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4a ri

Indications and timingof CABG1. ACC/AHA 2004 Guideline Update for Coronary ArteryBypass Graft Surgery2. Influence of time elapsed between myocardial infarction and coronary artery bypass grafting surgery on operative mortalityEuropean Journal of Cardio-thoracic Surgery 29 (2006) 319—323

4A Ri 陳晉瑋

introduction
Introduction
  • 1991 guidelines: the evidence is completethat the coronary artery bypass operation relieves angina inmost patients.
    • Lancet 1998;352:1419-25.
    • JThorac Cardiovasc Surg 1988;95:773-81
  • Bypass surgery also relievedangina better than coronary stents in a randomized trial
    • NEngl J Med 2001;344:1117-24.
  • Relief angina symptoms and prolongation of life
  • 7~8 yrs survival superior for CABG compared with PTCA
    • J Am Coll Cardiol 2000;35:1116-1129.
early intervention of cabg
Early intervention of CABG
  • Advantage
    • Limitation of infarct expansion
    • Avoidance of LV dysfunction, heart failure
  • Disadvantage
    • Ischemia-reperfusion injury hemorrhagic infarction
  • The best window for intervention is quite an art
2004 acc aha guidelines
2004 ACC/AHA guidelines
  • Class I:

procedure/treatment should be performed/ administered

  • Class IIa:

it is reasonable to perform/administer

  • Class IIb:

procedure/treatment is considered

  • Class III:

procedure/treatment is not helpful and may be harmful

asymptomatic or mild angina
Asymptomatic or mild Angina
  • Indications: class I
    • Significant (50%) left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosisof the

proximalLAD and proximalleft circumflexartery.

    • 3-vessel disease (EF less than 0.50)
  • Indications: class IIa
    • proximal LAD stenosis with 1- or 2-vessel disease. ( Class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.)
  • Indications: class IIb
    • 1- or 2-vessel disease not involving the proximal LAD (If a large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes Class I)
asymptomatic or mild angina1
Asymptomatic or mild Angina
  • 108/6326 (1.7%)mortality rate in this categery
    • European Journal of Cardio-thoracic Surgery 29 (2006) 319—323
  • Extent of coronary disease
  • Timing was not recommended in the guidelines
stable angina
Stable angina
  • Indications: Class I
    • Significant (50%) left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosisof the

proximalLAD and proximalleft circumflexartery.

    • 3-vessel disease(benefits greater: EF less than 0.50 )
    • 2-vessel disease with significant proximal LAD stenosis and either EF less than 0.50 or ischemia on noninvasive testing
    • 1- or 2-vessel CAD without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing
    • Disabling angina despite maximal noninvasive therapy
  • Indications: class IIa
    • Proximal LAD stenosis with 1-vessel disease
stable angina1
Stable angina
  • The patient factors most influencing a decision to recommend CABG
    • Presence of severe proximal multivessel coronary disease
    • LV dysfunction
    • Strongly positive stress test,
    • Diabetes
  • Timing was not mentioned
  • PCI did not reduce the risk of death, myocardial infarction, stroke, or hospitalization when added to optimal medical therapy
    • N Engl J Med 2007;356.
unstable angina non st segment elevation nstemi
Unstable angina/ Non-ST-segment elevation (NSTEMI)
  • Indications: class I
    • Significant (50%)left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosis of the

proximal LAD and LCX.

    • Ongoing ischemia not responsive to maximal nonsurgical therapy.
  • Indications: class IIa
    • Proximal LAD stenosis with 1- or 2-vessel disease
unstable angina non st segment elevation nstemi1
Unstable angina/ Non-ST-segment elevation (NSTEMI)
  • Medical vs CABG: overall no difference
    • EF (0.3 to 0.58), 3-vessel disease, LV dysfunction with EKG change improved in survival with CABG
  • 5-year overall survival: CABG (88.8%) or PTCA (86.1%, P equals NS)
    • Cardiac mortality: PTCA (8.8%) vs CABG (4.9%)
  • The results for postoperative morbidity
    • six predictors: sex, age, left ventricular function, timing of surgery, extent of coronary artery disease and the type of myocardial protection used
    • Tn I level ~ Circulation, Volume 114(1) July 4, 2006
prognostic value of preoperative cardiac troponin i in patients undergoing emergency cabg
Prognostic value of preoperative cardiac troponin I in patients undergoing emergency CABG

Gray bar: NSTEMI

Black bar: STEMI

Circulation, Volume 114(1) suppl I.July 4, 2006

st segment elevation mi stemi
ST-Segment Elevation MI (STEMI)
  • Emergency or urgent CABG indication:
    • Failed angioplasty (PTCA)
    • Ventricular septal rupture or mitral valve insufficiency
    • In the early hours(6~12 hrs) of evolving STEMI (class IIa)
    • Persistent or recurrent ischemia refractory to medical therapy
    • Cardiogenic shock in <75 y/o, LBBB
    • Post. MI developed shock within 36 hrs, CABG should be performed within 18 hrs
    • Life-threatening ventricular arrhythmias with 50% left mainstenosis and/or 3-vessels disease
st segment elevation mi stemi1
ST-Segment Elevation MI (STEMI)
  • Indications:
    • Significant (50%)left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosis of the

proximal LAD and LCX.

    • Ongoing ischemia not responsive to maximal nonsurgical therapy.
  • Beyond 7 days after infarction, the criteria for revascularization
  • Risk factors: Besides time interval between MI and CABG
    • Age
    • renal insufficiency
    • previous stroke
    • LVEF< 40%
slide17

Asterisk: p<0.05 vs no MI

European Journal of Cardio-thoracic Surgery 29 (2006) 319—323

poor lv function
Poor LV function
  • Indications:
    • Significant (50%) left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosisof the proximal LAD and proximal LCX.
    • 3-vessel disease
poor lv function1
Poor LV function
  • low EF and clinical heart failure are predictive of higher operative mortality rates with CABG
  • EFs less than 0.30:
    • although having a higher immediate risk for bypass surgery, may achieve a greater long-term gain in terms of survival advantage
cabg after failed ptca
CABG after failed PTCA
  • Emergency bypass for failed PTCA
    • a higher rate of death and subsequent MI compared with elective bypass surgery
  • Factors that influence the outcome of surgery
    • LV dysfunction, older age, and previous MI
    • Extent of multivessel disease, collaterals
    • Total ischemic time (a delay in transport to the operating room)
  • Cooperative interaction between the cardiologist, cardiac surgeon, and anesthesia team are necessary to expedite resuscitation, transfer, and revascularization of patients with failed PTCA
patients with previous cabg
Patients With Previous CABG
  • Indication:
    • Repeating angina despite optimal nonsurgical therapy
    • Vein grafts stenosis, native-vessel CAD
  • Percutaneous procedures have been ineffective in the treatment of atherosclerotic vein graft stenoses
  • redo-CABG benefit: improvement in LVEF, heart

failure symptoms, angina and mid-term prognosis

    • Heart. 93(2):221-5, 2007 Feb
  • Use of the left IMA to LAD graft, platelet inhibitors and statin decreased reoperation rate
homework
Homework
  • Indications for CABG:
    • Significant (50%) left maincoronary artery stenosis.
    • Significant (greater than or equal to 70%) stenosisof the proximalLAD and proximalleft circumflexartery.
    • 3-vessel disease (EF less than 0.50)
  • Timing of CABG for AMI(NSTEMI or STEMI)
    • >65 y/o: >30 days
    • <65 y/o: >7 days
    • Previous CABG: >1 year