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

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

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
4:25

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.
6:30.5

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
7:11.0

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
7:11.0

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.
8:19.5

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
9:38.5

10. 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

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.
9:38.5

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.
9:38.5

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.
9:38.5

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
9:38.5

15. New guidelines for CABG
Availability of guidelines
American College of Cardiology
9:38.5
Eagle K, et al. J Am Coll Cardiol 1999;34: