2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft ......guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American

Journal of the American College of Cardiology Vol. 58, No. 24, 2011© 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00

PRACTICE GUIDELINE

2011 ACCF/AHA Guideline forCoronary Artery Bypass Graft SurgeryA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Developed in Collaboration With the American Association for Thoracic Surgery,Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons

Published by Elsevier Inc. doi:10.1016/j.jacc.2011.08.009

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WritingCommitteeMembers*

ovedthein J

f ThSurge ofis LDiS

angeSabik JF, Selnes O, Shahianguideline for coronary arter

L. David Hillis, MD, FACC, Chair†eter K. Smith, MD, FACC, Vice Chair*†

Jeffrey L. Anderson, MD, FACC, FAHA*‡John A. Bittl, MD, FACC§Charles R. Bridges, MD, SCD, FACC, FAHA*†ohn G. Byrne, MD, FACC†oaquin E. Cigarroa, MD, FACC†erdi J. DiSesa, MD, FACC†oren F. Hiratzka, MD, FACC, FAHA†dolph M. Hutter, JR, MD, MACC, FAHA†

Michael E. Jessen, MD, FACC*†Ellen C. Keeley, MD, MS†Stephen J. Lahey, MD†Richard A. Lange, MD, FACC, FAHA†§

Steven M. Ettinger, MD, FACC

by the American College of Cardiology FoundationAmerican Heart Association Science Advisory anduly 2011, by the Society of Cardiovascular Anesthesi-oracic Surgeons in August 2011, and by the Americanery in September 2011.Cardiology Foundation requests that this documentD, Smith PK, Anderson JL, Bittl JA, Bridges CR,esa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME,RA, London MJ, Mack MJ, Patel MR, Puskas JD,DM, Trost JC, Winniford MD. 2011 ACCF/AHAy bypass graft surgery: a report of the American

College of CPractice Guid

This articleCopies: Thi

College of Ca(my.americanhReprint Depa

Permissionstribution of thAmerican Coelsevier.com.

Michael J. Mack, MD, FACC*¶Manesh R. Patel, MD, FACC†John D. Puskas, MD, FACC*†Joseph F. Sabik, MD, FACC*#Ola Selnes, PHD†David M. Shahian, MD, FACC, FAHA**Jeffrey C. Trost, MD, FACC*†Michael D. Winniford, MD, FACC†

*Writing committee members are required to recuse themselves fromvoting on sections to which their specific relationships with industry andother entities may apply; see Appendix 1 for recusal information.†ACCF/AHA Representative. ‡ACCF/AHA Task Force on PracticeGuidelines Liaison. §Joint Revascularization Section Author. �Societyof Cardiovascular Anesthesiologists Representative. ¶American Asso-ciation for Thoracic Surgery Representative. #Society of ThoracicSurgeons Representative. **ACCF/AHA Task Force on Performance

Martin J. London, MD� Measures Liaison.

ACCF/AHATask ForceMembers

Alice K. Jacobs, MD, FACC, FAHA, ChairJeffrey L. Anderson, MD, FACC, FAHA,

Chair-Elect

Nancy Albert, PHD, CCNS, CCRN, FAHAMark A. Creager, MD, FACC, FAHA

Robert A. Guyton, MD, FACCJonathan L. Halperin, MD, FACC, FAHAJudith S. Hochman, MD, FACC, FAHAFrederick G. Kushner, MD, FACC, FAHAE. Magnus Ohman, MD, FACCWilliam Stevenson, MD, FACC, FAHA

Clyde W. Yancy, MD, FACC, FAHA

ardiology Foundation/American Heart Association Task Force onelines. J Am Coll Cardiol 2011;58:e123–210.is copublished in Circulation.s document is available on the World Wide Web sites of the Americanrdiology (www.cardiosource.org) and the American Heart Associationeart.org). For copies of this document, please contact the Elsevier Inc.

rtment, fax (212) 633-3820, e-mail [email protected].: Multiple copies, modification, alteration, enhancement, and/or dis-is document are not permitted without the express permission of the

This document was apprBoard of Trustees andCoordinating Committeeologists and the Society oAssociation for Thoracic

The American Collegbe cited as follows: HillByrne JG, Cigarroa JE,Keeley EC, Lahey SJ, L

llege of Cardiology Foundation. Please contact healthpermissions@

http://www.cardiosource.orghttp://my.americanheart.orgmailto:[email protected]:[email protected]:[email protected]

e124 Hillis et al. JACC Vol. 58, No. 24, 20112011 ACCF/AHA CABG Guideline December 6, 2011:e123–210

TABLE OF CONTENTS

Preamble. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e125

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e127

1.1. Methodology and Evidence Review . . . . . . . . . . . .e127

1.2. Organization of the Writing Committee . . . . . . . .e128

1.3. Document Review and Approval . . . . . . . . . . . . . . . .e128

2. Procedural Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . .e128

2.1. Intraoperative Considerations . . . . . . . . . . . . . . . . . .e1282.1.1. Anesthetic Considerations:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e1282.1.2. Use of CPB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1302.1.3. Off-Pump CABG Versus

Traditional On-Pump CABG. . . . . . . . . . . . . . .e1312.1.4. Bypass Graft Conduit: Recommendations. . . . . . .e132

2.1.4.1. SAPHENOUS VEIN GRAFTS . . . . . . . . . . . . . . . . . .e1322.1.4.2. INTERNAL MAMMARY ARTERIES . . . . . . . . . . . . .e1322.1.4.3. RADIAL, GASTROEPIPLOIC, AND

INFERIOR EPIGASTRIC ARTERIES . . . . . . . . . . . . .e1322.1.5. Incisions for Cardiac Access. . . . . . . . . . . . . . . . .e1332.1.6. Anastomotic Techniques . . . . . . . . . . . . . . . . . . . .e1332.1.7. Intraoperative TEE: Recommendations . . . . .e1332.1.8. Preconditioning/Management of

Myocardial Ischemia: Recommendations . . . . . .e1352.2. Clinical Subsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e136

2.2.1. CABG in Patients With Acute MI:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e136

2.2.2. Life-Threatening Ventricular Arrhythmias:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e137

2.2.3. Emergency CABG After Failed PCI:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e138

2.2.4. CABG in Association With OtherCardiac Procedures: Recommendations. . . . . .e138

3. CAD Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e139

3.1. Heart Team Approach to RevascularizationDecisions: Recommendations . . . . . . . . . . . . . . . . . . .e139

3.2. Revascularization to Improve Survival:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e141

3.3. Revascularization to Improve Symptoms:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e142

3.4. CABG Versus Contemporaneous MedicalTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e142

3.5. PCI Versus Medical Therapy. . . . . . . . . . . . . . . . . . . . .e143

3.6. CABG Versus PCI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1433.6.1. CABG Versus Balloon Angioplasty or BMS . . . .e1433.6.2. CABG Versus DES. . . . . . . . . . . . . . . . . . . . . . . . .e144

3.7. Left Main CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1443.7.1. CABG or PCI Versus Medical Therapy for

Left Main CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1443.7.2. Studies Comparing PCI Versus CABG for

Left Main CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1453.7.3. Revascularization Considerations for

Left Main CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1453.8. Proximal LAD Artery Disease . . . . . . . . . . . . . . . . . . .e146

3.9. Clinical Factors That May Influence the Choiceof Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e146

3.9.1. Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . .e146

3.9.2. Chronic Kidney Disease. . . . . . . . . . . . . . . . . . . . .e1463.9.3. Completeness of Revascularization . . . . . . . . . .e1473.9.4. LV Systolic Dysfunction . . . . . . . . . . . . . . . . . . . .e1473.9.5. Previous CABG. . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1473.9.6. Unstable Angina/Non�ST-Elevation

Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . .e1473.9.7. DAPT Compliance and Stent Thrombosis:

Recommendation. . . . . . . . . . . . . . . . . . . . . . . . . . . .e1473.10. TMR as an Adjunct to CABG . . . . . . . . . . . . . . . . . . . . .e148

3.11. Hybrid Coronary Revascularization:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e148

4. Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . .e148

4.1. Preoperative Antiplatelet Therapy:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e148

4.2. Postoperative Antiplatelet Therapy:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e149

4.3. Management of Hyperlipidemia:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1504.3.1. Timing of Statin Use and CABG Outcomes. . . .e150

4.3.1.1. POTENTIAL ADVERSE EFFECTS OF

PERIOPERATIVE STATIN THERAPY . . . . . . . . . . . .e150

4.4. Hormonal Manipulation: Recommendations . . .e1514.4.1. Glucose Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1514.4.2. Postmenopausal Hormone Therapy . . . . . . . . .e1524.4.3. CABG in Patients With Hypothyroidism. . . . .e152

4.5. Perioperative Beta Blockers:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e152

4.6. ACE Inhibitors/ARBs: Recommendations . . . . . .e153

4.7. Smoking Cessation: Recommendations. . . . . . . .e154

4.8. Emotional Dysfunction andPsychosocial Considerations: Recommendation . .e1554.8.1. Effects of Mood Disturbance and Anxiety on

CABG Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . .e1554.8.2. Interventions to Treat Depression in

CABG Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1554.9. Cardiac Rehabilitation: Recommendation . . . . . . .e155

4.10. Perioperative Monitoring . . . . . . . . . . . . . . . . . . . . . . . .e1564.10.1. Electrocardiographic Monitoring:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e1564.10.2. Pulmonary Artery Catheterization:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e1564.10.3. Central Nervous System Monitoring:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e156

