New guidelines for CABG Kim Eagle, MD Director of Clinical Cardiology University of Michigan at Ann Arbor Ann Arbor, MI

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. 0:52.3 Kirlin JW, et al. J Am Coll Cardiol 1991;17:543-589

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. 2:25 Eagle K, et al. J Am Coll Cardiol 1999;34:1262-1347

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 4:25

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. 6:30.5

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 7:11.0

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 7:11.0

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. 8:19.5

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 9:38.5

New guidelines for CABG Secondary prevention Aggressive control of lipid levels (LDL<130 mg/dL or even <100 mg/dL) Smoking cessation Depression and social isolation (risk factors for poor outcome) Cardiac rehabilitation 9:38.5

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. 9:38.5

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. 9:38.5

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. 9:38.5

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 9:38.5

New guidelines for CABG Availability of guidelines American College of Cardiology http://www.acc.org/clinical/guidelines/bypass/dirIndex.htm 9:38.5 Eagle K, et al. J Am Coll Cardiol 1999;34:1262-1347