Indications and timing of CABG 1. ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery 2. Influence of time elapsed between myocardial infarction and coronary artery bypass grafting surgery on operative mortality

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Indications and timing of CABG1. ACC/AHA 2004
Guideline Update for Coronary Artery Bypass
Graft Surgery2. Influence of time elapsed
between myocardial infarction and coronary
artery bypass grafting surgery on operative
mortality European Journal of
Cardio-thoracic Surgery 29 (2006) 319323

• 4A Ri

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Introduction

• 1991 guidelines the evidence is complete that
  the coronary artery bypass operation relieves
  angina in most patients.
• Lancet 19983521419-25.
• J Thorac Cardiovasc Surg 198895773-81
• Bypass surgery also relieved angina better than
  coronary stents in a randomized trial
• N Engl J Med 20013441117-24.
• Relief angina symptoms and prolongation of life
• 78 yrs survival superior for CABG compared with
  PTCA
• J Am Coll Cardiol 2000351116-1129.

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Early intervention of CABG

• Advantage
• Limitation of infarct expansion
• Avoidance of LV dysfunction heart failure
• Disadvantage
• Ischemia-reperfusion injury hemorrhagic
  infarction
• The best window for intervention is quite an art

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2004 ACC/AHA guidelines

• Class I
• procedure/treatment should be performed/
  administered
• Class IIa
• it is reasonable to perform/administer
• Class IIb
• procedure/treatment is considered
• Class III
• procedure/treatment is not helpful and may be
  harmful

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Asymptomatic or mild Angina

• Indications class I
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the
• proximal LAD and proximal left
  circumflex artery.
• 3-vessel disease (EF less than 0.50)
• Indications class IIa
• proximal LAD stenosis with 1- or 2-vessel
  disease. ( Class I if extensive ischemia is
  documented by noninvasive study and/or LVEF is
  less than 0.50.)
• Indications class IIb
• 1- or 2-vessel disease not involving the proximal
  LAD (If a large area of viable myocardium and
  high-risk criteria are met on noninvasive
  testing this recommendation becomes Class I)

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Asymptomatic or mild Angina

• 108/6326 (1.7)mortality rate in this categery
• European Journal of Cardio-thoracic Surgery 29
  (2006) 319323
• Extent of coronary disease
• Timing was not recommended in the guidelines

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Stable angina

• Indications Class I
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the
• proximal LAD and proximal left
  circumflex artery.
• 3-vessel disease (benefits greater EF less than
  0.50 )
• 2-vessel disease with significant proximal LAD
  stenosis and either EF less than 0.50 or ischemia
  on noninvasive testing
• 1- or 2-vessel CAD without significant proximal
  LAD stenosis but with a large area of viable
  myocardium and high-risk criteria on noninvasive
  testing
• Disabling angina despite maximal noninvasive
  therapy
• Indications class IIa
• Proximal LAD stenosis with 1-vessel disease

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Stable angina

• The patient factors most influencing a decision
  to recommend CABG
• Presence of severe proximal multivessel coronary
  disease
• LV dysfunction
• Strongly positive stress test
• Diabetes
• Timing was not mentioned
• PCI did not reduce the risk of death myocardial
  infarction stroke or hospitalization when added
  to optimal medical therapy
• N Engl J Med 2007356.

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Unstable angina/ Non-ST-segment elevation (NSTEMI)

• Indications class I
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the
• proximal LAD and LCX.
• Ongoing ischemia not responsive to maximal
  nonsurgical therapy.
• Indications class IIa
• Proximal LAD stenosis with 1- or 2-vessel disease

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Unstable angina/ Non-ST-segment elevation (NSTEMI)

• Medical vs CABG overall no difference
• EF (0.3 to 0.58) 3-vessel disease LV
  dysfunction with EKG change improved in survival
  with CABG
• 5-year overall survival CABG (88.8) or PTCA
  (86.1 P equals NS)
• Cardiac mortality PTCA (8.8) vs CABG (4.9)
• The results for postoperative morbidity
• six predictors sex age left ventricular
  function timing of surgery extent of coronary
  artery disease and the type of myocardial
  protection used
• Tn I level Circulation Volume 114(1) July 4
  2006

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Prognostic value of preoperative cardiac troponin
I in patients undergoing emergency CABG
Gray bar NSTEMI Black bar STEMI
Circulation Volume 114(1) suppl I.July 4 2006
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Circulation Volume 114(1) suppl I.July 4 2006
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ST-Segment Elevation MI (STEMI)

• Emergency or urgent CABG indication
• Failed angioplasty (PTCA)
• Ventricular septal rupture or mitral valve
  insufficiency
• In the early hours(612 hrs) of evolving STEMI
  (class IIa)
• Persistent or recurrent ischemia refractory to
  medical therapy
• Cardiogenic shock in lt75 y/o LBBB
• Post. MI developed shock within 36 hrs CABG
  should be performed within 18 hrs
• Life-threatening ventricular arrhythmias with 50
  left mainstenosis and/or 3-vessels disease

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ST-Segment Elevation MI (STEMI)

• Indications
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the
• proximal LAD and LCX.
• Ongoing ischemia not responsive to maximal
  nonsurgical therapy.
• Beyond 7 days after infarction the criteria for
  revascularization
• Risk factors Besides time interval between MI
  and CABG
• Age
• renal insufficiency
• previous stroke
• LVEFlt 40

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European Journal of Cardio-thoracic Surgery 29
(2006) 319323
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Asterisk plt0.05 vs no MI
European Journal of Cardio-thoracic Surgery 29
(2006) 319323
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European Journal of Cardio-thoracic Surgery 29
(2006) 319323
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European Journal of Cardio-thoracic Surgery 29
(2006) 319323
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European Journal of Cardio-thoracic Surgery 29
(2006) 319323
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Poor LV function

• Indications
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the proximal LAD and proximal LCX.
• 3-vessel disease

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Poor LV function

• low EF and clinical heart failure are predictive
  of higher operative mortality rates with CABG
• EFs less than 0.30
• although having a higher immediate risk for
  bypass surgery may achieve a greater long-term
  gain in terms of survival advantage

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CABG after failed PTCA

• Emergency bypass for failed PTCA
• a higher rate of death and subsequent MI compared
  with elective bypass surgery
• Factors that influence the outcome of surgery
• LV dysfunction older age and previous MI
• Extent of multivessel disease collaterals
• Total ischemic time (a delay in transport to the
  operating room)
• Cooperative interaction between the cardiologist
  cardiac surgeon and anesthesia team are
  necessary to expedite resuscitation transfer
  and revascularization of patients with failed PTCA

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Patients With Previous CABG

• Indication
• Repeating angina despite optimal nonsurgical
  therapy
• Vein grafts stenosis native-vessel CAD
• Percutaneous procedures have been ineffective in
  the treatment of atherosclerotic vein graft
  stenoses
• redo-CABG benefit improvement in LVEF heart
• failure symptoms angina and mid-term
  prognosis
• Heart. 93(2)221-5 2007 Feb
• Use of the left IMA to LAD graft platelet
  inhibitors and statin decreased reoperation rate

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Homework

• Indications for CABG
• Significant (50) left main coronary artery
  stenosis.
• Significant (greater than or equal to 70)
  stenosis of the proximal LAD and proximal left
  circumflex artery.
• 3-vessel disease (EF less than 0.50)
• Timing of CABG for AMI(NSTEMI or STEMI)
• gt65 y/o gt30 days
• lt65 y/o gt7 days
• Previous CABG gt1 year