5. CABG-Associated Morbidity and Mortality:Occurrence and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . .e157

5.1. Public Reporting of Cardiac Surgery Outcomes:Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1575.1.1. Use of Outcomes or Volume as CABG

Quality Measures: Recommendations . . . . . . .e1585.2. Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e159

5.2.1. Adverse Cerebral Outcomes . . . . . . . . . . . . . . . . .e1595.2.1.1. STROKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e159

5.2.1.1.1. USE OF EPIAORTIC ULTRASOUND

IMAGING TO REDUCE STROKE RATES:

RECOMMENDATION . . . . . . . . . . . . . .e1595.2.1.1.2. THE ROLE OF PREOPERATIVE CAROTID

ARTERY NONINVASIVE SCREENING IN

CABG PATIENTS: RECOMMENDATIONS . .e1605.2.1.2. DELIRIUM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e161

5.2.1.3. POSTOPERATIVE COGNITIVE IMPAIRMENT . . . . . .e161

e125JACC Vol. 58, No. 24, 2011 Hillis et al.December 6, 2011:e123–210 2011 ACCF/AHA CABG Guideline

5.2.2. Mediastinitis/Perioperative Infection:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e161

5.2.3. Renal Dysfunction: Recommendations . . . . . . . .e1635.2.4. Perioperative Myocardial Dysfunction:

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e1645.2.4.1. TRANSFUSION: RECOMMENDATION . . . . . . . . . . .e165

5.2.5. Perioperative Dysrhythmias:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e165

5.2.6. Perioperative Bleeding/Transfusion:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .e165

6. Specific Patient Subsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e166

6.1. Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e166

6.2. Women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e167

6.3. Patients With Diabetes Mellitus . . . . . . . . . . . . . . . .e167

6.4. Anomalous Coronary Arteries:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e168

6.5. Patients With Chronic Obstructive PulmonaryDisease/Respiratory Insufficiency:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e169

6.6. Patients With End-Stage Renal Disease onDialysis: Recommendations . . . . . . . . . . . . . . . . . . . . .e169

6.7. Patients With Concomitant Valvular Disease:Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e170

6.8. Patients With Previous Cardiac Surgery:Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1706.8.1. Indications for Repeat CABG . . . . . . . . . . . . . .e1706.8.2. Operative Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e1706.8.3. Long-Term Outcomes . . . . . . . . . . . . . . . . . . . . . .e170

6.9. Patients With Previous Stroke. . . . . . . . . . . . . . . . . .e171

6.10. Patients With PAD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e171

7. Economic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e171

7.1. Cost-Effectiveness of CABG and PCI . . . . . . . . . . .e1727.1.1. Cost-Effectiveness of CABG Versus PCI . . . . . . .e1727.1.2. CABG Versus PCI With DES . . . . . . . . . . . . .e172

8. Future Research Directions. . . . . . . . . . . . . . . . . . . . . . . . . . .e172

8.1. Hybrid CABG/PCI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e173

8.2. Protein and Gene Therapy . . . . . . . . . . . . . . . . . . . . . . .e173

8.3. Teaching CABG to the Next Generation:Use of Surgical Simulators . . . . . . . . . . . . . . . . . . . . . .e173

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e174

Appendix 1. Author Relationships With Industryand Other Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . . . .e204

Appendix 2. Reviewer Relationships With Industryand Other Entitites (Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . . .e207

Appendix 3. Abbreviation List. . . . . . . . . . . . . . . . . . . . . . . . . . . .e210

Preamble

The medical profession should play a central role in evalu-ating the evidence related to drugs, devices, and procedures

for the detection, management, and prevention of disease.

When properly applied, expert analysis of available data onthe benefits and risks of these therapies and procedures canimprove the quality of care, optimize patient outcomes, andfavorably affect costs by focusing resources on the mosteffective strategies. An organized and directed approach to athorough review of evidence has resulted in the productionof clinical practice guidelines that assist physicians in select-ing the best management strategy for an individual patient.Moreover, clinical practice guidelines can provide a foun-dation for other applications, such as performance measures,appropriate use criteria, and both quality improvement andclinical decision support tools.

The American College of Cardiology Foundation(ACCF) and the American Heart Association (AHA) havejointly produced guidelines in the area of cardiovasculardisease since 1980. The ACCF/AHA Task Force onPractice Guidelines (Task Force), charged with developing,updating, and revising practice guidelines for cardiovasculardiseases and procedures, directs and oversees this effort.Writing committees are charged with regularly reviewingand evaluating all available evidence to develop balanced,patient-centric recommendations for clinical practice.

Experts in the subject under consideration are selected bythe ACCF and AHA to examine subject-specific data andwrite guidelines in partnership with representatives fromother medical organizations and specialty groups. Writingcommittees are asked to perform a formal literature review;weigh the strength of evidence for or against particular tests,treatments, or procedures; and include estimates of expectedoutcomes where such data exist. Patient-specific modifiers,comorbidities, and issues of patient preference that mayinfluence the choice of tests or therapies are considered.When available, information from studies on cost is con-sidered, but data on efficacy and outcomes constitute theprimary basis for the recommendations contained herein.

In analyzing the data and developing recommendationsand supporting text, the writing committee uses evidence-based methodologies developed by the Task Force (1). TheClass of Recommendation (COR) is an estimate of the sizeof the treatment effect considering risks versus benefits inaddition to evidence and/or agreement that a given treat-ment or procedure is or is not useful/effective or in somesituations may cause harm. The Level of Evidence (LOE) isan estimate of the certainty or precision of the treatmenteffect. The writing committee reviews and ranks evidencesupporting each recommendation with the weight of evi-dence ranked as LOE A, B, or C according to specificdefinitions that are included in Table 1. Studies are identi-fied as observational, retrospective, prospective, or random-ized where appropriate. For certain conditions for whichinadequate data are available, recommendations are basedon expert consensus and clinical experience and are rankedas LOE C. When recommendations at LOE C are sup-ported by historical clinical data, appropriate references(including clinical reviews) are cited if available. For issues

for which sparse data are available, a survey of current

Level o


practice among the clinicians on the writing committee isthe basis for LOE C recommendations, and no referencesare cited. The schema for COR and LOE is summarized inTable 1, which also provides suggested phrases for writingrecommendations within each COR. A new addition to thismethodology is separation of the Class III recommenda-tions to delineate if the recommendation is determined to beof “no benefit” or is associated with “harm” to the patient. Inaddition, in view of the increasing number of comparativeeffectiveness studies, comparator verbs and suggestedphrases for writing recommendations for the comparativeeffectiveness of one treatment or strategy versus another

Table 1. Applying Classification of Recommendations and Leve

A recommendation with Level of Evidence B or C does not imply that the recommendation is weakAlthough randomized trials are unavailable, there may be a very clear clinical consensus that a

*Data available from clinical trials or registries about the usefulness/efficacy in different subpfailure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa;comparisons of the treatments or strategies being evaluated.

have been added for COR I and IIa, LOE A or B only.

In view of the advances in medical therapy across thespectrum of cardiovascular diseases, the Task Force hasdesignated the term guideline�directed medical therapy(GDMT) to represent optimal medical therapy as defined byACCF/AHA guideline–recommended therapies (primarilyClass I). This new term, GDMT, will be used herein andthroughout all future guidelines.

Because the ACCF/AHA practice guidelines addresspatient populations (and healthcare providers) residing inNorth America, drugs that are not currently available inNorth America are discussed in the text without a specificCOR. For studies performed in large numbers of subjects

vidence

important clinical questions addressed in the guidelines do not lend themselves to clinical trials.lar test or therapy is useful or effective.ons, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heartf Evidence A and B only), studies that support the use of comparator verbs should involve direct

l of E

. Manyparticuopulati

outside North America, each writing committee reviews the

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potential influence of different practice patterns and patientpopulations on the treatment effect and relevance to theACCF/AHA target population to determine whether thefindings should inform a specific recommendation.

The ACCF/AHA practice guidelines are intended to assisthealthcare providers in clinical decision making by describing arange of generally acceptable approaches to the diagnosis,management, and prevention of specific diseases or conditions.The guidelines attempt to define practices that meet the needsof most patients in most circumstances. The ultimate judg-ment regarding the care of a particular patient must be made bythe healthcare provider and patient in light of all the circum-stances presented by that patient. As a result, situations mayarise for which deviations from these guidelines may beappropriate. Clinical decision making should involve consid-eration of the quality and availability of expertise in the areawhere care is provided. When these guidelines are used as thebasis for regulatory or payer decisions, the goal should beimprovement in quality of care. The Task Force recognizes thatsituations arise in which additional data are needed to informpatient care more effectively; these areas will be identified withineach respective guideline when appropriate.

Prescribed courses of treatment in accordance with theserecommendations are effective only if followed. Because lack ofpatient understanding and adherence may adversely affectoutcomes, physicians and other healthcare providers shouldmake every effort to engage the patient’s active participation inprescribed medical regimens and lifestyles. In addition, patientsshould be informed of the risks, benefits, and alternatives to aparticular treatment and be involved in shared decision makingwhenever feasible, particularly for COR IIa and IIb, where thebenefit-to-risk ratio may be lower.

