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]

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Related Studies

Ontology: Coronary Artery Bypass Surgery (C0010055)

Definition (MEDLINEPLUS)

In coronary artery disease (CAD), the arteries that supply blood and oxygen to your heart muscle grow hardened and narrowed. You may try treatments such as lifestyle changes, medicines, and angioplasty, a procedure to open the arteries. If these treatments don't help, you may need coronary artery bypass surgery.

The surgery creates a new path for blood to flow to the heart. The surgeon takes a healthy piece of vein from the leg or artery from the chest or wrist. Then the surgeon attaches it to the coronary artery, just above and below the narrowed area or blockage. This allows blood to bypass (get around) the blockage. Sometimes people need more than one bypass.

The results of the surgery usually are excellent. Many people remain symptom-free for many years. You may need surgery again if blockages form in the grafted arteries or veins or in arteries that weren't blocked before. Lifestyle changes and medicines may help prevent arteries from becoming clogged again.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI_NCI-GLOSS) Surgery in which a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart. This restores the flow of oxygen and nutrients to the heart.
Definition (NCI_CDISC) Surgery performed to bypass partially or completely occluded coronary arteries, thereby increasing the blood supply of the heart.
Definition (NCI) Surgery performed to bypass partially or completely occluded coronary arteries, thereby increasing the blood supply of the heart.
Definition (MSH) Surgical therapy of ischemic coronary artery disease achieved by grafting a section of saphenous vein, internal mammary artery, or other substitute between the aorta and the obstructed coronary artery distal to the obstructive lesion.
Definition (CSP) surgical procedure creating a bridge between the ascending aorta and one or more of the three major coronary arteries, distal to an obstructive lesion, using autologous tissue transplanted from the saphenous vein.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D001026
ICD9 36.10, 36.1
SnomedCT 119563008, 149173009, 149169006, 149174003, 175006004, 67166004, 232717009, 90205004
LNC LA14276-2
English Aortocoronary Bypass, Aortocoronary Bypasses, Artery Bypass, Coronary, Artery Bypasses, Coronary, Bypass Surgery, Coronary Artery, Bypass, Coronary Artery, Bypasses, Aortocoronary, Bypasses, Coronary Artery, Coronary Artery Bypass, Coronary Artery Bypass Grafting, Coronary Artery Bypasses, Bypass, Aortocoronary, coronary bypass, CABG - Coronary art bypass gr, Coronary Artery Bypass Graft, Heart Bypass, CABG, Coronary bypass, Coronary artery bypass, CORONARY ARTERY BYPASS SURG, BYPASS SURG CORONARY ARTERY, coronary artery bypass graft, coronary artery bypass graft (CABG) (treatment), coronary artery bypass graft (coronary artery bypass graft), coronary artery bypass graft (CABG), CABG (coronary artery bypass graft), Coronary art bypass graft ops, Aortocoronary bypass NOS, Coronary artery bypass graft (CABG), Graft;coronary artery bypass, coronary artery bypass surgery, coronary artery bypass graft (GABG), coronary bypass surgery, Aortocoronary bypass, Coronary artery operations (& bypass), Coronary artery operations, Coronary artery operations (& bypass) (procedure), Coronary A. operations, Coronary artery bypass graft (procedure), cardiac revascularization with bypass anastomosis (treatment), CAB, coronary artery bypass, aortocoronary bypass, Coronary Artery Bypass Graft Surgery, CORONARY ARTERY BYPASS GRAFT, Aortocoronary artery bypass graft, ACB graft, Vascular aortocoronary bypass, Cardiac revascularization with aortocoronary bypass anastomosis, CABG - Coronary artery bypass