Chapter 7 Coronary Artery Bypass Graft Surgeryother platelet inhibitors 7 to 10 days before elective
cardiac operations appears prudent to decrease the
risk of postoperative bleeding and transfusion [1].
For clopidogrel, the recommendation is to discon-
tinue the agent 5 or more days before surgery when
the clinical situation will permit [1].
The serine protease inhibitor aprotinin with
antifi brinolytic activity, signifi cantly decreases
postoperative blood loss and transfusion require-
ments in high-risk patients undergoing cardiac
surgery [58,59]. However, aprotinin has been with-
drawn from the market by the FDA secondary to
increased mortality risk noted in a recent random-
ized study [124].
Epsilon-aminocaproic acid and tranexamic acid
have antifi brinolytic activity, and both have been
shown to decrease mediastinal drainage after cardiac
surgery [60,61]. However, graft patency and throm-
botic potential in post-CABG patients have not been
resolved with either of these two agents [62].
Blood conservation during and after CABG is
effective when using a multi-modality approach
embracing individualized and algorithmically-
driven techniques [63]. Both mechanical and phar-
macologic means for blood conservation were used
in a recent series of 100 consecutive elective patients
undergoing CABG without a transfusion [64].
Prehospital autologous blood donation can be
effective in reducing transfusion requirements if a
patient is without exclusionary criteria (hemoglobin
<12 mg/dL, heart failure, unstable angina, left main
disease, or symptoms on the proposed day of dona-
tion) [1]. One to 3 U of autologous blood is donated
over 30 days before operation. Alternatively, the
patient and surgical team may opt to “donate” the
patient’s blood in the operating prior going on CPB.
This blood is removed from the patient prior to an
incision, and this blood is set aside, not exposed to
the CPB circuitry. The autologous units of blood are
reinfused into the patient after separation from
CPB.
General management considerations
Acuteness of operation is an important determinant
of operative risk. Prior to operative intervention,
thought should be given to application of temporiz-
ing measures (i.e. pharmacologic therapy, IABP)
when possible to improve the patient’s condition
prior to surgery [1]. Such concern is particularly
important in the patient with pulmonary edema [1].
Ideally, operation is deferred until resolution of the
edema [1].Maximizing postoperative benefi t
Antiplatelet therapy for SVG patency
Class I
Aspirin is the drug of choice for prophylaxis against
early saphenous vein graft closure. It is the standard
of care and should be continued indefi nitely given
its benefi ts in preventing subsequent clinical events.
(Level of Evidence: A)
Aspirin therapy should be started within 48 hours
of completing surgery, and this regimen has been
shown to reduce mortality, MI, stroke, renal failure,
and bowel infarction [65]. Ticlopidine offers no
advantage over aspirin and life-threatening neutro-
penia is a rare but recognized side effect [1]. Clopi-
dogrel offers a potential alternative to aspirin (in the
truly aspirin allergic patient) with a similar side
effect profi le as aspirin [1]. Whether the combina-
tion of aspirin and clopidogrel is a superior regimen
to either alone has not been resolved.Pharmacologic management of hyperlipidemia
Class I
All patients undergoing CABG should receive statin
therapy unless otherwise contraindicated. (Level of
Evidence: A)
Statin therapy lowers low-density lipoprotein
cholesterol (LDL-C) levels and retards atheroscle-
rotic vein-graft disease [1].Hormonal manipulation
Class III
Initiation of hormone therapy is not recommended
for women undergoing CABG surgery. (Level of Evi-
dence: B)Smoking cessation
Class I
1 All smokers should receive educational counsel-
ing and be offered smoking cessation therapy after
CABG. (Level of Evidence: B)
2 Pharmacologic therapy including nicotine
replacement and buproprion should be offered to
select patients indicating a willingness to quit. (Level
of Evidence: B)