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4A Ri 陳晉瑋

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4A Ri 陳晉瑋

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  1. 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

  2. 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.

  3. 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

  4. 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

  5. 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)

  6. 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

  7. 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

  8. 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.

  9. 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

  10. 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

  11. 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

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

  13. 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

  14. 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%

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

  16. Asterisk: p<0.05 vs no MI European Journal of Cardio-thoracic Surgery 29 (2006) 319—323

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

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

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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

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