The right coronary artery can be approached by using a right anterior thoracotomy. Table 9 provides a review of pharmacological approaches in the randomized trials. Patients with advanced preoperative renal dysfunction who undergo CABG surgery have an extraordinarily high rate of requiring postoperative dialysis. The benefits include better physical mobility and perceived health. use post CABG were available on approximately 1,580 subjects and 953 of those had angiography at 1 year. (2) Antimicrobial prophylaxis in surgery. Long-term patency of these alternative grafts has not been extensively studied. CI indicates confidence interval; CABG, coronary artery bypass graft. This can be accomplished by regional blood blanks at the time of donation or at the bedside by use of a transfusion filter. In some studies, additional predictors include angina class, hypertension, prior MI, renal dysfunction, and clinical congestive heart failure. Administration of corticosteroids before cardiopulmonary bypass may reduce complement activation and release of proinflammatory cytokines. The aspirin should be started within 24 hours after surgery because its benefit on saphenous vein graft patency is lost when begun later. 1999;100:1464-1480. During operation, loss of the pericardial constraint may lead to acute dilatation of the dysfunctional right ventricle, which then fails to recover even with optimal myocardial protection and revascularization. More recently, short-term follow-up studies suggest that patients undergoing multiple arterial grafts have even lower rates of reoperation. In een kritische review van studies naar gecombineerde en gestageerde carotisendarteriëctomie en CABG-operaties worden percentages beroerte/overlijden gemeld van 6 tot 9%, waarvan 40% aan de ipsilaterale zijde (=kant van de carotisstenose) (Naylor, 2004). Thus, in patients with modest reductions in LV function, significant left main or 3-vessel disease, and/or unstable angina, coronary revascularization can lead to relief of coronary symptoms, improvement in overall functional status, and improved long-term survival in this select high-risk patient population. Recently, the radial artery has been used more frequently as a conduit for coronary bypass surgery. In patients for whom mammary artery, radial artery, and standard vein conduits are unavailable, the in situ right gastroepiploic artery, the inferior epigastric free artery graft, and either lesser saphenous or upper-extremity vein conduits have been used. Among patients who develop postoperative renal dysfunction (defined as a postoperative serum creatinine level >2.0 mg/dL or an increase in baseline creatinine level of >0.7 mg/dL), 18% require dialysis. Accordingly, although the clinical trials have provided important insights, their interpretation must be viewed with caution, given the evolution in all types of coronary therapies. 1994;344:563–570. Neurological impairment after bypass surgery may be attributable to hypoxia, emboli, hemorrhage, and/or metabolic abnormalities. While observational studies have suggested that hormone replacement therapy in postmenopausal women leads to a reduction in all-cause mortality, a recent, randomized trial for secondary coronary prevention failed to show a beneficial effect on the overall rate of coronary events. Within these subsets, the cost-effectiveness of CABG compares favorably with that of other accepted medical therapies. 1. Hemodynamically significant carotid stenoses are thought to be responsible for up to 30% of early postoperative strokes. Ischemia in the non-LAD distribution with a patent internal mammary graft to the LAD supplying functioning myocardium and without an aggressive attempt at medical management and/or percutaneous revascularization. Abstract: CABG, abbreviation for coronary artery bypass graft is a type of surgery used to bypass a blockage in one of the P values for heterogeneity across studies were 0.49, 0.84, and 0.95 at 5, 7, and 10 years, respectively. Patients with severe LV dysfunction have increased perioperative and long-term mortality compared with patients with normal LV function. If one defines 3-vessel disease as stenosis of 50% or more in all 3 major coronary territories, the overall extension of survival was 7 months in CABG patients compared with medically treated patients. In patients with severe, proximal LAD stenosis, the relative risk reduction due to bypass surgery compared with medical therapy was 42% at 5 years and 22% at 10 years. use prohibited. “ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)” was approved by the American College of Cardiology Board of Trustees in March 1999 and by the American Heart Association Science Advisory and Coordinating Committee in July 1999. Pharmacological Strategies for Prevention of Atrial Fibrillation (AF) After Coronary Artery Bypass Graft Surgery. One- or 2-vessel disease not involving significant proximal LAD stenosis, in