The Task Force makes every effort to avoid actual,potential, or perceived conflicts of interest that may arise asa result of industry relationships or personal interests amongthe members of the writing committee. All writing com-mittee members and peer reviewers of the guideline arerequired to disclose all such current relationships, as well asthose existing 12 months previously. In December 2009, theACCF and AHA implemented a new policy for relation-ships with industry and other entities (RWI) that requiresthe writing committee chair plus a minimum of 50% of thewriting committee to have no relevant RWI (Appendix 1for the ACCF/AHA definition of relevance). These state-ments are reviewed by the Task Force and all membersduring each conference call and meeting of the writingcommittee and are updated as changes occur. All guidelinerecommendations require a confidential vote by the writingcommittee and must be approved by a consensus of thevoting members. Members are not permitted to write, andmust recuse themselves from voting on, any recommenda-tion or section to which their RWI apply. Members whorecused themselves from voting are indicated in the list ofwriting committee members, and section recusals are noted in

ppendix 1. Authors’ and peer reviewers’ RWI pertinent to

his guideline are disclosed in Appendixes 1 and 2, respectively.

Additionally, to ensure complete transparency, writing com-mittee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available asan online supplement. Comprehensive disclosure informationfor the Task Force is also available online at www.ardiosource.org/ACC/About-ACC/Leadership/Guidelines-nd-Documents-Task-Forces.aspx. The work of the writingommittee was supported exclusively by the ACCF and AHAithout commercial support. Writing committee membersolunteered their time for this activity.

In an effort to maintain relevance at the point of care forracticing physicians, the Task Force continues to overseen ongoing process improvement initiative. As a result, inesponse to pilot projects, evidence tables (with referencesinked to abstracts in PubMed) have been added.

In April 2011, the Institute of Medicine released 2eports: Finding What Works in Health Care: Standards forystematic Reviews and Clinical Practice Guidelines We Canrust (2,3). It is noteworthy that the ACCF/AHA guide-

ines are cited as being compliant with many of the proposedtandards. A thorough review of these reports and of oururrent methodology is under way, with further enhance-ents anticipated.The recommendations in this guideline are considered

urrent until they are superseded by a focused update or theull-text guideline is revised. Guidelines are official policy ofoth the ACCF and AHA.

Alice K. Jacobs, MD, FACC, FAHA ChairACCF/AHA Task Force on Practice Guidelines

1. Introduction

1.1. Methodology and Evidence Review

Whenever possible, the recommendations listed in this docu-ment are evidence based. Articles reviewed in this guidelinerevision covered evidence from the past 10 years throughJanuary 2011, as well as selected other references through April2011. Searches were limited to studies, reviews, and otherevidence conducted in human subjects that were published inEnglish. Key search words included but were not limited to thefollowing: analgesia, anastomotic techniques, antiplatelet agents,automated proximal clampless anastomosis device, asymptomaticischemia, Cardica C-port, cost effectiveness, depressed left ventric-ular (LV) function, distal anastomotic techniques, direct proximalanastomosis on aorta, distal anastomotic devices, emergency coro-nary artery bypass graft (CABG) and ST-elevation myocardialinfarction (STEMI), heart failure, interrupted sutures, LV systolicdysfunction, magnetic connectors, PAS-Port automated proximalclampless anastomotic device, patency, proximal connectors, renaldisease, sequential anastomosis, sternotomy, symmetry connector,symptomatic ischemia, proximal connectors, sequential anastomosis,T grafts, thoracotomy, U-clips, Ventrica Magnetic Vascular Portsystem, Y grafts. Additionally, the committee reviewed docu-

ments related to the subject matter previously published by the

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ACCF and AHA. References selected and published in thisdocument are representative but not all-inclusive.

To provide clinicians with a comprehensive set of data,whenever deemed appropriate or when published, the absoluterisk difference and number needed to treat or harm areprovided in the guideline, along with confidence interval (CI)and data related to the relative treatment effects such as oddsratio (OR), relative risk (RR), hazard ratio (HR), or incidencerate ratio.

The focus of these guidelines is the safe, appropriate, andefficacious performance of CABG.

1.2. Organization of the Writing Committee

The committee was composed of acknowledged experts inCABG, interventional cardiology, general cardiology, andcardiovascular anesthesiology. The committee included rep-resentatives from the ACCF, AHA, American Associationfor Thoracic Surgery, Society of Cardiovascular Anesthesi-ologists, and Society of Thoracic Surgeons (STS).

1.3. Document Review and Approval

This document was reviewed by 2 official reviewers, eachnominated by both the ACCF and the AHA, as well as 1reviewer each from the American Association for ThoracicSurgery, Society of Cardiovascular Anesthesiologists, andSTS, as well as members from the ACCF/AHA Task Forceon Data Standards, ACCF/AHA Task Force on Perfor-mance Measures, ACCF Surgeons’ Scientific Council,ACCF Interventional Scientific Council, and SouthernThoracic Surgical Association. All information on review-ers’ RWI was distributed to the writing committee and ispublished in this document (Appendix 2).

This document was approved for publication by thegoverning bodies of the ACCF and the AHA and endorsedby the American Association for Thoracic Surgery, Societyof Cardiovascular Anesthesiologists, and STS.

2. Procedural Considerations

2.1. Intraoperative Considerations

2.1.1. Anesthetic Considerations: Recommendations

CLASS I1. Anesthetic management directed toward early postoperative extu-

bation and accelerated recovery of low- to medium-risk patientsundergoing uncomplicated CABG is recommended (4–6). (Level ofEvidence: B)

. Multidisciplinary efforts are indicated to ensure an optimal level ofanalgesia and patient comfort throughout the perioperative period(7–11). (Level of Evidence: B)

. Efforts are recommended to improve interdisciplinary communicationand patient safety in the perioperative environment (e.g., formalizedchecklist-guided multidisciplinary communication) (12–15). (Level ofEvidence: B)

. A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative trans-

esophageal echocardiography (TEE) is recommended to provide or

supervise anesthetic care of patients who are considered to be athigh risk (16–18). (Level of Evidence: C)

CLASS IIa1. Volatile anesthetic-based regimens can be useful in facilitating

early extubation and reducing patient recall (5,19–21). (Level ofEvidence: A)

CLASS IIb1. The effectiveness of high thoracic epidural anesthesia/analgesia for

routine analgesic use is uncertain (22–25). (Level of Evidence: B)

CLASS III: HARM1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in

the postoperative period after CABG (26,27). (Level of Evidence: B)2. Routine use of early extubation strategies in facilities with limited

backup for airway emergencies or advanced respiratory support ispotentially harmful. (Level of Evidence: C)

See Online Data Supplement 1 for additional data on anestheticconsiderations.

Anesthetic management of the CABG patient mandatesa favorable balance of myocardial oxygen supply and de-mand to prevent or minimize myocardial injury (Section2.1.8). Historically, the popularity of several anesthetictechniques for CABG has varied on the basis of theirknown or potential adverse cardiovascular effects (e.g.,cardiovascular depression with high doses of volatile anes-thesia, lack of such depression with high-dose opioids, orcoronary vasodilation and concern for a “steal” phenomenonwith isoflurane) as well as concerns about interactions withpreoperative medications (e.g., cardiovascular depressionwith beta blockers or hypotension with angiotensin-converting enzyme [ACE] inhibitors and angiotensin-receptor blockers [ARBs] [28–30]) (Sections 2.1.8 and 4.5).Independent of these concerns, efforts to improve outcomesand to reduce costs have led to shorter periods of postop-erative mechanical ventilation and even, in some patients, toprompt extubation in the operating room (“acceleratedrecovery protocols” or “fast-track management”) (5,31).

High-dose opioid anesthesia with benzodiazepine sup-plementation was used commonly in CABG patients in theUnited States in the 1970s and 1980s. Subsequently, itbecame clear that volatile anesthetics are protective in thesetting of myocardial ischemia and reperfusion, and this, incombination with a shift to accelerated recovery or “fast-track” strategies, led to their ubiquitous use. As a result,opioids have been relegated to an adjuvant role (32,33).Despite their widespread use, volatile anesthetics have notbeen shown to provide a mortality rate advantage whencompared with other intravenous regimens (Section 2.1.8).

Optimal anesthesia care in CABG patients should in-clude 1) a careful preoperative evaluation and treatment ofmodifiable risk factors; 2) proper handling of all medicationsgiven preoperatively (Sections 4.1, 4.3, and 4.5); 3) estab-lishment of central venous access and careful cardiovascularmonitoring; 4) induction of a state of unconsciousness,

analgesia, and immobility; and 5) a smooth transition to the

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early postoperative period, with a goal of early extubation,patient mobilization, and hospital discharge. Attentionshould be directed at preventing or minimizing adversehemodynamic and hormonal alterations that may inducemyocardial ischemia or exert a deleterious effect on myocar-dial metabolism (as may occur during cardiopulmonarybypass [CPB]) (Section 2.1.8). This requires close interac-tion between the anesthesiologist and surgeon, particularlywhen manipulation of the heart or great vessels is likely toinduce hemodynamic instability. During on-pump CABG,particular care is required during vascular cannulation andweaning from CPB; with off-pump CABG, the hemody-namic alterations often caused by displacement or vertical-ization of the heart and application of stabilizer devices onthe epicardium, with resultant changes in heart rate, cardiacoutput, and systemic vascular resistance, should be moni-tored carefully and managed appropriately.

