Preprocedural Evaluation
Before performing coronary artery bypass grafting (CABG), clinicians should carefully examine the patient’s medical history for factors that might predispose to complications, such as the following:
-
Recent myocardial infarction (MI)
-
Previous cardiac surgery or chest radiation
-
Conditions predisposing to bleeding
-
Renal dysfunction
-
Cerebrovascular disease including carotid bruits and transient ischemic attack (TIA)
-
Electrolyte disturbances that might predispose the patient to dysrhythmias
-
Infection including urinary tract infection, skin infections, and dental abscesses
-
Respiratory function including the presence of chronic obstructive pulmonary disease or infection [4]
The Euroscore is one of several scoring systems used to predict CABG mortality. Results can be rendered logistically or as a simple score, which can be calculated by using the Euroscore interactive calculator. [5]
Routine preoperative investigations include the following [4] :
-
Full blood count (abnormalities corrected)
-
Clotting screen
-
Creatinine and electrolyte levels (abnormalities corrected and discussed with the anesthetist)
-
Liver function tests
-
Screening for methicillin-resistant Staphylococcus aureus
-
Chest radiography
-
Electrocardiography (ECG)
-
Echocardiography or ventriculography (to assess left ventricular [LV] function)
-
Coronary angiography (to define the extent and location of coronary artery disease [CAD])
A raised white blood cell (WBC) count should prompt a careful examination for any cause of infection. If possible, CABG should be postponed until infection has been excluded or treated. If the patient’s demographic characteristics (eg, age or smoking) indicate an increased risk of cancer, a gastrointestinal or urinary tract malignancy should be excluded.
The initial CABGs in the 1960s were performed “off pump” (OPCABG) because of the lack of cardiopulmonary bypass technology. [45] With the subsequent development of safe and effective cardiopulmonary bypass, most CABGs are now performed “on pump” (ONCABG). However, the off-pump approach has been reintroduced, with varying degrees of popularity, in an effort to reduce the complications associated with cardiopulmonary bypass. The surgical experience of the operating surgeons performing the OPCABG is critical to the outcome of the procedure. In a Cochrane review that analyzed 86 randomized trials involving 10,716 patients, Moller and colleagues reported that OPCABG resulted in increased all-cause mortality compared to ONCABG (3.7% vs 3.1%; P = 0.04), but there were no significant differences in MI, stroke, renal insufficiency, or coronary artery reintervention between the two techniques other than that OPCABG resulted in fever distal anastomoses. [46]
Elderly patients who have major comorbid conditions (eg, previous stroke or TIA; peripheral vascular disease [PVD]; bleeding disorders; or current respiratory, liver, or renal disease) may benefit from an off-pump approach. The off-pump approach may also be preferred in patients with a heavily calcified or atheromatous aorta, where cannulation is associated with a high risk of stroke. [47]
Assessment of Risk
Risk models to predict 30-day mortality following isolated CABG is an active area of research. Risk models such as the Euroscore system, [5] and the Society of Thoracic Surgeons (STS) Cardiac Surgery Risk Model, [6] are the most commonly used predictors in cardiac surgery. Shared variables in these two impressive models include age, previous MI, PVD, renal failure, hemodynamic state, and ejection fraction (EF). In the STS model, 78% of the variance is explained by eight of the most important variables, which include age, surgical acuity, reoperative status, creatinine level, dialysis, shock, chronic lung disease, and EF.
Patient Preparation
Premedication
The aims of premedication are to minimize myocardial oxygen demands by reducing heart rate and systemic arterial pressure and to improve myocardial blood flow with vasodilators.
Before the advent of coronary artery bypass grafting (CABG), the majority of patients with coronary artery disease (CAD) received beta-adrenoceptor blocking drugs and calcium channel antagonists or nitrates. These drugs were continued until the point of surgery because sudden withdrawal of the medications could cause tachycardia, rebound hypertension, and a loss of coronary vasodilatation.
Administration of temazepam immediately before CABG can decrease the risk of tachycardia and hypertension resulting from anxiety regarding the procedure. In the operating room, intravenous (IV) administration of a small dose of midazolam before arterial line insertion can also reduce anxiety, tachycardia, and hypertension.