patients (1) who have mild symptoms that are unlikely due to myocardial ischemia or have not received an adequate trial of medical therapy and (A) have only a small area of viable myocardium or (B) have no demonstrable ischemia on noninvasive testing. However, in the cardiac surgery literature, the results have been mixed. Median survival for surgically treated patients was 13.3 years versus 6.6 years in medically treated patients. Reprinted with permission from Managano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Managano DT. 1. The trials defined significant left main coronary artery stenosis as a >50% reduction in lumen diameter. Such an approach is relevant to the patient whose ascending aorta is involved with severe atherosclerosis, for which the implantation of free vein grafts or arterial grafts leads to risk for atheroembolism. Proper timing and duration of corticosteroid application are incompletely resolved. In appropriate candidates, CABG appears to offer morbidity and mortality benefit in such patients. Currently, “less-invasive” CABG surgery can be divided into 3 categories: (1) off-bypass CABG performed through a median sternotomy with a smaller skin incision, (2) minimally invasive direct CABG (MID-CAB) performed through a left anterior thoracotomy without cardiopulmonary bypass, and (3) port-access CABG with femoral-to-femoral cardiopulmonary bypass and cardioplegic arrest with limited incision. Most recently, the results of SPRINT (Systolic Blood Pressure Intervention Trial) were published, noting significantly lower event rates and improved survival for patients with cardiovascular risk factors who were randomized to intensive BP reduction with a target systolic pressure <120 mmHg, compared with a standard systolic BP <140 mmHg.25 Many medical conditions that are common in the CABG population were key exclusion criteria for the trial, such as a history of diabetes, previous stroke, heart failure, and chronic kidney disease. While moderate to severe degrees of obstructive pulmonary disease represent a significant risk factor for early mortality and morbidity after CABG, it is also true that with careful preoperative assessment and treatment of the underlying pulmonary abnormality, many such patients are successfully carried through the operative procedure. 9, 21 Two other studies which showed the lowest incidence of post‐CABG AF among the included RCTs, only used low‐to‐moderate dosages of BB for prophylaxis. Age alone should not be a contraindication to CABG if it is thought that long-term benefits outweigh the procedural risk. However, by 5 years, the cumulative cost of PTCA compared with initial surgical therapy is within 5% of CABG, or a difference of <$3000. Three-vessel disease in asymptomatic patients or those with mild or stable angina 4. Table 2 can be used to estimate the risk for an individual patient. 1999;34:1275) for detailed information concerning the trials listed here in column 1. Future studies from this group will help determine whether early high-intensity statin therapy has an impact on the development of vein graft disease in the years that follow surgery.21,22, Figure 1: Incidence of Vein Graft Stenosis or Occlusion at 1 Year Among Patients Randomized to Atorvastatin 10 mg or Atorvastatin 80 mg Early After CABG. Preoperative antibiotic administration reduces the risk of postoperative infection 5-fold. 1. Other opportunities that exist to improve the long-term clinical outcomes after CABG include the aggressive management of hypertension and diabetes mellitus, smoking cessation, weight loss, and cardiac rehabilitation. 142, Issue 16_suppl_2, Basic, Translational, and Clinical Research, ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations, Global Impact of the 2017 ACC/AHA Hypertension Guidelines, 1.5 g preoperatively 1.5 g after CPB 1.5 g Q12×48, First-line agents; low toxicity; pharmacokinetics vary; shorter prophylaxis duration <24 h may be equally efficacious for cefuroxime, 1 g Q6×48 (Initial dose to be given 30–60 minutes before skin incision), 1 g Q12/h/until lines/tubes out At least 2 doses, Reserved for penicillin-allergic; justified, (During 30–60-minute infusion timed to end before skin incision), Resumption of patient’s preoperative β-blocker, Resumption of β-blocker reduced AF by 45%, Nearly 5-fold decrease in incidence; if no longer needed after revascularization, may taper as outpatient, Postoperative initiation (10±7 h postoperatively), Odds ratio 0.17; confidence interval 0.03–0.98 in favor of β-blocker over controls in meta-analysis, Preoperatively (begun 72 h before operation), Excellent option if preoperative phase practical, Class III properties; sotalol not tolerated in 10% of patients, Continuous IV infusion for a total of 178 mEq over first 4 postoperative days, Goal is normal serum magnesium: ≥1 mmol/L, <2 mEq/L, which is usually low after cardiopulmonary bypass, 600 mg Orally daily for 7 days