In the United States, nearly all patients undergoingCABG receive general anesthesia with endotracheal intu-bation utilizing volatile halogenated general anestheticswith opioid supplementation. Intravenous benzodiazepinesoften are given as premedication or for induction of anes-thesia, along with other agents such as propofol or etomi-date. Nondepolarizing neuromuscular-blocking agents, par-ticularly nonvagolytic agents with intermediate duration ofaction, are preferred to the longer-acting agent, pancuro-nium. Use of the latter is associated with higher intraoper-ative heart rates and a higher incidence of residual neuro-muscular depression in the early postoperative period, witha resultant delay in extubation (23,34). In addition, lowconcentrations of volatile anesthetic usually are adminis-tered via the venous oxygenator during CPB, facilitatingamnesia and reducing systemic vascular resistance.

Outside the United States, alternative anesthetic tech-niques, particularly total intravenous anesthesia via propofoland opioid infusions with benzodiazepine supplementationwith or without high thoracic epidural anesthesia, arecommonly used. The use of high thoracic epidural anesthe-sia exerts salutary effects on the coronary circulation as wellas myocardial and pulmonary function, attenuates the stressresponse, and provides prolonged postoperative analgesia(24,25,35). In the United States, however, concerns aboutthe potential for neuraxial bleeding (particularly in thesetting of heparinization, platelet inhibitors, and CPB-induced thrombocytopenia), local anesthetic toxicity, andlogistical issues related to the timing of epidural catheterinsertion and management have resulted in limited use ofthese techniques (22). Their selective use in patients withsevere pulmonary dysfunction (Section 6.5) or chronic painsyndromes may be considered. Although meta-analyses ofrandomized controlled trials (RCTs) of high thoracic epi-dural anesthesia/analgesia in CABG patients (particularlyon-pump) have yielded inconsistent results on morbidityand mortality rates, it does appear to reduce time toextubation, pain, and pulmonary complications (36–38). Of

interest, although none of the RCTs have reported the

occurrence of epidural hematoma or abscess, these entitiesoccur on occasion (38). Finally, the use of other regionalanesthetic approaches for postoperative analgesia, such asparasternal block, has been reported (39).

Over the past decade, early extubation strategies (“fast-track” anesthesia) often have been used in low- to medium-risk CABG patients. These strategies allow a shorter time toextubation, a decreased length of intensive care unit (ICU)stay, and variable effects on length of hospital stay (4–6).Immediate extubation in the operating room, with orwithout markedly accelerated postoperative recovery path-ways (e.g., “ultra-fast-tracking,” “rapid recovery protocol,”“short-stay intensive care”) have been used safely, with lowrates of reintubation and no influence on quality of life(40–44). Observational data suggest that physician judg-ment in triaging lower-risk patients to early or immediateextubation works well, with rates of reintubation �1% (45).Certain factors appear to predict fast-track “failure,” includ-ing previous cardiac surgery, use of intra-aortic ballooncounterpulsation, and possibly advanced patient age.

Provision of adequate perioperative analgesia is importantin enhancing patient mobilization, preventing pulmonarycomplications, and improving the patient’s psychologicalwell-being (9,11). The intraoperative use of high-dosemorphine (40 mg) may offer superior postoperative painrelief and enhance patient well-being compared with fenta-nyl (despite similar times to extubation) (46).

The safety of nonsteroidal anti-inflammatory agents foranalgesia is controversial, with greater evidence for adversecardiovascular events with the selective cyclooxygenase-2inhibitors than the nonselective agents. A 2007 AHAscientific statement presented a stepped-care approach tothe management of musculoskeletal pain in patients with orat risk for coronary artery disease (CAD), with the goal oflimiting the use of these agents to patients in whom safertherapies fail (47). In patients hospitalized with unstableangina (UA) and non–ST-elevation myocardial infarction(NSTEMI), these agents should be discontinued promptlyand reinstituted later according to the stepped-care ap-proach (48).

In the setting of cardiac surgery, nonsteroidal anti-inflammatory agents previously were used for perioperativeanalgesia. A meta-analysis of 20 trials of patients undergo-ing thoracic or cardiac surgery, which evaluated studiespublished before 2005, reported significant reductions inpain scores, with no increase in adverse outcomes (49). Sub-sequently, 2 RCTs, both studying the oral cyclooxygenase-2inhibitor valdecoxib and its intravenous prodrug, parecoxib,reported a higher incidence of sternal infections in 1 trialand a significant increase in adverse cardiovascular events inthe other (26,27). On the basis of the results of these 2studies (as well as other nonsurgical reports of increased riskwith cyclooxygenase-2–selective agents), the U.S. Food andDrug Administration in 2005 issued a “black box” warningfor all nonsteroidal anti-inflammatory agents (except aspirin)

immediately after CABG (50). The concurrent administration


of ibuprofen with aspirin has been shown to attenuate thelatter’s inhibition of platelet aggregation, likely because ofcompetitive inhibition of cyclooxygenase at the platelet-receptor binding site (51).

Observational analyses in patients undergoing noncardiacsurgery have shown a significant reduction in perioperativedeath with the use of checklists, multidisciplinary surgicalcare, intraoperative time-outs, postsurgical debriefings, andother communication strategies (14,15). Such methodologyis being used increasingly in CABG patients (12–14).

In contrast to extensive literature on the role of thesurgeon in determining outcomes with CABG, limited dataon the influence of the anesthesiologist are available. Of 2such reports from single centers in the 1980s, 1 suggestedthat the failure to control heart rate to �110 beats perminute was associated with a higher mortality rate, and theother suggested that increasing duration of CPB adverselyinfluenced outcome (52,53). Another observational analysisof data from vascular surgery patients suggested that anes-thetic specialization was independently associated with areduction in mortality rate (54).

To meet the challenges of providing care for the increas-ingly higher-risk patients undergoing CABG, efforts havebeen directed at enhancing the experience of trainees,particularly in the use of newer technologies such as TEE.Cardiac anesthesiologists, in collaboration with cardiolo-gists and surgeons, have implemented national training andcertification processes for practitioners in the use of periop-erative TEE (Section 2.1.7) (164,165). Accreditation ofcardiothoracic anesthesia fellowship programs from theAccreditation Council for Graduate Medical Education wasinitiated in 2004, and efforts are ongoing to obtain formalsubspecialty certification (18).

2.1.2. Use of CPB

Several adverse outcomes have been attributed to CPB,including 1) neurological deficits (e.g., stroke, coma, post-operative neurocognitive dysfunction); 2) renal dysfunction;and 3) the Systemic Inflammatory Response Syndrome(SIRS). The SIRS is manifested as generalized systemicinflammation occurring after a major morbid event, such astrauma, infection, or major surgery. It is often particularlyapparent after on-pump cardiac surgery, during whichsurgical trauma, contact of blood with nonphysiologicalsurfaces (e.g., pump tubing, oxygenator surfaces), myocar-dial ischemia and reperfusion, and hypothermia combine tocause a dramatic release of cytokines (e.g., interleukin [IL]6 and IL8) and other mediators of inflammation (55). Someinvestigators have used serum concentrations of S100 betaas a marker of brain injury (56) and have correlatedincreased serum levels with the number of microemboliexiting the CPB circuit during CABG. In contrast, othershave noted the increased incidence of microemboli withon-pump CABG (relative to off-pump CABG) but havefailed to show a corresponding worsening of neurocognitive

function 1 week to 6 months postoperatively (57,58). Blood

retrieved from the operative field during on-pump CABGcontains lipid material and particulate matter, which havebeen implicated as possible causes of postoperative neuro-cognitive dysfunction. Although a study (59) reported thatCPB-associated neurocognitive dysfunction can be miti-gated by the routine processing of shed blood with a cellsaver before its reinfusion, another study (60) failed to showsuch an improvement.

It has been suggested that CPB leads to an increasedincidence of postoperative renal failure requiring dialysis,but a large RCT comparing on-pump and off-pump CABGshowed no difference in its occurrence (61). Of interest, thisstudy failed to show a decreased incidence of postoperativeadverse neurological events (stroke, coma, or neurocognitivedeficit) in those undergoing off-pump CABG.

The occurrence of SIRS in patients undergoing CPB hasled to the development of strategies designed to prevent orto minimize its occurrence. Many reports have focused onthe increased serum concentrations of cytokines (e.g., IL-2R,IL-6, IL-8, tumor necrosis factor alpha) and other modu-lators of inflammation (e.g., P-selectin, sE-selectin, solubleintercellular adhesion molecule-1, plasma endothelial celladhesion molecule-1, and plasma malondialdehyde), whichreflect leukocyte and platelet activation, in triggering theonset of SIRS. A study showed a greater upregulation ofneutrophil CD11b expression (a marker of leukocyte acti-vation) in patients who sustained a �50% increase in theserum creatinine concentration after CPB, thereby impli-cating activated neutrophils in the pathophysiology of SIRSand the occurrence of post-CPB renal dysfunction (62).Modulating neutrophil activation to reduce the occurrenceof SIRS has been investigated; however, the results havebeen inconsistent. Preoperative intravenous methylpred-nisolone (10 mg/kg) caused a reduction in the serumconcentrations of many of these cytokines after CPB, butthis reduction was not associated with improved hemody-namic variables, diminished blood loss, less use of inotropicagents, shorter duration of ventilation, or shorter ICUlength of stay (63). Similarly, the use of intravenous immu-noglobulin G in patients with post-CPB SIRS has not beenassociated with decreased rates of short-term morbidity or28-day mortality (64).