In patients referred for CABG, aspirin should be continued up to the time of surgery, especially in those who present with an acute coronary syndrome (ACS). In patients receiving a thienopyridine (eg, clopidogrel or prasugrel) in whom elective CABG is planned, the drug should be withheld if possible for either 5 days (for clopidogrel) or 7 days (for prasugrel) before the procedure.
Each patient should be cross-matched with 2 units of blood (for simple cases) or 6 units of blood, fresh frozen plasma, and platelets (for complex cases). [4, 7, 8] Tranexamic acid (1-g bolus before surgical incision followed by an infusion of 400 mg/hr during surgery) may be considered to reduce the amount of postoperative mediastinal bleeding and the quantity of blood products used (ie, red blood cell and fresh frozen plasma) [9]
Antidepressant treatment for 2-3 weeks before undergoing CABG and continued for 6 months afterward may foster a faster postoperative mental health recovery and have a beneficial effect on postoperative pain. [48, 49]
Anesthesia
After standard monitoring equipment is attached and peripheral venous access is achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, ensure that a radial artery graft will not be used for CABG.
During induction and tracheal intubation, it is important to maintain a steady heart rate and blood pressure. Thus, patients should be preoxygenated. Induction of anesthesia is accomplished with high doses of an opioid (usually fentanyl or remifentanil) to minimize the dose of propofol, etomidate, or thiopental, and thereby maximize cardiovascular stability. Although etomidate usually does not cause changes in blood pressure, it may induce hypotension in cardiac patients.
A number of agents may be used for muscle relaxation. However, they each have their own associated complications, as follows:
-
Pancuronium increases myocardial oxygen demand
-
Vecuronium may cause bradycardia in association with opioids
-
Rocuronium can cause tachycardia
-
Atracurium (which is not considered suitable for operations of long duration) can cause hypotension secondary to histamine release
The trachea should be intubated orally because nasal intubation may cause significant bleeding once heparin is administered. A double-lumen endotracheal tube is required if CABG is being performed via a left thoracotomy.
Central venous access should be obtained, as it is not uncommon for the patient to become hypotensive. To ensure that there is sufficient diastolic pressure to maintain coronary perfusion, hypotension should be treated with IV fluids or with an alpha agonist if left ventricular function is depressed.
Typically, maintenance of anesthesia is accomplished with an opioid infusion (fentanyl, alfentanil, sufentanil, or remifentanil) combined with either a propofol infusion (total IV anesthesia) or a volatile agent. Volatile agents are generally carried in an air-oxygen mixture because the use of nitrous oxide as a carrier is controversial. Isoflurane may have a myocardial protective effect and is therefore especially useful in off-pump surgery.
Positioning
For a standard sternotomy, the anterior thorax is exposed with the patient in a supine position. A roll is placed in the interscapular region to improve access to the sternum by extending the neck and elevating the sternal notch. Usually the sterile field extends from the chin to the toes to include the sternotomy incision as well as access to the saphenous veins for harvesting as a conduit. If the radial artery is being used as a conduit, the appropriate arm is also prepped into the sterile field.
Monitoring and Follow-up
In addition to the standard anesthetic monitoring (electrocardiography [ECG], pulse oximetry, nasopharyngeal temperature, urine output, and gas analysis), there are a number of specific monitoring requirements for cardiac surgery, including the following:
-
Invasive blood pressure
-
Central venous access
-
Transesophageal echocardiography (TEE)
-
Neurologic monitoring
-
Pulmonary artery pressure monitoring with a Swan-Ganz catheter
-
Cerebral oxygen saturation monitors bilaterally
Accurate and rapidly updated blood pressure measurements are required during cardiac anesthesia. Generally, the radial artery of the nondominant hand is cannulated, although the right radial artery should be used if the patient requires additional aortic surgery or insertion of an intra-aortic balloon pump (IABP). Care should be taken to ensure that radial grafts will not be used for bypass conduits in the procedure.
Central venous access is required for administering vasoactive drugs, inserting a transverse pacing wire (if indicated), monitoring central venous pressure, and passing a pulmonary artery catheter.
TEE is often useful during coronary artery bypass grafting (CABG) to assess left ventricular (LV) function, determine the presence of mitral valve insufficiency, and evaluate the patient who is difficult to wean from cardiopulmonary bypass. TEE is now almost universally accepted as a standard of care for major intraoperative monitoring.
