li:ely to resol(e

with re(asculari>ation should ha(e concomitantmitral repair or replacement at the time of CA#".

I IIa IIb III

I IIa IIb III

&atients ,ith Conco"itantal$ular isease (cont *


140/142

al$ular isease (cont)*

In patients undergoing CA#" who ha(e moderate

ischemic mitral regurgitation not li:ely to resol(e with

re(asculari>ation, concomitant mitral repair or

replacement at the time of CA#" is reasona&le.

%atients undergoing CA#" who ha(e mild aortic

stenosis may &e considered for concomitant aortic

(al(e replacement when e(idence 1e.g., moderateR

se(ere leaflet calcification suggests that progression ofthe aortic stenosis may &e rapid and the ris: of the

com&ined procedure is accepta&le.

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141/142

&atients ,ith &re$ious

Cardiac Surgery

&atients ,ith &re$ious CardiacSurgery


142/142

Surgery

In patients with a patent 3I5A to the 3A4 artery and

ischemia in the distri&ution of the right or left circumfle/

coronary arteries, it is reasona&le to recommend

reoperati(e CA#" to treat angina if "45T has failedand the coronary stenoses are not amena&le to %CI.

I IIa IIb III

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2011 CABG Guidelines

Documents