Other strategies to mitigate the occurrence of SIRS afterCPB have been evaluated, including the use of 1) CPBcircuits (including oxygenators) coated with materialsknown to reduce complement and leukocyte activation;2) CPB tubing that is covalently bonded to heparin; and3) CPB tubing coated with polyethylene oxide polymer orPoly (2-methoxyethylacrylate). Leukocyte depletion via spe-cialized filters in the CPB circuits has been shown to reducethe plasma concentrations of P-selectin, intercellular adhe-sion molecule-1, IL-8, plasma endothelial cell adhesionmolecule-1, and plasma malondialdehyde after CPB (65).

Finally, closed mini-circuits for CPB have been devel-oped in an attempt to minimize the blood–air interface and

blood contact with nonbiological surfaces, both of which

nrs


promote cytokine elaboration, but it is uncertain if thesemaneuvers and techniques have a discernible effect on out-comes after CABG.

2.1.3. Off-Pump CABG VersusTraditional On-Pump CABG

Since the first CABG was performed in the late 1960s, thestandard surgical approach has included the use of cardiacarrest coupled with CPB (so-called on-pump CABG),thereby optimizing the conditions for construction of vas-cular anastomoses to all diseased coronary arteries withoutcardiac motion or hemodynamic compromise. Such on-pump CABG has become the gold standard and is per-formed in about 80% of subjects undergoing the procedurein the United States. Despite the excellent results that havebeen achieved, the use of CPB and the associated manipu-lation of the ascending aorta are linked with certain peri-operative complications, including myonecrosis during aor-tic occlusion, cerebrovascular accidents, generalizedneurocognitive dysfunction, renal dysfunction, and SIRS. Inan effort to avoid these complications, off-pump CABG wasdeveloped (58,66). Off-pump CABG is performed on thebeating heart with the use of stabilizing devices (whichminimize cardiac motion); in addition, it incorporates tech-niques to minimize myocardial ischemia and systemic he-modynamic compromise. As a result, the need for CPB isobviated. This technique does not necessarily decrease theneed for manipulation of the ascending aorta during con-struction of the proximal anastomoses.

To date, the results of several RCTs comparing on-pumpand off-pump CABG in various patient populations havebeen published (61,67,68). In addition, registry data and theresults of meta-analyses have been used to assess the relativeefficacies of the 2 techniques (69,70). In 2005, an AHAscientific statement comparing the 2 techniques concludedthat both procedures usually result in excellent outcomesand that neither technique should be considered superior tothe other (71). At the same time, several differences werenoted. Off-pump CABG was associated with less bleeding,less renal dysfunction, a shorter length of hospital stay, andless neurocognitive dysfunction. The incidence of perioper-ative stroke was similar with the 2 techniques. On-pumpCABG was noted to be less technically complex andallowed better access to diseased coronary arteries in certainanatomic locations (e.g., those on the lateral LV wall) aswell as better long-term graft patency.

In 2009, the results of the largest RCT to date comparingon-pump CABG to off-pump CABG, the ROOBY (Ran-domized On/Off Bypass) trial, were published, reportingthe outcomes for 2,203 patients (99% men) at 18 VeteransAffairs Medical Centers (61). The primary short-term end-point, a composite of death or complications (reoperation,

ew mechanical support, cardiac arrest, coma, stroke, orenal failure) within 30 days of surgery, occurred with

imilar frequency (5.6% for on-pump CABG; 7.0% for

off-pump CABG; p�0.19). The primary long-term end-point, a composite of death from any cause, a repeatrevascularization procedure, or a nonfatal myocardial infarc-tion (MI) within 1 year of surgery, occurred more often inthose undergoing off-pump CABG (9.9%) than in thosehaving on-pump CABG (7.4%; p�0.04). Neuropsycholog-ical outcomes and resource utilization were similar betweenthe 2 groups. One year after surgery, graft patency washigher in the on-pump group (87.8% versus 82.6%;p�0.01). In short, the ROOBY investigators failed to showan advantage of off-pump CABG compared with on-pumpCABG in a patient population considered to be at low risk.Instead, use of the on-pump technique was associated withbetter 1-year composite outcomes and 1-year graft patencyrates, with no difference in neuropsychological outcomes orresource utilization.

Although numerous investigators have used single-centerregistries, the STS database, and meta-analyses in anattempt to identify patient subgroups in whom off-pumpCABG is the preferred procedure, even these analyses havereached inconsistent conclusions about off-pump CABG’sability to reduce morbidity and mortality rates (69,72–83).A retrospective cohort study of 14,766 consecutive patientsundergoing isolated CABG identified a mortality benefit(OR: 0.45) for off-pump CABG in patients with a predictedrisk of mortality �2.5% (82), but a subsequent randomizedcomparison of off-pump CABG to traditional on-pumpCABG in 341 high-risk patients (a Euroscore �5) showedno difference in the composite endpoint of all-cause death,acute MI, stroke, or a required reintervention procedure(78). An analysis of data from the New York State CardiacSurgery Reporting system did not demonstrate a reductionin mortality rate with off-pump CABG in any patientsubgroup, including the elderly (age �80 years) or thosewith cerebrovascular disease, azotemia, or an extensivelycalcified ascending aorta (69).

Despite these results, off-pump CABG is the preferredapproach by some surgeons who have extensive experiencewith it and therefore are comfortable with its technicalnuances. Recently, published data suggested that the avoid-ance of aortic manipulation is the most important factor inreducing the risk of neurological complications (84,85).Patients with extensive disease of the ascending aorta pose aspecial challenge for on-pump CABG; for these patients,cannulation or cross-clamping of the aorta may create anunacceptably high risk of stroke. In such individuals, off-pump CABG in conjunction with avoidance of manipula-tion of the ascending aorta (including placement of proxi-mal anastomoses) may be beneficial. Surgeons typicallyprefer an on-pump strategy in patients with hemodynamiccompromise because CPB offers support for the systemiccirculation. In the end, most surgeons consider eitherapproach to be reasonable for the majority of subjects

undergoing CABG.

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2.1.4. Bypass Graft Conduit: Recommendations

CLASS I1. If possible, the left internal mammary artery (LIMA) should be used

to bypass the left anterior descending (LAD) artery when bypass ofthe LAD artery is indicated (86–89). (Level of Evidence: B)

CLASS IIa1. The right internal mammary artery (IMA) is probably indicated to

bypass the LAD artery when the LIMA is unavailable or unsuitable asa bypass conduit. (Level of Evidence: C)

. When anatomically and clinically suitable, use of a second IMA tograft the left circumflex or right coronary artery (when criticallystenosed and perfusing LV myocardium) is reasonable to improvethe likelihood of survival and to decrease reintervention (90–94).(Level of Evidence: B)

CLASS IIb1. Complete arterial revascularization may be reasonable in patients

less than or equal to 60 years of age with few or no comorbidities.(Level of Evidence: C)

2. Arterial grafting of the right coronary artery may be reasonablewhen a critical (�90%) stenosis is present (89,93,95). (Level ofEvidence: B)

3. Use of a radial artery graft may be reasonable when graftingleft-sided coronary arteries with severe stenoses (�70%) and right-sided arteries with critical stenoses (�90%) that perfuse LV myo-cardium (96–101). (Level of Evidence: B)

CLASS III: HARM1. An arterial graft should not be used to bypass the right coronary

artery with less than a critical stenosis (�90%) (89). (Level ofEvidence: C)

Arteries (internal mammary, radial, gastroepiploic, and inferiorepigastric) or veins (greater and lesser saphenous) may beused as conduits for CABG. The effectiveness of CABG inrelieving symptoms and prolonging life is directly related tograft patency. Because arterial and venous grafts havedifferent patency rates and modes of failure, conduit selec-tion is important in determining the long-term efficacy ofCABG.

2.1.4.1. SAPHENOUS VEIN GRAFTS

Reversed saphenous vein grafts (SVGs) are commonly usedin patients undergoing CABG. Their disadvantage is adeclining patency with time: 10% to as many as 25% ofthem occlude within 1 year of CABG (89,102,103); anadditional 1% to 2% occlude each year during the 1 to 5years after surgery; and 4% to 5% occlude each year between6 and 10 years postoperatively (104). Therefore, 10 yearsafter CABG, 50% to 60% of SVGs are patent, only half ofwhich have no angiographic evidence of atherosclerosis(104). During SVG harvesting and initial exposure toarterial pressure, the endothelium often is damaged, which,if extensive, may lead to platelet aggregation and graftthrombosis. Platelet adherence to the endothelium beginsthe process of intimal hyperplasia that later causes SVGatherosclerosis (103,105). After adhering to the intima, theplatelets release mitogens that stimulate smooth muscle cell

migration, leading to intimal proliferation and hyperplasia.

Lipid is incorporated into these areas of intimal hyperplasia,resulting in atherosclerotic plaque formation (106). Theperioperative administration of aspirin and dipyridamoleimproves early (�1 month) and 1-year SVG patency anddecreases lipid accumulation in the SVG intima (103,106,107).

2.1.4.2. INTERNAL MAMMARY ARTERIES

Unlike SVGs, IMAs usually are patent for many yearspostoperatively (10-year patency �90%) (89,95,102,108–117) because of the fact that �4% of IMAs developatherosclerosis, and only 1% have atherosclerotic stenoses ofhemodynamic significance (118–120). This resistance tothe development of atherosclerosis is presumably due to1) the nearly continuous internal elastic lamina that preventssmooth muscle cell migration and 2) the release ofprostacyclin and nitric oxide, potent vasodilators andinhibitors of platelet function, by the endothelium ofIMAs (119,121,122).