Neurologic monitoring is regularly used in CABG, but no monitoring device enables accurate and easy identification of potential neurologic damage (a complication in 1-3% of patients). Available monitors include electroencephalography (EEG), transcranial Doppler ultrasonography, jugular venous bulb oxygen saturation, and near-infrared spectroscopy for monitoring cerebral oxygen saturation.
After CABG, transport the patient to a dedicated cardiac surgery intensive care unit (SICU). If the patient’s condition is uncomplicated, basic management and progress assessment include the following:
-
During the first 6-12 hours after CABG, there is usually a decline in myocardial function secondary to a number of factors, including myocardial edema and ischemia-reperfusion injury. If this occurs, the patient may require increased inotropic support or pacing. However, most patients can be weaned from inotropic support within 24 hours after the operation, and the temporary epicardial pacing wires can be removed at around 3 days.
-
In the early postoperative period, a continuous infusion of nitroglycerin should be administered if a radial graft has been used, because such grafts are prone to spasm in the period immediately following the operation, resulting in myocardial ischemia.
-
Although many patients can be extubated in the first 6 hours following CABG, the majority are not extubated until postoperative day 1.
-
The patient’s temperature should be carefully regulated. Some patients may have peripheral vasodilation and hypotension secondary to an elevated body temperature arising from difficulties in central thermoregulation. This hypotension is associated with a worse neurologic outcome.
-
There is usually a 1 mL/kg/h diuresis immediately after CABG as a consequence of the amount of fluid administered intraoperatively. The urinary catheter can be removed once the patient is mobile. Oral furosemide can be used postoperatively, if needed. If LV function is preserved and the patient’s weight has returned to baseline, diuretic therapy can usually be discontinued late in the first postoperative week.
-
Drainage from the mediastinum should gradually decrease over the first 6 hours after CABG. The mediastinal drains often can be removed on postoperative day 1 when there has been no drainage for 3 consecutive hours. After their removal, a chest radiograph should be taken.
-
Ideally, patients should be sitting in a chair on postoperative day 1 and should be mobilized as soon as possible.
Also note the following:
-
In the first 6 hours after CABG, many patients require increased insulin. Lactulose and senna can be used as a laxative from day 1. Patients are encouraged to drink fluids and ingest an advancing diet after extubation and confirmation of normal mental status. Shortly thereafter, insulin sliding scales can be stopped and normal antihyperglycemic drugs started.
-
A prophylactic dose of 75 mg of aspirin once daily by mouth should be commenced in the first 6 hours after the procedure. Statins should be started on postoperative day 1. Low-molecular-weight heparin and antiembolism stockings should be used for prophylaxis of deep vein thrombosis; the stockings have the added benefit of reducing edema in the saphenous donor leg. [50]
-
In the absence of epidural analgesia, patient-controlled analgesia should be used for pain relief once the patient has been extubated. It is usually required for only 2-3 days postoperatively, by which time orally administered analgesia typically provides sufficient pain relief.
-
Coronary Artery Bypass Grafting. Illustration of a median sternotomy.
-
Coronary Artery Bypass Grafting. Illustration of an internal thoracic (mammary) artery (IMA) harvest as a pedicle.
-
Coronary Artery Bypass Grafting. Illustration of the open saphenous vein harvest technique.
-
Coronary Artery Bypass Grafting. Cannulation, illustrated.
-
Coronary Artery Bypass Grafting. Illustration of the distal anastomotic technique.
-
Coronary Artery Bypass Grafting. Illustration of the proximal anastomotic technique.
-
Coronary Artery Bypass Grafting. This video demonstrates coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest. Video courtesy of Dale K Mueller, MD.
