Chapter 7 Coronary Artery Bypass Graft Surgerynonsurgical therapy. (If angina is not typical, then
objective evidence of ischemia should be obtained.)
(Level of Evidence: B)
2 CABG should be performed in patients with prior
CABG without patent bypass grafts but with Class I
indications for surgery for native-vessel CASHD
(signifi cant left main coronary stenosis, left main
equivalent, 3-vessel disease.) (Level of Evidence: B)
Class IIa
1 CABG is reasonable in patients with prior CABG
and bypassable distal vessels with a large area of
threatened myocardium by noninvasive studies.
(Level of Evidence: B)
2 CABG is reasonable in patients who have prior
CABG if atherosclerotic vein grafts with stenoses
greater than 50% supplying the LAD coronary artery
or large areas of myocardium are present. (Level of
Evidence: B)
Hospital mortality is increased 3-fold with reopera-
tive CABG compared with the primary operation
[1]. Reoperation is typically reserved for relief of
disabling symptoms or for compelling evidence of
life-threatening areas of myocardium at risk quanti-
fi ed by noninvasive studies. In the patient with a
patent IMA graft supplying the LAD and recurrent
ischemia in other regions of the heart, reoperation
poses an especially high risk secondary to potential
irreparable damage to the patent IMA consequent
to the reoperation. The potential loss of the IMA to
the LAD in such a reoperation represents a major
negative factor in the long-term therapy of that
patient. This is cause for additional caution in the
recommendation of a reoperation in a patient with
a patent IMA graft.Future guidelines
Techniques of coronary revascularization have
evolved rapidly in the last six years with the advent
of drug-eluting stents and more widespread use of
CABG. Prospective trials comparing methods of
revascularization in multivessel disease are in prog-
ress, but at present there is insuffi cient data available
to make alterations in the ACC/AHA guidelines.
The authors anticipate that data from these random-
ized trials will lead to reconsiderations of revascu-
larization guidelines in the near future.References available online at http://www.Wiley.com/go/
AHAGuidelineHandbook.