The disadvantage of using the IMA is that it may spasmand eventually atrophy if used to bypass a coronary arterywithout a flow-limiting stenosis (89,95,118,123–130). Ob-servational studies suggest an improved survival rate inpatients undergoing CABG when the LIMA (rather thanan SVG) is used to graft the LAD artery (86–88); thissurvival benefit is independent of the patient’s sex, age,extent of CAD, and LV systolic function (87,88). Apartfrom improving survival rate, LIMA grafting of the LADartery reduces the incidence of late MI, hospitalization forcardiac events, need for reoperation, and recurrence ofangina (86,88). The LIMA should be used to bypass theLAD artery provided that a contraindication to its use (e.g.,emergency surgery, poor LIMA blood flow, subclavianartery stenosis, radiation injury, atherosclerosis) is notpresent.

Because of the beneficial influence on morbidity andmortality rates of using the IMA for grafting, several centershave advocated bilateral IMA grafting in hopes of furtherimproving CABG results (90,91,94). In fact, numerousobservational studies have demonstrated improved morbid-ity and mortality rates when both IMAs are used. On theother hand, bilateral IMA grafting appears to be associatedwith an increased incidence of sternal wound infections inpatients with diabetes mellitus and those who are obese(body mass index �30 kg/m2).

2.1.4.3. RADIAL, GASTROEPIPLOIC, AND INFERIOR EPIGASTRIC ARTERIES

Ever since the observation that IMAs are superior to SVGsin decreasing the occurrence of ischemic events and pro-longing survival, other arterial conduits, such as the radial,gastroepiploic, and inferior epigastric arteries, have beenused in an attempt to improve the results of CABG.Information about these other arterial conduits is sparse incomparison to what is known about IMAs and SVGs,however. The radial artery is a muscular artery that issusceptible to spasm and atrophy when used to graft a

coronary artery that is not severely narrowed. Radial artery


graft patency is best when used to graft a left-sided coronaryartery with �70% stenosis and worst when it is used tobypass the right coronary artery with a stenosis of onlymoderate severity (96–100).

The gastroepiploic artery is most often used to bypass theright coronary artery or its branches, although it may beused to bypass the LAD artery if the length of thegastroepiploic artery is adequate. Similar to the radial artery,it is prone to spasm and therefore should only be used tobypass coronary arteries that are severely stenotic (131). The1-, 5-, and 10-year patency rates of the gastroepiploic arteryare reportedly 91%, 80%, and 62%, respectively (132).

The inferior epigastric artery is only 8 to 10 centimetersin length and therefore is usually used as a “Y” or “T” graftconnected to another arterial conduit. On occasion it is usedas a free graft from the aorta to a high diagonal branch ofthe LAD artery. Because it is a muscular artery, it is proneto spasm and therefore is best used to bypass a severelystenotic coronary artery. Its reported 1-year patency is about90% (133,134).

2.1.5. Incisions for Cardiac Access

Although the time-honored incision for CABG is a mediansternotomy, surgeons have begun to access the heart viaseveral other approaches in an attempt to 1) reduce thetraumatic effects often seen with full median sternotomy,2) hasten postoperative recovery, and 3) enhance cosmesis.The utility and benefit of these smaller incisions has beenevident in subjects undergoing valvular surgery, for whichonly limited access to the heart is required.

The most minimally invasive access incisions for CABGare seen with robotically assisted totally endoscopic CABG.A study showed that totally endoscopic CABG with robotictechnology was associated with improved physical health,shorter hospital stay, and a more rapid return to theactivities of daily living compared with traditional tech-niques. At present, direct comparisons of robotically assistedand conventional CABG are lacking (135).

The use of minimally invasive cardiac access incisions forCABG is limited. The need for adequate exposure of theascending aorta and all surfaces of the heart to accomplishfull revascularization usually precludes the use of minimalaccess incisions, such as upper sternotomy, lower sternot-omy, or anterolateral thoracotomy. Nevertheless, use oflimited incisions may increase in the future with the adventof hybrid strategies that use a direct surgical approach(usually for grafting the LAD artery through a smallparasternal incision) and percutaneous coronary interven-tion (PCI) of the other diseased coronary arteries. Thebenefit of hybrid revascularization and hybrid operatingrooms, in which PCI and CABG can be accomplished inone procedure, is yet to be determined. In patients withcertain comorbid conditions, such as severe aortic calcifica-tion, previous chest irradiation, and obesity in combination

with severe diabetes mellitus, full median sternotomy may

be problematic (136), and hybrid revascularization may bepreferable.

2.1.6. Anastomotic Techniques

At present, most coronary bypass grafts are constructed withhand-sewn suture techniques for the proximal and distalanastomoses, a practice that has resulted in good short- andintermediate-term patency rates. Because surgeons havedifferent preferences with regard to the technical aspects ofthe procedure, a wide variety of suture configurations isused. Sewing of the proximal and distal anastomoses with acontinuous polypropylene suture is commonly done, buttechniques with interrupted silk sutures have been used,with similar results for graft patency and adverse events.

Certain clinical scenarios have precipitated an interest inalternative techniques of constructing coronary bypass anas-tomoses. Some surgeons and patients wish to avoid thepotential morbidity and cosmetic results of a median ster-notomy, yet the least invasive incisions usually are too smallto allow hand-sewn anastomoses. To solve this problem,coronary connector devices have been developed for usewith arterial or venous conduits to enable grafting withoutdirect suturing. In addition, these devices have been used insubjects with diseased ascending aortas, in whom a tech-nique that allows construction of a proximal anastomosiswith minimal manipulation of the ascending aorta (typicallyby eliminating the need for aortic cross-clamping) mayresult in less embolization of debris, thereby reducing theoccurrence of adverse neurological outcomes. In this situa-tion, the operation is performed through a median sternot-omy, and the proximal anastomoses are created with aconnector (or may be hand-sewn with the assistance of adevice that provides a bloodless operative field) withoutpartial or complete clamping of the ascending aorta.

2.1.7. Intraoperative TEE: Recommendations

CLASS I1. Intraoperative TEE should be performed for evaluation of acute,

persistent, and life-threatening hemodynamic disturbances thathave not responded to treatment (137,138). (Level of Evidence: B)

2. Intraoperative TEE should be performed in patients undergoingconcomitant valvular surgery (137,139). (Level of Evidence: B)

CLASS IIa1. Intraoperative TEE is reasonable for monitoring of hemodynamic

status, ventricular function, regional wall motion, and valvular func-tion in patients undergoing CABG (138,140–145). (Level of Evi-dence: B)

The use of intraoperative TEE in patients undergoingcardiac surgery has increased steadily since its introductionin the late 1980s. Although its utility is considered to behighest in patients undergoing valvular and complex opengreat-vessel/aortic surgery, it is commonly used in subjectsundergoing CABG. TEE is most often used (146), al-though epicardial and epiaortic imaging, performed underaseptic conditions, allows visualization of imaging planes

not possible with TEE (147,148). Specifically, epiaortic


imaging allows visualization of the “blind spot” of theascending aorta (caused by interposition of the trachea withthe esophagus), the site of aortic cannulation for CPB, fromwhich dislodgement of friable atheroma, a major risk factorfor perioperative stroke, may occur (Section 5.2.1). Inaddition, epicardial probes allow imaging when TEE iscontraindicated, cannot be performed, or produces inade-quate images. It can facilitate the identification of intraven-tricular thrombi when TEE images are equivocal.

The “2003 ACC/AHA/ASE Guideline Update for theClinical Application of Echocardiography” based its recom-mendations on those reported in the 1996 American Societyof Anesthesiologists/Society of Cardiovascular Anesthesiol-ogists practice guideline and considered the use of TEE inCABG patients (149). The latter document was updated in2010 (139). Because of the use of different grading meth-odologies in the American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists guideline rela-tive to that of the ACCF/AHA, precise comparisons aredifficult. However, it is noted that TEE “should be consid-ered” in subjects undergoing CABG, to confirm and refinethe preoperative diagnosis, detect new or unsuspected pa-thology, adjust the anesthetic and surgical plan accordingly,and assess the results of surgery. The strongest recommen-dation is given for treatment of acute life-threateninghemodynamic instability that has not responded to conven-tional therapies.

Observational cohort analyses and case reports havesuggested the utility of TEE for diagnosing acute life-threatening hemodynamic or surgical problems in CABGpatients, many of which are difficult or impossible to detector treat without direct imaging. Evaluation of ventricularcross-sectional areas and ejection fraction (EF) and estima-tion or direct measurement of cardiac output by TEE mayfacilitate anesthetic, fluid, and inotropic/pressor manage-ment. The utility of echocardiography for the evaluation ofLV end-diastolic area/volume and its potential superiorityover pulmonary artery occlusion or pulmonary artery dia-stolic pressure, particularly in the early postoperative period,has been reported (150,151) (Section 4.10). In subjectswithout preoperative transthoracic imaging, intraoperativeTEE may provide useful diagnostic information (over andabove that detected during cardiac catheterization) on val-vular function as well as evidence of pulmonary hyperten-sion, intracardiac shunts, or other complications that mayalter the planned surgery.

In patients undergoing CABG, intraoperative TEE isused most often for the detection of regional wall motionabnormalities (possibly caused by myocardial ischemia orinfarction) and their effect on LV function. Observationalstudies have suggested that regional wall motion abnormal-ities detected with TEE can guide surgical therapy, leadingto revision of a failed or inadequate conduit or the place-ment of additional grafts not originally planned. The

presence of new wall motion abnormalities after CPB

correlates with adverse perioperative and long-term out-comes (143).