Tables
- Table 1. ACC/AHA Indications for Coronary Artery Bypass Grafting [2, 3]
- Table 2. Treatment Recommendations for Patients with Acute Heart Failure in Setting of Acute Myocardial Infarction
- Table 3. Specific Treatment Recommendations for Coronary Artery Disease in Patients with Mild to Moderate Chronic Kidney Disease
- Table 4. Specific Treatment Recommendations for Coronary Artery Disease in Diabetic Patients
- Table 5. Recommendations for Combining Valve Surgery and Coronary Artery Bypass Grafting
- Table 6. Carotid Revascularization in Patients Scheduled for Coronary Artery Bypass Grafting
- Table 7. Management of Patients with Associated Coronary and Peripheral Arterial Disease
- Table 8. Management of Patients with Renal Artery Stenosis
- Table 9. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Angina Symptoms
- Table 10. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Heart Failure Symptoms (No or Mild Angina: Canadian Cardiovascular Society 1-2)
- Table 11. Technical Recommendations for Coronary Artery Bypass Grafting
- Table 12. Multidisciplinary Decision Pathways, Patient Informed Consent, and Timing of Intervention [28]
- Table 13. Indications for Coronary Artery Bypass Grafting
- Table 14. Updated ACC/AHA/SCAI Recommendations for Revascularization for Survival Improvement in Stable Ischemic Heart Disease Versus Medical Therapy [1]
- Table 15. Preoperative management of antiplatelet therapy in patients undergoing CABG
- Table 16. Postoperative management of antiplatelet therapy in patients undergoing CABG
Indication |
Asymptomatic or Mild Angina |
Stable Angina |
Unstable Angina/ NSTEMI |
Poor Left Ventricular Function |
Left main stenosis >50% |
Class I |
Class I |
Class I |
Class I |
Stenosis of proximal LAD and proximal circumflex artery >70% |
Class I |
Class I |
Class I |
Class I |
3-Vessel disease |
Class I |
Class I |
|
Class I, with proximal LAD stenosis |
2-Vessel disease |
|
Class I if there is a large area of viable myocardium in a high-risk area; Class IIa if there is a moderate viable area and ischemia |
Class IIb |
|
With >70% proximal LAD stenosis |
Class IIa |
Class I with either an ejection fraction < 50% or demonstrable ischemia on noninvasive testing |
Class IIa |
Class I |
Involving proximal LAD |
Class IIb |
|
|
|
1-Vessel disease |
|
Class I if there is a large area of viable myocardium in a high-risk area; Class IIa, if there is a viable moderate area and ischemia |
Class IIb |
|
With >70% proximal LAD stenosis |
Class IIa |
Class IIa |
Class IIa |
|
Involving proximal LAD |
Class IIb |
|
|
|
ACC = American College of Cardiology; AHA = American Heart Association; LAD = left anterior descending (artery); NSTEMI = non–ST-segment elevation myocardial infarction. |
||||
|
Class of Recommendation |
Level of Evidence |
Patients with NSTE-ACS or STEMI and unstable hemodynamics should immediately be transferred for invasive evaluation and target vessel revascularization |
Class I |
A |
Immediate reperfusion is indicated in acute heart failure with ongoing ischemia |
Class I |
B |
Echocardiography should be performed to assess LV function and to exclude mechanical complications |
Class I |
C |
Emergency angiography and revascularization of all critically narrowed arteries by PCI/CABG as appropriate is indicated in patients in cardiogenic shock |
Class I |
B |
IABP insertion is recommended in patients with hemodynamic instability (particularly those in cardiogenic shock and with mechanical complications) |
Class I |
C |
Surgery for mechanical complications of AMI should be performed as soon as possible with persistent hemodynamic deterioration despite IABP |
Class I |
B |
Emergency surgery after failure of PCI or fibrinolysis is indicated only in patients with persistent hemodynamic instability or life-threatening ventricular arrhythmia due to extensive ischemia (left main or severe 3-vessel disease) |
Class I |
C |
If the patient continues to deteriorate without adequate cardiac output to prevent end-organ failure, temporary mechanical assistance (surgical implantation of LVAD/BiVAD) should be considered |
Class IIa |
C |
Routine use of percutaneous centrifugal pumps is not recommended |
Class III |
B |
AMI = acute myocardial infarction; BiVAD = biventricular assist device; CABG = coronary artery bypass grafting; IABP = intra-aortic balloon pump; LV = left ventricle; LVAD = left ventricular assist device; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
||
|
Recommendation |
Level of Evidence |
CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach, the patient’s risk profile is acceptable, and the life expectancy is reasonable |
