Coronary Artery Bypass Graft

Aka: Coronary Artery Bypass Graft, CABG

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II. Efficacy

  1. Graft patency after Coronary Artery Bypass Graft
    1. Internal mammary graft stays patent in >90% for >10 years
    2. Saphenous vein graft patency is much more tenuous
      1. Year 2: 85% are patent
      2. Year 5: 75% are patent
      3. Year 8: 65% are patent
  2. References
    1. Loop (1986) N Engl J Med 314:1 [PubMed]

III. Precautions: PTCA as an alternative for Left Main Disease

  1. PTCA with DES may be a reasonable alternative to CABG in moderate coronary disease cases previously limited to CABG (e.g. Left main disease)
    1. For moderate left main disease, PTCA with DES outcomes over 10 years are similar to CABG outcomes
    2. PTCA is a safe, much less invasive procedure than CABG
    3. CABG has a higher rate of perioperative Cerebrovascular Accident
  2. Caveats
    1. CABG is associated with decreased Angina
    2. CABG is associated with a better outcome with severe left main disease or multi-vessel disease
    3. CABG has better outcomes when repeat revascularization is required
  3. References
    1. Rihal (2012) Mayo POIM Conference, Rochester

IV. Indications: Absolute Indications in Stable CAD

  1. Disabling Angina despite maximal medical therapy given acceptable surgical risk
    1. If atypical Angina, confirm cardiac ischemia is cause of symptoms
  2. Significant proximal LAD stenosis (>70%)
  3. Significant left main Coronary Artery stenosis
  4. One to two vessel CAD (without proximal LAD stenosis)
    1. LARGE area of viable Myocardium and
    2. High risk criteria on noninvasive testing
  5. Two vessel CAD
    1. Significant proximal LAD stenosis and
    2. Ejection Fraction (EF) <50% or ischemia on noninvasive testing
  6. Three vessel CAD
    1. Especially if Ejection Fraction (EF) <50%

V. Indications: Possible Indications in Stable CAD

  1. One vessel CAD and
    1. Proximal LAD Stenosis
  2. One to two vessel CAD (without proximal LAD stenosis)
    1. MODERATE area of viable Myocardium and
    2. Ischemia on noninvasive testing

VI. Indications: Avoid CABG in these patients (cases in which CABG is NOT recommended)

  1. Borderline Coronary Artery stenosis (<60%) not involving left main Coronary Artery and negative noninvasive testing
  2. Insignificant Coronary Artery stenosis (<50%)
  3. One to two vessel CAD (without proximal LAD stenosis)
    1. SMALL area of viable Myocardium and
    2. No ischemia on noninvasive testing and
    3. Mild symptoms unlikely to be ischemia or inadequate medical management trial

VII. Complications (based on STS Guidelines from 2008)

  1. Transfusion required: <50%
  2. Incomplete revascularization: <20%
  3. Major morbidity (e.g. CVA): <5%
  4. Mortality: <2%

VIII. Management: Perioperative Medications and Interventions to reduce readmission rates

  1. Aspirin
    1. Dose: 325 mg orally daily for one year, then 81 mg daily
    2. Start and continue 81 mg daily if comorbid bleeding risks
  2. Beta Blockers
    1. Start at least several days prior to CABG to reduce Atrial Fibrillation risk
    2. Titrate Heart Rate to 60 bpm as tolerated
    3. Preferred agents (best evidence): Metoprolol Succinate, Carvedilol, bisproprolol
    4. Duration
      1. Continue for 1 month following CABG at a minimum
      2. Continue for at least 3 years following Myocardial Infarction
      3. Continue indefinately for Systolic Dysfunction
  3. Statins
    1. High dose Statin (e.g. Atorvastatin 80 mg) for most patients
    2. Low dose Statin for those cannot tolerate high dose
  4. Cardiac Rehabilitation
    1. Reduces risk of future Myocardial Infarctions
    2. Reduces readmission rates and mortality rates
    3. Reinforces Medication Compliance
  5. Follow-up
    1. Phone follow-up within 2-3 days of CABG discharge
    2. Office follow-up within 7-14 days of CABG discharge
  6. References
    1. (2015) Presc Lett 22(5): 25
    2. Kulik (2015) Circulation 131(10):927-64 [PubMed]

IX. References

  1. Eagle (2004) Circulation 110(9): 1168-76 [PubMed]

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