Chapter 7 Coronary Artery Bypass Graft Surgeryage, prior heart surgery, sex, LV ejection fraction
(LVEF), percent stenosis of left main, and number
of major coronaries with >70% stenosis) as being
predictive of mortality [2]. Variables relating to
urgency of operation, age, and prior CABG demon-
strated the greatest predictive power. While elderly
patients face an increased morbidity and mortality
risk after CABG [3,4], age itself should not exclude
a patient from being offered CABG, assuming there
is no prohibitive comorbidity [1]. Early mortality
after CABG continues to be associated particularly
with advancing age, poor LV functions, and the
urgency of operation [1].
CABG in the presence of or immediately after an
acute myocardial infarction (MI) is controversial [1]
and deserves special comment. Some believe that
myocardium can be salvaged if operation is carried
out within six hours of the onset of chest pain [5–8].
Percutaneous coronary intervention (PCI) appears
to be the preferable fi rst-line mode of therapy in the
presence of an evolving MI. CABG is appropriate for
patients with evidence of ongoing ischemia despite
PCI, persistent angina, or intractable ventricular
arrhythmias [6]. CABG during an evolving acute MI
may also be performed coincident with repair of
mechanical complications of an infarction (i.e., ven-
tricular free wall rupture, ventricular septal defect,
or papillary muscle rupture). CABG may also benefi t
patients with shock complicating a recent acute MI
[9].
The American College of Cardiology (ACC),
the American Heart Association (AHA), and the
European Society of Cardiology (ESC) created a
committee to establish guidelines for optimal surgi-
cal management of CASHD. The committee was
composed of representatives of the ACC, AHA, and
the ESC.
Management recommendations in the
reduction of perioperative mortality and
morbidity
Preventing adverse cerebral outcomes
Ascending aortic atherosclerosis
Class I
Signifi cant atherosclerosis of the ascending aorta
mandates a surgical approach that will minimize the
possibility of arteriosclerotic emboli. (Level of Evi-
dence: C)
The surgeon’s identifi cation of an atherosclerotic
ascending aorta is the single most signifi cant marker
for an adverse cerebral outcome after coronary
bypass operations [10]. Most perioperative cerebral
atheroembolization likely arises intraoperatively
from manipulation of the ascending or transverse
aorta during cannulation, clamping, or placement
of proximal anastomoses [11–13]. An aggressive
approach to managing patients with severely athero-
sclerotic ascending aortas identifi ed most accurately
by intraoperative, surgeon-controlled epivascular
ultrasound of the ascending aorta and arch appears
to reduce the risk of postoperative stroke [14,15].
Important in this discussion is a potentially small
population of patients who have such extensive
aortic atherosclerosis that CABG would offer very
little benefi t [16], although this population is diffi -
cult to defi ne. Alternative means of surgical revas-
cularization, including off-pump CABG (OPCAB)
and hybrid procedures should be explored for some
of these high-risk patients. The relative value of
OPCAB surgery in such patients remains unknown
[1].Atrial fi brillation and postoperative stroke
Class IIa
In post-CABG atrial fi brillation (AF) that is recur-
rent or persists more than 24 hours, warfarin anti-
coagulation for four weeks is probably indicated.
(Level of Evidence: C)
New-onset AF occurs in 30% of patients undergo-
ing CABG [1], with the peak incidence on the second
postoperative day. It is associated with a 2- to 3- fold
increase in postoperative risk for stroke [17]. Most
strokes in this circumstance arise from thrombus
that develops in the left atrial appendage.Recent anterior MI, LV mural thrombus, and
stroke risk
Class IIa
Long-term (3–6 months) anticoagulation is prob-
ably indicated for the patient with recent anteroapi-
cal infarct and persistent wall-motion abnormality
after CABG. (Level of Evidence: C)Class IIb
In patients having a recent anterior MI, preoperative
screening with echocardiography may be considered
to detect LV thrombus, because the technical