Class IIa |
B |
Off-pump CABG may be considered rather than on-pump CABG |
Class IIb |
B |
For PCI, drug-eluting stents may be considered, rather than bare metal stents |
Class IIb |
C |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; PCI = percutaneous coronary intervention. |
||
|
Recommendation |
Level of Evidence |
In patients presenting with STEMI, primary PCI is preferred over fibrinolysis if it can be performed within recommended time limits |
Class I |
A |
In stable patients with extensive CAD, revascularization is indicated to improve MACCE-free survival |
Class I |
A |
Use of drug-eluting stents is recommended to reduce restenosis and repeat target vessel revascularization |
Class I |
A |
In patients on metformin, renal function should be carefully monitored after coronary angiography/PCI |
Class I |
C |
CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach (especially multivessel disease) and the patient’s risk profile is acceptable |
Class IIa |
B |
In patients with known renal failure undergoing PCI, metformin may be stopped 48 hours before the procedure |
Class IIb |
C |
Systematic use of glucose insulin potassium in diabetic patients undergoing revascularization is not indicated |
Class III |
B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; MACCE = major adverse cardiac and cerebral event; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
||
|
Recommendation |
Level of Evidence |
In combination with valve surgery: |
||
CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis = 70% |
Class I |
C |
CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis of 50-70% |
Class IIa |
C |
In combination with CABG: |
||
Mitral valve surgery is indicated in patients with a primary indication for CABG and severe ischemic mitral regurgitation and an EF >30%* |
Class I |
C |
Mitral valve surgery should be considered in patients with a primary indication for CABG and moderate ischemic mitral regurgitation, provided that valve repair is feasible and performed by experienced operators |
Class IIa |
C |
Aortic valve surgery should be considered in patients with a primary indication for CABG and moderate aortic stenosis (mean gradient 30-50 mm Hg, Doppler velocity of 3-4 m/sec, or heavily calcified aortic valve even with Doppler velocity of 2.5-3 m/sec) |
Class IIa |
C |
* Definition of severe mitral regurgitation is at http://www.escardio.org/guidelines. CABG = coronary artery bypass grafting; EF = ejection fraction. |
||
|
Recommendation |
Level of Evidence |
CEA or CAS should be performed only by teams with demonstrated 30-day combined death-stroke rates of < 3% in patients without previous neurologic symptoms and < 6% in patients with previous neurologic symptoms |
Class I |
A |
Indication for carotid revascularization should be individualized after discussion by a multidisciplinary team, including a neurologist |
Class I |
C |
Timing of procedures (synchronous or staged) should be dictated by local expertise and clinical presentation, with the most symptomatic territory targeted first |
Class I |
C |
In patients with previous TIA/nondisabling stroke: |
||
Carotid revascularization is recommended for 70-99% carotid stenosis |
Class I |
C |
Carotid revascularization may be considered for 50-69% carotid stenosis in men with symptoms of < 6 months |
Class IIb |
C |
Carotid revascularization is not recommended if carotid stenosis is < 50% in men and < 70% in women |
Class III |
C |
In patients with no previous TIA/stroke: |
||
Carotid revascularization may be considered in men with bilateral 70-99% carotid stenosis or 70-99% carotid stenosis and contralateral occlusion |
Class IIb |
C |
Carotid revascularization is not recommended in women or patients with a life expectancy < 5 years |
Class III |
C |
CAS = carotid artery stenting; CEA = carotid endarterectomy; TIA = transient ischemic attack. |
||
|
Recommendation |
Level of Evidence |
In patients with unstable CAD, vascular surgery is postponed and CAD treated first, except when vascular surgery cannot be delayed because of a life-threatening condition |
Class I |
B |
Beta-blockers and statins are indicated preoperatively and should be continued postoperatively in patients with known CAD who are scheduled for high-risk vascular surgery |
Class I |
B |
The choice between CABG and PCI should be individualized and assessed by the heart team taking into account the patterns of CAD, PAD, comorbidity, and clinical presentation |
Class I |
C |