Although the initial hope that an estimation of coronaryblood flow with intramyocardial contrast enhancement vi-sualized by TEE would facilitate surgical intervention hasnot been realized, technical advances in imaging of coronaryarteries and grafts may ultimately provide reliable informa-tion. At present, the evaluation of graft flow with conven-tional nonimaging handheld Doppler probes appears ade-quate (Section 8). Intraoperative evaluation of mitralregurgitation may facilitate detection of myocardial isch-emia and provide guidance about the need for mitral valveannuloplasty (Section 6.7). Newer technologies, includingnonimaging methods for analyzing systolic and diastolicvelocity and direction and timing of regional wall motion(Doppler tissue imaging and speckle tracking), as well as“real-time” 3-dimensional imaging, may facilitate the diag-nosis of myocardial ischemia and evaluation of ventricularfunction. At present, however, their cost-effectiveness hasnot been determined, and they are too complex for routineuse (152–154).

Among different centers, the rate of intraoperative TEEuse in CABG patients varies from none to routine; its useis influenced by many factors, such as institutional andpractitioner preferences, the healthcare system and reim-bursement strategies, tertiary care status, and presence oftraining programs (155). The efficacy of intraoperativeTEE is likely influenced by the presence of 1) LV systolicand diastolic dysfunction, 2) concomitant valvular dis-ease, 3) the planned surgical procedure (on pump versusoff pump, primary versus reoperative), 4) the surgicalapproach (full sternotomy versus partial sternotomy ver-sus endoscopic or robotic), 5) its acuity (elective versusemergency); and 6) physician training and experience(137,138,140 –142,144,145,156 –163).

The safety of intraoperative TEE in patients undergoingcardiac surgery is uncertain. Retrospective analyses of datafrom patients undergoing diagnostic upper gastrointestinalendoscopy, nonoperative diagnostic TEE imaging, andintraoperative imaging by skilled operators in high-volumecenters demonstrate a low frequency of complications re-lated to insertion or manipulation of the probe (164,165).Nevertheless, minor (primarily pharyngeal injury fromprobe insertion) and major (esophageal perforation, gastricbleeding, or late mediastinitis) complications are reported(166,167). A more indolent complication is that of acquireddysphagia and possible aspiration postoperatively. Althoughretrospective analyses of postoperative cardiac surgical pa-tients with clinically manifest esophageal dysfunction haveidentified TEE use as a risk factor (168–170), such dys-function also has been reported in subjects in whom TEEwas not used (171). Advanced age, prolonged intubation,and neurological injury seem to be risk factors for itsdevelopment. The significance of the incidental intraoper-ative detection and repair of a patent foramen ovale, a

common occurrence, is controversial (172). A 2009 obser-

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vational analysis of 13,092 patients (25% isolated CABG;29% CABG or other cardiac procedure), of whom 17% hada patent foramen ovale detected by TEE (28% of whichwere repaired), reported an increase in postoperative strokein the patients who had patent foramen ovale repair (OR:2.47; 95% CI: 1.02 to 6.0) with no improvement inlong-term outcome (173).

2.1.8. Preconditioning/Management ofMyocardial Ischemia: RecommendationsCLASS I1. Management targeted at optimizing the determinants of coronary

arterial perfusion (e.g., heart rate, diastolic or mean arterial pres-sure, and right ventricular or LV end-diastolic pressure) is recom-mended to reduce the risk of perioperative myocardial ischemiaand infarction (53,174–177). (Level of Evidence: B)

CLASS IIa1. Volatile-based anesthesia can be useful in reducing the risk of

perioperative myocardial ischemia and infarction (178–181). (Levelof Evidence: A)

CLASS IIb1. The effectiveness of prophylactic pharmacological therapies or

controlled reperfusion strategies aimed at inducing preconditioningor attenuating the adverse consequences of myocardial reperfusioninjury or surgically induced systemic inflammation is uncertain(182–189). (Level of Evidence: A)

. Mechanical preconditioning might be considered to reduce the riskof perioperative myocardial ischemia and infarction in patientsundergoing off-pump CABG (190–192). (Level of Evidence: B)

3. Remote ischemic preconditioning strategies using peripheral-extremity occlusion/reperfusion might be considered to attenuatethe adverse consequences of myocardial reperfusion injury (193–195). (Level of Evidence: B)

4. The effectiveness of postconditioning strategies to attenuate theadverse consequences of myocardial reperfusion injury is uncertain(196,197). (Level of Evidence: C)

See Online Data Supplements 2 to 4 for additional data onreconditioning.

Perioperative myocardial injury is associated with adverseutcomes after CABG (198–200), and available data sug-est a direct correlation between the amount of myonecrosisnd the likelihood of an adverse outcome (198,201–204)Section 5.2.4).

The etiologies of perioperative myocardial ischemia andnfarction and their complications (electrical or mechanical)ange from alterations in the determinants of global oregional myocardial oxygen supply and demand to complexiochemical and microanatomic, systemic, or vascular ab-ormalities, many of which are not amenable to routineiagnostic and therapeutic interventions. Adequate surgicaleperfusion is important in determining outcome, evenhough it may initially induce reperfusion injury. Varioustudies delineating the major mediators of reperfusion injuryave focused attention on the mitochondrial permeabilityransition pore, the opening of which during reperfusion

ncouples oxidative phosphorylation, ultimately leading to p

ell death (205). Although several pharmacological inter-entions targeting components of reperfusion injury haveeen tried, none has been found to be efficacious for thisurpose (182,184–189,205–207).The severity of reperfusion injury is influenced by numer-

us factors, including 1) the status of the patient’s coronaryirculation, 2) the presence of active ongoing ischemia ornfarction, 3) preexisting medical therapy (Sections 4.3 and.5), 4) concurrent use of mechanical assistance to improveoronary perfusion (i.e., intra-aortic balloon counterpulsa-ion), and 5) the surgical approach used (on pump or offump). CPB with ischemic arrest is known to induce theelease of cytokines and chemokines involved in cellularomeostasis, thrombosis, and coagulation; oxidative stress;dhesion of blood cell elements to the endothelium; andeuroendocrine stress responses; all of these may contributeo myocardial injury (208,209). Controlled reperfusiontrategies during CPB, involving prolonged reperfusionith warm-blood cardioplegia in conjunction with meta-olic enhancers, are rarely used in lieu of more routineethods of preservation (e.g., asystolic arrest, anterograde

r retrograde blood cardioplegia during aortic cross-lamping). Several studies suggest that the magnitude ofIRS is greater with on-pump CABG than with off-pumpABG (201,208,210–213).Initial studies of preconditioning used mechanical occlu-

ion of arterial inflow followed by reperfusion via aorticross-clamping immediately on institution of bypass or withoronary artery occlusion proximal to the planned distalnastomosis during off-pump CABG (190,191,214–217).ecause of concerns of the potential adverse cerebral effectsf aortic manipulation, enthusiasm for further study of thisechnique in on-pump CABG patients is limited (Section.2.1). Despite intense interest in the physiology of post-onditioning, few data are available (197). A small 2008tudy in patients undergoing valve surgery, which usedepeated manipulation of the ascending aorta, reported aeduction in surrogate markers of inflammation and myo-ecrosis (196). In lieu of techniques utilizing mechanicalcclusion, pharmacological conditioning agents are likely toe used. An alternative approach that avoids much (but notll) of the safety concerns related to potential vascular injurys remote preconditioning of arterial inflow to the leg ormore commonly) the arm via blood pressure cuff occlusion218). Two studies of patients undergoing on-pump CABGt a single center, the first of which used 2 differentyocardial protection strategies and the second of which

epeated the study with a standardized cold-blood cardio-legia routine, reported similar amounts of troponin releaseuring the 72 hours postoperatively, with no apparentomplications (193,195). A larger trial was unable to con-rm any benefits of a similar protocol, casting doubt on thetility of this approach (194).Volatile halogenated anesthetics and opioids have anti-

schemic or conditioning properties (32,33,219,220), and

ropofol has antioxidant properties of potential value in


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subjects with reperfusion injury (221,222). The salutaryproperties of volatile anesthetics during myocardial ischemiaare well known. Their negative inotropic and chronotropiceffects are considered to be beneficial, particularly in thesetting of elevated adrenergic tone that is common withsurgical stimulation. Although contemporary volatile agentsdemonstrate some degree of coronary arterial vasodilation(with isoflurane considered the most potent), the role of a“steal phenomena” in the genesis of ischemia is consideredto be trivial (33). In comparison to propofol/opioid infu-sions, volatile agents seem to reduce troponin release,preserve myocardial function, and improve resource utiliza-tion (i.e., ICU or hospital lengths of stay) and 1-yearoutcome (223–227). It is postulated that multiple factorsthat influence myocardial preservation modulate the poten-tial impact of a specific anesthetic regimen.

Observational analyses have reported an association be-tween elevated perioperative heart rates and adverse out-comes (228,229), but it is difficult to recommend a specificheart rate for all CABG patients. Instead, the heart rate mayneed to be adjusted up or down to maintain an adequatecardiac output (230,231). Similarly, controversy exists aboutmanagement of blood pressure in the perioperative period(232), particularly with regard to systolic pressure (233) andpulse pressure (234). Intraoperative hypotension is consid-ered to be a risk factor for adverse outcomes in patientsundergoing many types of surgery. Unique to CABG areunavoidable periods of hypotension associated with surgicalmanipulation, cannulation for CPB, weaning from CPB, orduring suspension and stabilization of the heart with off-pump CABG. Minimization of such periods is desirable butis often difficult to achieve, particularly in patients who areunstable hemodynamically.

