Kim Eagle, MD

1
New guidelines for CABG

• Kim Eagle, MD
• Director of Clinical Cardiology
• University of Michigan at Ann Arbor
• Ann Arbor, MI

2
New guidelines for CABG
Why new guidelines?

• The first ACC/AHA guidelines were in 1991.
• All aspects of coronary care have advanced since
  then.
• Surgical guidelines needed updating.

Kirlin JW, et al. J Am Coll Cardiol
199117543-589
3
New guidelines for CABG
Review of the literature

• Medical vs surgical therapy for stable coronary
  heart disease was re-reviewed.
• Registry data, and trials comparing angioplasty
  vs surgical therapy were also reviewed.

Eagle K, et al. J Am Coll Cardiol
1999341262-1347
4
New guidelines for CABG
General indications for surgery

• Left main coronary artery disease
• 3-vessel coronary disease with any of
• more advanced angina
• reduced resting LV function
• very positive exercise stress test
• 2-vessel disease with very important proximal LAD
  stenosis, especially with any of above indicators

5
New guidelines for CABG
Perioperative risk

• A risk tool with a scoring system for the
  prediction of perioperative risk is included with
  these guidelines.
• The tool is based on a logistical regression
  model and calculates the risk of
• death,
• stroke, and
• deep sternal wound infection.

6
New guidelines for CABG
Focal neurological deficits

• Major strokes are caused by
• emboli from atheromatous plaque in the
  ascending aorta
• carotid disease
• cardiovascular emboli from the left ventricle
  or atrium

7
New guidelines for CABG
Ascending atheromata

• Multiple options in the patient with particularly
  mobile atheromata
• 1) use a no cross-clamp technique
• (eg, internal mammary graft to LAD
  and further percutaneous treatment options
  if necessary)
• 2) possibility of replacing the aorta with a
  graft

8
New guidelines for CABG
Patients at risk

• At risk patients for cardiac sources of emboli
  are those with recent anterior-wall MI and
  unsuspected atrial fibrillation.
• The management and disposition of patients with
  carotid disease is also discussed in the
  guidelines.

9
New guidelines for CABG
Other issues

• The frequency of myocardial dysfunction after
  bypass surgery may be reduced by
• the use of the internal mammary artery
• (reduces long-term and perioperative risk)
• the use of blood cardioplegia
• (for acute ischemic or chronically impaired
  hearts)
• the use of IABP for perioperative support
• antibiotics to
• (reduce perioperative infection)
• prophylaxis against atrial fibrillation

10
New guidelines for CABG
Secondary prevention

• Aggressive control of lipid levels
• (LDLlt130 mg/dL or even lt100 mg/dL)
• Smoking cessation
• Depression and social isolation
• (risk factors for poor outcome)
• Cardiac rehabilitation

11
New guidelines for CABG
Artery vs vein

• Vein grafts are inferior conduits compared to
  mammary arteries.
• Other arteries fall in-between vein grafts and
  the mammary artery.
• 3) The data on total arterial bypass is not yet
  solid.
• The current US standard is IMA to LAD, and vein
  graft to other territories.

12
New guidelines for CABG
Using both mammary arteries

• The bilateral use of internal mammary arteries
  may lead to a greater risk of deep sternal wound
  infection in obese and diabetic patients.
• This leads to an unacceptable perioperative
  trade-off in mortality.
• The use of both mammary arteries is still an area
  of active debate.

13
New guidelines for CABG
Minimally invasive CABG

• Rapidly evolving technology, but questions
  remain
• high learning curve
• insufficient grafts
• limited access to marginal vessels
• Not all patients benefit from the current
  technology.

14
New guidelines for CABG
Quality of care

• The new guidelines offer tools for use in day to
  day care
• risk prediction tool
• guidelines for complication assessment
• incorporate into pre-set orders for
  peri-operative care
• patient materials

15
New guidelines for CABG
Availability of guidelines

• American College of Cardiology
• http//www.acc.org/clinical/guidelines/bypass/dirI
  ndex.htm

Eagle K, et al. J Am Coll Cardiol
1999341262-1347