Prophylactic myocardial revascularization before high-risk vascular surgery may be considered in stable patients if they have persistent signs of extensive ischemic or high cardiac risk |
Class IIb |
B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; PAD = peripheral arterial disease; PCI = percutaneous coronary intervention. |
||
|
Recommendation |
Level of Evidence |
Functional assessment of renal artery stenosis severity using pressure gradient measurements may be useful in selecting hypertensive patients who may benefit from renal artery stenting |
Class IIb |
B |
Routine renal artery stenting to prevent deterioration of renal function is not recommended |
Class III |
B |
|
Recommendation |
Level of Evidence |
CABG is recommended for the following:
|
Class I |
B |
CABG with surgical ventricular reconstruction may be considered in patients with LVESV index = 60 mL/m2 and scarred left anterior descending territory |
Class IIb |
B |
PCI may be considered in the presence of viable myocardium if the anatomy is suitable |
Class IIb |
C |
CABG = coronary artery bypass grafting; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention. |
||
|
Recommendation |
Level of Evidence |
LV aneurysmectomy during CABG is indicated in patients with a large LV aneurysm |
Class I |
C |
CABG should be considered in the presence of viable myocardium, irrespective of the LVESV |
Class IIa |
B |
CABG with SVR may be considered in patients with scarred LAD territory |
Class IIb |
B |
PCI may be considered in the presence of viable myocardium if the anatomy is suitable |
Class IIb |
C |
Revascularization in the absence of evidence of myocardial viability is not recommended |
Class III |
B |
CABG = coronary artery bypass grafting; LAD = left anterior descending (artery); LV = left ventricle; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention; SVR = surgical ventricular reconstruction. |
||
|
Recommendation |
Level of Evidence |
Procedures should be performed in a hospital structure and by a team specialized in cardiac surgery, using written protocols |
Class I |
B |
Arterial grafting to the LAD system is indicated |
Class I |
A |
Complete revascularization with arterial grafting to a non-LAD coronary system is indicated in patients with a reasonable life expectancy |
Class I |
A |
Minimization of aortic manipulation is recommended |
Class I |
C |
Graft evaluation is recommended before departure from the operating theater |
Class I |
C |
LAD = left anterior descending (artery). |
||
|
Acute Coronary Syndrome
|
Stable Multivessel Disease |
Stable with Indication for Ad Hoc PCI |
|||
|
Shock |
STEMI |
NSTE-ACS |
Other ACS |
||
Multidisciplinary decision making |
Not mandatory |
Not mandatory |
Not required for culprit lesion but required for nonculprit vessel(s) |
Required |
Required |
According to predefined protocols |
Informed consent |
Oral witnessed informed consent or family consent if possible without delay |
Oral witnessed informed consent may be sufficient unless written consent is legally required |
Written informed consent* (if time permits) |
Written informed consent* |
Written informed consent* |
Written informed consent* |
Time to revascularization |
Emergency: No delay |
Emergency: No delay |
Urgency: Within 24 h if possible and no later than 72 h |
Urgency: Time constraints apply |
Elective: No time constraints |
Elective: No time constraints |
Procedure |
Proceed with intervention on basis of best evidence/ availability |
Proceed with intervention on basis of best evidence/availability |
Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol |
Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol |
Plan most appropriate intervention, allowing enough time from diagnostic catheterization to intervention |
Proceed with intervention according to institutional protocol defined by local heart team |
* May not apply to countries that legally do not ask for written informed consent, although European Society of Cardiology and European Association for Cardiothoracic Surgery strongly advocate documentation of patient consent for all revascularization procedures. ACS = acute coronary syndrome; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
||||||
Indication |
ACC/AHA |
ESC/EACT |
Left main disease |
Class I |
Class I |
Three-vessel disease with or without proximal LAD artery disease |
Class I |
Class I |
Two-vessel disease with proximal LAD artery disease |
Class I |
Class I |
Two-vessel disease without proximal LAD artery disease |
Class IIa (with extensive ischemia) |
Class IIb |
Single-vessel disease with proximal LAD artery disease |
Class IIa (with LIMA for long-term benefit) |
