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coronary artery bypass grafting (CABG)

Vein or artery grafted surgically to permit blood to travel from the aorta to a branch of the coronary artery at a point past an obstruction. Indications: 1) recurrent myocardial ischemia (unstable angina) secondary to coronary artery disease - *not anatomically appropriate for PTCA (PCI) 2) coronary artery disease with mechanical complications that require surgical repair a) *mitral regurgitation [18] b) ventricular septal rupture 3) myocardial infarction a) urgent CABG for failed PCI or thrombolytic therapy after STEMI, includes patients with diabetes mellitus b) *with impaired left ventricular function c) *2 or more coronary vessels with > 50% stenosis d) *viable left ventricular myocardium with abnormal wall motion 4) stable angina a) *with normal left ventricular function b) significant left main coronary artery disease c) proximal left anterior descending artery disease & proximal left circumflex artery disease - *>= 70% stenosis d) 3-vessel disease or severe 2-vessel disease 5) coronary artery disease in patients with diabetes mellitus 6) CABG is recommended for patients with - left main disease - triple vessel disease & reduced systolic function - multivessel disease with involvement of the proximal left anterior descending artery in the presence of diabetes [2] CABG improves survival in patients with: 1) left main coronary artery disease (appears controversial) - either PCI or CABG reasonable for left main coronary artery disease [39] 2) three vessel disease & a) *moderate left ventricular dysfunction, or b) myocardial ischemia at low workloads 3) multivessel disease with involvement of proximal left anterior descending artery (LAD) CABG improves quality-of-life for up to 36 months in patients with ischemic left ventricular dysfunction [23] Advantages: 1) CABG is indicated for patients with diabetes mellitus who would otherwise be eligible for PTCA (better 5 year survival, 80% vs 65%) [10] 2) CABG is superior to PTCA (PCI) for patients > 65 years of age [10] Contraindications: 1) Caution: (Risk factors) a) age b) female sex c) poor left ventricular function d) left main coronary artery disease e) unstable angina f) diabetes mellitus 2) CABG does NOT prevent myocardial infarction 3) CABG does NOT reduce incidence of ventricular arrhythmias Benefit/risk: - number needed to treat (NNT) [24] - 25 to prevent 1 death within 10 years - 10-14 to prevent 1 non-fatal MI within 10 years - number needed to harm [24] - 83 to cause 1 death - 100 to cause 1 non-fatal stroke - 43 to cause 1 case of renal failure - 3-5 to cause 1 case of cognitive impairment - 14 cases of extended life support - 28 patients need reoperation Procedure: - saphenous vein graft* - radial artery graft* - internal thoracic artery graft - bilateral & single internal thoracic artery graft grafts with no difference in mortality in patients with multivessel disease [36] * compared saphenous vein graft, radial artery graft for CABG associated with lower rate of adverse cardiac events (RR=0.67) & a lower rate of occlusion at 5 years (RR=0.44) [34] Laboratory: - elevation of markers of myocardial infarction after bypass associated with increased mortality at 1 year [13] - serum creatine kinase MB - serum troponin I Radiology: - myocardial perfusion imaging to assess myocardial viability have not uniformly shown which patients will benefit from CABG [38] Complications: 1) cognitive impairment [4,8] a) short term (53% at hospital discharge) b) long-term (24% at 6 months, 42% at 5 years) c) use of cardiopulmonary bypass pump a factor [6] - no difference on or off bypass pump [8], 50% at 5 years d) strongest predictor of postoperative cognitive decline is preoperative cognitive impairment [19] e) risk of cognitive impairment after CABG, PCI or cardiac valve replacement is uncertain [25] 2) delirium after CABG is associated with increassed mortality [12] 3) pulmonary complications common [7] a) pneumonia, atelectasis, pleural effusion, ventilator dependence b) inspiratory muscle training daily for 2 weeks prior to CABG reduces pulmonary complications [7] 4) harvesting of veins for coronary artery bypass grafting a) wound infection b) postoperative pain c) vein graft failure d) subclavian steal (internal mammary artery) 5) endoscopic harvesting with higher rate of composite of death, MI, & revascularization (3 year hazard ratio, 1.22) than open harvesting 6) bilateral vs single internal thoracic artery grafting associated with early excess of sternal wound complications [30] 7) accelerated idioventricular rhythm (ventricular tachycardia) is common following coronary reperfusion & does not require intervention when it occurs within the 1st 24 hours [2] 8) new-onset post-operative atrial fibrillation [32] - anticoagulation indicated - long-term risk of thromboembolic stroke - < preoperative atrial fibrillation (RR=0.67) - ~ same as no post-CABG atrial fibrillation (RR=1.11) [32] - 15 year RR=0.55 vs no anticoagulation 9) infection - invasive infection with Mycobacterium chimaera due to contamination of heater-cooler devices* [28] 10) graft aneurysm [35] * LivaNova's Stockert 3T heater-cooler devices used to help regulate blood temperature during bypass surgert in 60% of bypass surgeries in the U.S. [28] Management: - discontinuation of aspirin prior to CABG (4 days) neither beneficial or harmful [26] - aspirin administration during 1st 48 hours after CABG reduces in hospital mortality [5] - tight glycemic control (serum glucose 90-120 mg/dL) increases the incidence of hypoglycemic events & does not result in any significant improvement in clinical outcomes relative to moderate glycemic control (serum glucose 120-180 mg/dL) [14] - cardiac stress testing (stress echocardiography) after CABG may be appropriate [17] - preoperative beta-blocker is not associated with improved outcomes in patients without recent myocardial infarction [22] - statin use (equivalent of >= 20 mg atorvastatin) within 24 hours before CABG associated with reduced 30-day mortality [31] (1.7% vs 3.8% for no statin use within 72 hours) - routine electrocardiogram, cardiac stress testing or angiography (invasive or CT angiography) in asymptomatic patients after successful CABG not indicated [2] - aspirin (81 mg) + clopidogrel, ticagrelor or prasugrel indicated for 12 months after CABG in patients with MI or acute coronary syndrome [2] - aspirin or clopidogrel after CABG in patients with stable chronic angina pectoris [2] - ticagrelor alone superior to aspirin alone, but non-inferior to ticagrelor + aspirin, in patients undergoing elective CABG with saphenous vein graft (1 year graft patency) [33] - delay non-cardiac surgery for at least 30 days after CABG [2,29] - aspirin + ticagrelor associated with reduced risk for venous graft failure (RR=0.5); same for aspirin + clopidogrel (RR=0.6) [37] Notes: 1) CABG provides relief from angina 2) closure rate on saphenous vein grafts are 20% at 1 year 3) CABG superior to PCI for severe coronary artery disease [9] 4) off-pump vs on pump CABG a) better outcomes & graft patency for on pump CABG [20] b) no significant advantage of off-pump vs on pump CABG [16] c) overall mortality 50% lower for on-pump versus off-pump CABG [21]

Related

Bypass Angioplasty Revascularization Investivation (BARI) coronary stent/coronary stenting percutaneous coronary intervention (PCI) percutaneous coronary intervention (PCI)/coronary stent vs CABG

Specific

minimally invasive direct coronary artery bypass (MIDCAB)

General

cardiac surgery (heart surgery) arterial bypass graft; bypass surgery coronary artery revascularization

References

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