2.2. Clinical Subsets

2.2.1. CABG in Patients With Acute MI:Recommendations

CLASS I1. Emergency CABG is recommended in patients with acute MI in

whom 1) primary PCI has failed or cannot be performed, 2) coronaryanatomy is suitable for CABG, and 3) persistent ischemia of asignificant area of myocardium at rest and/or hemodynamic insta-bility refractory to nonsurgical therapy is present (235–239). (Levelof Evidence: B)

2. Emergency CABG is recommended in patients undergoing surgicalrepair of a postinfarction mechanical complication of MI, such asventricular septal rupture, mitral valve insufficiency because ofpapillary muscle infarction and/or rupture, or free wall rupture(240–244). (Level of Evidence: B)

. Emergency CABG is recommended in patients with cardiogenicshock and who are suitable for CABG irrespective of the timeinterval from MI to onset of shock and time from MI to CABG(238,245–247). (Level of Evidence: B)

. Emergency CABG is recommended in patients with life-threateningventricular arrhythmias (believed to be ischemic in origin) in thepresence of left main stenosis greater than or equal to 50% and/or

3-vessel CAD (248). (Level of Evidence: C)

CLASS IIa1. The use of CABG is reasonable as a revascularization strategy in

patients with multivessel CAD with recurrent angina or MI within thefirst 48 hours of STEMI presentation as an alternative to a moredelayed strategy (235,237,239,249). (Level of Evidence: B)

2. Early revascularization with PCI or CABG is reasonable for selectedpatients greater than 75 years of age with ST-segment elevation orleft bundle branch block who are suitable for revascularizationirrespective of the time interval from MI to onset of shock (250–254). (Level of Evidence: B)

CLASS III: HARM1. Emergency CABG should not be performed in patients with persis-

tent angina and a small area of viable myocardium who are stablehemodynamically. (Level of Evidence: C)

2. Emergency CABG should not be performed in patients with no-reflow (successful epicardial reperfusion with unsuccessful micro-vascular reperfusion). (Level of Evidence: C)

See Online Data Supplement 5 for additional data on CABG inpatients with acute myocardial infarction.

With the widespread use of fibrinolytic therapy or pri-mary PCI in subjects with STEMI, emergency CABG isnow reserved for those with 1) left main and/or 3-vesselCAD, 2) ongoing ischemia after successful or failed PCI,3) coronary anatomy not amenable to PCI, 4) a mechanicalcomplication of STEMI (241,255,256), and 5) cardiogenicshock (defined as hypotension [systolic arterial pressure �90mm Hg for �30 minutes or need for supportive measures tomaintain a systolic pressure �90 mm Hg], evidence ofend-organ hypoperfusion, cardiac index �2.2 L/min/m2,and pulmonary capillary wedge pressure �15 mm Hg)(245,247). In the SHOCK (Should We Emergently Revas-cularize Occluded Coronaries for Cardiogenic Shock) trial,36% of patients randomly assigned to early revascularizationtherapy underwent emergency CABG (245). Althoughthose who underwent emergency CABG were more likelyto be diabetic and to have complex coronary anatomy thanwere those who had PCI, the survival rates of the 2 groupswere similar (247). The outcomes of high-risk STEMIpatients with cardiogenic shock undergoing emergencyCABG suggest that CABG may be preferred to PCI in thispatient population when complete revascularization cannotbe accomplished with PCI (236,238,246).

The need for emergency CABG in subjects with STEMIis relatively uncommon, ranging from 3.2% to 10.9%(257,258). Of the 1,572 patients enrolled in theDANAMI-2 (Danish Multicenter Randomized Study onThrombolytic Therapy Versus Acute Coronary Angioplastyin Acute Myocardial Infarction) study, only 50 (3.2%)underwent CABG within 30 days (30 patients initially treatedwith PCI and 20 given fibrinolysis), and only 3 patients (0.2%)randomly assigned to receive primary PCI underwent emer-gency CABG (257). Of the 1,100 patients who underwentcoronary angiography in the PAMI-2 (Primary Angioplasty inMyocardial Infarction) trial, CABG was performed before

hospital discharge in 120 (258).


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The in-hospital mortality rate is higher in STEMIpatients undergoing emergency CABG than in those un-dergoing it on a less urgent or a purely elective basis(239,257,259–264). In a study of 1,181 patients undergoingCABG, the in-hospital mortality rate increased as thepatients’ preoperative status worsened, ranging from 1.2% inthose with stable angina to 26% in those with cardiogenicshock (265).

Although patients requiring emergency or urgent CABGafter STEMI are at higher risk than those undergoing itelectively, the optimal timing of CABG after STEMI iscontroversial. A retrospective study performed before thewidespread availability of fibrinolysis and primary PCIreported an overall in-hospital mortality rate of 5.2% in 440STEMI patients undergoing CABG as primary reperfusiontherapy. Those undergoing CABG �6 hours after symptomonset had a lower in-hospital and long-term (10 years)mortality rate than those undergoing CABG �6 hours aftersymptom onset (237). Other studies have provided conflict-ing results, because of, at least in part, the lack of cleardelineation between STEMI and NSTEMI patients inthese large database reports (259,265). In an analysis of9,476 patients hospitalized with an acute coronary syn-drome (ACS) who underwent CABG during the indexhospitalization, 1,344 (14%) were STEMI patients withshock or intra-aortic balloon placement preoperatively(264). These individuals had a mortality rate of 4% whenCABG was performed on the third hospital day, which waslower than the mortality rates reported when CABG wasperformed earlier or later during the hospitalization (264).n studies in which the data from STEMI patients werenalyzed separately with regard to the optimal timing ofABG, however, the results appear to be different. In 1

nalysis of 44,365 patients who underwent CABG after MI22,984 with STEMI; 21,381 with NSTEMI), the in-ospital mortality rate was similar in the 2 groups under-oing CABG �6 hours after diagnosis (12.5% and 11.5%,espectively), but it was higher in STEMI patients than inSTEMI patients when CABG was performed 6 to 23

ours after diagnosis (13.6% versus 6.2%; p�0.006) (262).he groups had similar in-hospital mortality rates whenABG was performed at all later time points (1 to 7 days,to 14 days, and �15 days after the acute event) (262).

imilarly, in a study of 138 subjects with STEMI unrespon-ive to maximal nonsurgical therapy who underwent emer-ency CABG, the overall mortality rate was 8.7%, but itaried according to the time interval from symptom onset toime of operation. The mortality rate was 10.8% for patientsndergoing CABG within 6 hours of the onset of symp-oms, 23.8% in those undergoing CABG 7 to 24 hours afterymptom onset, 6.7% in patients undergoing CABG from 1o 3 days, 4.2% in those who underwent surgery from 4 to

days, and 2.4% after 8 days (266). In an analysis of datarom 150 patients with STEMI who did not qualify forrimary PCI and required CABG, the in-hospital mortality

ate increased according to the time interval between symp-

om onset and surgery (239). The mortality rate was 6.1%or subjects who underwent CABG within 6 hours of painnset, 50% in those who underwent CABG 7 to 23 hoursfter pain onset, and 7.1% in those who underwent CABGfter 15 days (239). Lastly, in another study, the timenterval of 6 hours was also found to be important inTEMI patients requiring CABG. The mean time fromymptom onset to CABG was significantly shorter inurvivors versus nonsurvivors (5.1�2.7 hours versus1.4�3.2 hours; p�0.0007) (235). In patients with cardio-enic shock, the benefits of early revascularization were appar-nt across a wide time interval between 1) MI and the onset ofhock and 2) MI and CABG. Therefore, although CABGxerts its most profound salutary effect when it is performed asoon as possible after MI and the appearance of shock, the timeindow in which it is beneficial is quite broad.Apart from the timing of CABG, the outcomes of

TEMI patients undergoing CABG depend on baselineemographic variables. Those with mechanical complica-ions of STEMI (e.g., ventricular septal rupture or mitralegurgitation caused by papillary muscle rupture) have aigh operative mortality rate (240–242,244,255,267). In atudy of 641 subjects with ACS, 22 with evolving STEMInd 20 with a mechanical complication of STEMI wereeferred for emergency CABG; the 30-day mortality rateas 0% in those with evolving STEMI and 25% in thoseith a mechanical complication of STEMI (268). In thoseith mechanical complications, several variables were pre-ictive of death, including advanced age, female sex, car-iogenic shock, the use of intra-aortic balloon counterpul-ation preoperatively, pulmonary disease, renal insufficiency,nd magnitude of elevation of the serum troponin concen-ration (235,239,263,265,266,269,270).

.2.2. Life-Threatening Ventricular Arrhythmias:ecommendations

CLASS I1. CABG is recommended in patients with resuscitated sudden cardiac

death or sustained ventricular tachycardia thought to be caused bysignificant CAD (�50% stenosis of left main coronary artery and/or�70% stenosis of 1, 2, or all 3 epicardial coronary arteries) andresultant myocardial ischemia (248,271,272). (Level of Evidence: B)

CLASS III: HARM1. CABG should not be performed in patients with ventricular tachy-

cardia with scar and no evidence of ischemia. (Level of Evidence: C)

See Online Data Supplement 6 for additional data on life-threatening ventricular arrhythmias.

Most studies evaluating the benefits of CABG in patientswith ve