Class I |
Single-vessel disease without proximal LAD artery disease |
Class III—Harmful |
Class IIb |
LV Dysfunction |
Class IIa (EF 35% to 50%) Class IIb (EF< 35%) |
Class I (EF< 40%) |
Survivors of sudden cardiac death with presumed ischemia-mediated VT |
Class I |
Class I |
LAD = left anterior descending (artery); LV = left ventricle; LIMA= left internal mammary artery EF = ejection fraction; VT = ventricular tachycardia |
||
| Recommendation | Level of Evidence | |
|---|---|---|
LV dysfunction and multivessel CAD |
||
| Patients with SIHD and multivessel CAD appropriate for CABG with severe LV systolic dysfunction (LVEF < 35%) | Class I | B |
| Selected patients with SIHD and multivessel CAD appropriate for CABG and mild-to-moderate LV systolic dysfunction (LVEF of 35-50%): CABG (to include a LIMA graft to the LAD) is reasonable | Class IIa | B |
Left main CAD |
||
| Patients with SIHD and significant left main stenosis | Class I | B |
| Patients with SIHD and significant left main stenosis for whom revascularization with PCI can provide equivalent to that possible with CABG: PCI is reasonable | Class IIa | B |
Multivessel CAD |
||
| Patients with SIHD, normal EF, significant stenosis of 3 major coronary arteries (± proximal LAD), and suitable anatomy for CABG: CABG may be reasonable | Class IIb | B |
| Patients with SIHD, normal EF, significant stenosis of 3 major coronary arteries (± proximal LAD), and suitable anatomy for PCI: PCI utility is uncertain | Class IIb | B |
Stenosis in the proximal LAD artery |
||
| Patients with SIHD, normal LVEF, and significant stenosis in the proximal LAD: coronary revascularization utility is uncertain | Class IIb | B |
Single- or double-vessel disease not involving the proimal LAD |
||
| Patients with SIHD, normal LVEF, and 1- or 2-vessel CAD not involving the proximal LAD: coronary revascularization not recommended | Class III | B |
| Patients with SIHD with ≥1 coronary arteries that are not anatomically or functionally significant (< 70% diameter of non–left main coronary artery stenosis, FFR >0.80): Do not perform coronary revascularization with the primary or sole intent to improve survival | Class III | B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; EF = ejection fraction; FFR = fractional flow reserve; LAD = left anterior descending (artery); LIMA = Left internal mammary artery; LV = left ventricle; PCI = percutaneous coronary intervention; SIHD = stable ischemic heart disease. |
||
Recommendation |
2011 ACC/AHA |
2012 ACC/AHA |
2014 ACC/AHA |
2014 ESC/EACT |
2012 STS |
Administer aspirin to CABG patients preoperatively |
(100 mg to 325 mg daily) Class I |
Class I |
(81–325 mg daily) Class I |
(75–160 mg daily) Class I |
|
In patients at increased risk for bleeding and those who refuse blood transfusion, discontinue aspirin 3-5 days prior to surgery |
Class I |
Class IIa |
|||
For non-urgent CABG, discontinue clopidogrel and ticagrelor for at least 5 days before surgery and prasugrel for at least 7 days to limit blood transfusions |
Class I |
Class I |
Class I |
Class I |
|
In patients referred for urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours to reduce major bleeding complications |
Class I |
Class I |
|||
In patients referred for urgent CABG, discontinue eptifibatide and tirofiban for at least 2-4 hours and abciximab for at 12 hours |
Class I |
(Discontinue eptifibatide and tirofiban 4 hours) Class I |
Class I |
||
Anticoagulant therapy: unfractionated heparin; discontinue enozaparin 12-24 hours; discontinue fondaparinux for 24 hours; discontinue bivalirudin for 3 hours |
Class I |
Recommendation |
2011 ACC/AHA |
2014 ACC/AHA |
2014 ESC/EACT |
2012 STS |
Administer aspirin to CABG patients indefinitely |
100 mg to 325 mg daily - Class I |
81–325 mg daily (Only 81 mg with ticagrelor) Class I |
75–160 mg daily Class I |
Class I |
Administer clopidogrel or ticagrelor, in addition to aspirin, for 12 months |
Class I |
Class IIb |
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Clopidogrel (75 mg daily) is a reasonable alternative in patients intolerant or allergic to aspirin |
Class IIa |
Class I |
||
In CABG after acute coronary syndromes, restart dual antiplatelet therapy when bleeding risk is diminished. |
Class I |
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Once postoperative bleeding risk is decreased, consider testing of response to antiplatelet drugs, either with genetic testing or with point-of-care platelet function testing, to optimize antiplatelet drug effect and minimize thrombotic risk to vein grafts |
Class IIb |