preoperatively; then 200 mg PO daily postoperatively; stop at discharge; total=4.8 g, Mixed group of coronary and valve patients, explaining very high AF incidence, 300 mg Intravenous bolus; then 1.2 g over 24 h for 2 days; then 900 mg every 24 h for 2 days, for a total of 4.5 g, Coronary bypass patients only in this study, Propafenone offers a less negative inotropic option for poor left ventricular function population, Carotid duplex ultrasound in defined population, Significant reduction in blood transfusion requirement, β-Blockers to prevent postoperative atrial fibrillation, Propafenone or amiodarone are alternatives if contraindication to β-blocker (Table 9, Minimize diffuse inflammatory response to cardiopulmonary bypass, Aspirin to prevent early vein-graft attrition, Ticlopidine or clopidogrel are alternatives if contraindications to aspirin, Cholesterol-lowering agent plus low-fat diet if low- density lipoprotein cholesterol >100 mg/dL, 3-Hydroxy-3-methyglutaryl/coenzyme A reductase inhibitors preferred if elevated low-density lipoprotein is major aberration, Smoking cessation education, and offer counseling and pharmacotherapies, Copyright © 1999 by American Heart Association. Beyond survival, bypass surgery may be indicated to alleviate symptoms of angina above and beyond medical therapy or to reduce the incidence of nonfatal complications like MI, congestive heart failure, and hospitalization. Another method to reduce the inflammatory response is perioperative leukocyte depletion through hematologic filtration. Aggressive treatment of hypercholesterolemia reduces progression of atherosclerotic vein graft disease in patients after bypass surgery. Placement of the intra-aortic balloon pump immediately before operation appears to be as effective as placement on the day preceding bypass surgery. Most of the trials did not have a long-term follow-up, ie, 5 to 10 years, and therefore were unable to provide clear inferences regarding long-term benefit of the 2 techniques in similar populations. A recent, preoperative cerebrovascular accident represents a situation in which delaying surgery may reduce the perioperative neurological risk. “ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)” was approved by the American College of Cardiology Board of Trustees in March 1999 and by the American Heart Association Science Advisory and Coordinating Committee in July 1999.When citing this document, the American College of Cardiology and the American Heart Association request that the following citation format be used: Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent W, O’Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). Perioperative atheroembolism from aortic plaque is thought to be responsible for approximately one third of strokes after CABG. *1, 1. 1. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y 12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I). 2. Statins have been shown to reduce the progression of native artery atherosclerosis, slow the process of vein graft disease, and reduce adverse cardiovascular events following surgical revascularization.1,2,16 For many years, statins were administered after CABG to reduce low-density lipoprotein levels to <100 mg/dL. The BARI trial suggested higher mortality associated with PTCA in several high-risk groups, including those with diabetes, unstable angina, and/or non–Q wave MI, and in patients with heart failure. Table 10. Foreign body in crucial anatomic position. Several of the other randomized trials, albeit with smaller numbers of patients, failed to show this trend. The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of diagnostic tests and therapies for patients with known or suspected cardiovascular disease. Contrariwise, patients with 1-vessel disease not involving the proximal LAD had improved survival with PTCA. The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of diagnostic tests and therapies for patients with known or suspected cardiovascular disease. Proximal LAD disease with 1- or 2-vessel disease.‡3. As noted in recent guideline statements,2,3 postoperative antiplatelet agents and lipid-lowering therapies continue to be mainstays of secondary prevention. New-onset postoperative atrial fibrillation occurs in ≈30% of post-CABG patients, particularly on the second and third postoperative days, and is associated with a 2- to 3-fold increased risk of postoperative stroke. After adjustment for various covariates, bypass surgery in the New York State registry experience was associated with longer survival in patients with severe proximal LAD stenosis and/or 3-vessel disease. Among all patients, the extension survival of CABG surgical patients compared with medically treated patients was 4.3 months at 10 years of follow-up. Overall, procedural complications were low for both procedures but tended to be higher with CABG surgery (Table 6). 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