graft, CAG - Coronary artery graft, CBG - Coronary bypass graft, Coronary artery bypass graft, Coronary artery bypass grafting, Coronary artery bypass graft operations, Cardiac revascularisation with aortocoronary bypass anastomosis, Cardiac revascularisation with bypass anastomosis, Cardiac revascularization with bypass anastomosis (procedure), Cardiac revascularization with bypass anastomosis, Coronary artery bypass grafting (procedure), Aortocoronary artery bypass graft (procedure), Aortocoronary bypass for heart revascularisation, Aortocoronary bypass for heart revascularization, Cardiac revascularization with bypass anastomosis, NOS, Aortocoronary bypass for heart revascularization, NOS, CAB graft, Coronary artery bypass graft (procedure) [Ambiguous], Coronary Artery Bypass Surgery, Aortocoronary bypass for heart revascularization, not otherwise specified, Bypass anastomosis for heart revascularization
Dutch CABG, arteria coronaris bypass, coronaire bypass, coronaire bypassoperatie, aortocoronaire bypass, Bypass, aortocoronaire, Bypass, coronaire arterie-, Coronaire arteriebypass
French Pontage de l'artère coronaire, Pontage coronaire, Pontage aorto-coronarien, Pontage aortocoronarien, PAC (Pontage AortoCoronarien), Revascularisation coronaire par pontage, Pontage aorto-coronaire, Pontage aortocoronaire, Greffe de pontage de l'artère coronaire
German Koronar-Bypass, CABG, koronare Bypass-Operation, Aortokoronarer Bypass, Aortokoronarer Shunt, Bypass, koronarer, Koronararterien-Bypass
Italian Bypass coronarico, Bypass di arteria coronarica, Innesto di bypass coronarico, Bypass aortocoronarico, Innesto sull’arteria coronaria con by-pass, Chirurgia con bypass dell'arteria coronaria, Innesto di bypass di arteria coronaria, Bypass dell'arteria coronaria
Portuguese Enxerto de bypass de artéria coronária, Bypass coronário, Bypass de artéria coronária, Enxerto de bypass da artéria coronária, Bypass aorto-coronário, Derivação da Artéria Coronária, Ponte Aortocoronária, Ponte de Artéria Coronária
Spanish AACI, Injerto anastomótico coronario, Derivación arterial coronaria, Derivación coronaria, bypass coronario, derivación aortocoronaria para revascularización cardíaca, revascularización cardíaca por derivación aortocoronaria, puente coronario, bypass aortocoronario con injerto, injerto en puente aortocoronario, derivación aortocoronaria vascular, Derivación aortocoronaria, injerto puente coronario, injerto puente coronario (procedimiento), Derivación de la Arteria Coronaria, bypass de arteria coronaria, injerto - puente de arteria coronaria (procedimiento), injerto - puente de arteria coronaria, injerto puente aortocoronario (procedimiento), injerto puente aortocoronario, injerto puente coronario (concepto no activo), revascularización cardíaca con anastomosis por bypass, revascularización cardíaca con anastomosis por puente, revascularización cardíaca con anastomosis quirúrgica (procedimiento), revascularización cardíaca con anastomosis quirúrgica, Puente Aortocoronario, Puente de Arteria Coronaria
Japanese 冠動脈バイパス, カンドウミャクバイパス, カンドウミャクバイパスイショク, CABG, CABG, 冠状動脈バイパス術, A-Cバイパス, ダイドウミャクカンドウミャクバイパス, バイパス術-大動脈冠状動脈, 冠動脈バイパス手術, 冠状動脈バイパス, 冠状動脈バイパスグラフト, 冠状動脈バイパス手術, 大動脈冠状動脈バイパス術, A-Cバイパス術, ACバイパス, バイパス手術-冠動脈, バイパス手術-冠状動脈, 冠動脈バイパスグラフト, 冠動脈バイパス移植, 冠動脈バイパス術, 冠動脈大動脈バイパス, 大動脈冠動脈バイパス
Swedish Koronar-bypass
Czech aortokoronární bypass, koronární artérie - bypass, Implantát bypassu koronární artérie, Aortokoronární bypass, CABG, Bypass koronární tepny
Finnish Sepelvaltimoiden ohitusleikkaus
Polish Pomostowanie tętnic wieńcowych, Pomostowanie naczyń wieńcowych, CABG, Pomostowanie aortalno-wieńcowe, Wszczepienie pomostów aortalno-wieńcowych, Bypass wieńcowy
Hungarian Arteria coronaria bypass, CABG, Arteria coronaria bypass graft, Coronaria bypass, Aorto-coronariás bypass
Norwegian Bypass-operasjon, Koronar bypass