ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery

Age alone should not be a contraindication to CABG if it is thought that long-term benefits outweigh the procedural risk. HomeCirculationVol.100,No.13ACC/AHAGuidelinesforCoronaryArteryBypassGraftSurgery:ExecutiveSummaryandRecommendations FreeAccessOtherPDF/EPUBAboutViewPDFViewEPUBSections ToolsAddtofavoritesDownloadcitationsTrackcitationsPermissions ShareShareonFacebookTwitterLinkedInMendeleyRedditDiggEmail JumptoFreeAccessOtherPDF/EPUBACC/AHAGuidelinesforCoronaryArteryBypassGraftSurgery:ExecutiveSummaryandRecommendationsAReportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(CommitteetoRevisethe1991GuidelinesforCoronaryArteryBypassGraftSurgery)KimA.Eagle,RobertA.Guyton,RavinDavidoff,GordonA.Ewy,JamesFonger,TimothyJ.Gardner,JohnParkerGott,HowardC.Herrmann,RobertA.Marlow,WilliamNugent,GeraldT.O’Connor,ThomasA.Orszulak,RichardE.Rieselbach,WilliamL.WintersandSalimYusufRaymondJ.Gibbons,JosephS.Alpert,KimA.Eagle,TimothyJ.Gardner,ArthurGarsonJr,GabrielGregoratos,RichardO.Russell,ThomasJ.RyanandSidneyC.SmithJrSearchformorepapersbythisauthorKimA.EagleKimA.EagleSearchformorepapersbythisauthor,RobertA.GuytonRobertA.GuytonSearchformorepapersbythisauthor,RavinDavidoffRavinDavidoffSearchformorepapersbythisauthor,GordonA.EwyGordonA.EwySearchformorepapersbythisauthor,JamesFongerJamesFongerSearchformorepapersbythisauthor,TimothyJ.GardnerTimothyJ.GardnerSearchformorepapersbythisauthor,JohnParkerGottJohnParkerGottSearchformorepapersbythisauthor,HowardC.HerrmannHowardC.HerrmannSearchformorepapersbythisauthor,RobertA.MarlowRobertA.MarlowSearchformorepapersbythisauthor,WilliamNugentWilliamNugentSearchformorepapersbythisauthor,GeraldT.O’ConnorGeraldT.O’ConnorSearchformorepapersbythisauthor,ThomasA.OrszulakThomasA.OrszulakSearchformorepapersbythisauthor,RichardE.RieselbachRichardE.RieselbachSearchformorepapersbythisauthor,WilliamL.WintersWilliamL.WintersSearchformorepapersbythisauthorandSalimYusufSalimYusufSearchformorepapersbythisauthorSearchformorepapersbythisauthorRaymondJ.GibbonsRaymondJ.GibbonsSearchformorepapersbythisauthor,JosephS.AlpertJosephS.AlpertSearchformorepapersbythisauthor,KimA.EagleKimA.EagleSearchformorepapersbythisauthor,TimothyJ.GardnerTimothyJ.GardnerSearchformorepapersbythisauthor,ArthurGarsonJrArthurGarsonJrSearchformorepapersbythisauthor,GabrielGregoratosGabrielGregoratosSearchformorepapersbythisauthor,RichardO.RussellRichardO.RussellSearchformorepapersbythisauthor,ThomasJ.RyanThomasJ.RyanSearchformorepapersbythisauthorandSidneyC.SmithJrSidneyC.SmithJrSearchformorepapersbythisauthorandCommitteeMembersandTaskForceMembersOriginallypublished28Sep1999https://doi.org/10.1161/01.CIR.100.13.1464Circulation.1999;100:1464–1480I.IntroductionTheAmericanCollegeofCardiology/AmericanHeartAssociation(ACC/AHA)TaskForceonPracticeGuidelineswasformedtomakerecommendationsregardingtheappropriateuseofdiagnostictestsandtherapiesforpatientswithknownorsuspectedcardiovasculardisease.Coronaryarterybypassgraft(CABG)surgeryisamongthemostcommonoperationsperformedintheworldandaccountsformoreresourcesexpendedincardiovascularmedicinethananyothersingleprocedure.SincetheoriginalGuidelineswerepublishedin1991,therehasbeenconsiderableevolutioninthesurgicalapproachtocoronarydisease,andatthesametimetherehavebeenadvancesinpreventive,medical,andpercutaneouscatheterapproachestotherapy.TheserevisedguidelinesarebasedonacomputerizedsearchoftheEnglishliteraturesince1989,amanualsearchoffinalarticles,andexpertopinion.AswithotherACC/AHAguidelines,thisdocumentusesACC/AHAclassificationsI,II,andIIIassummarizedbelow:ClassI:Conditionsforwhichthereisevidenceand/orgeneralagreementthatagivenprocedureortreatmentisusefulandeffective.ClassII:Conditionsforwhichthereisconflictingevidenceand/oradivergenceofopinionabouttheusefulnessorefficacyofaprocedure.ClassIIa:Weightofevidence/opinionisinfavorofusefulness/efficacy.ClassIIb:Usefulness/efficacyislesswellestablishedbyevidence/opinion.ClassIII:Conditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedure/treatmentisnotuseful/effectiveandinsomecasesmaybeharmful.II.OutcomesA.HospitalOutcomesSevencorevariables(priorityofoperation,age,priorheartsurgery,sex,leftventricular[LV]ejectionfraction[EF],percentstenosisoftheleftmaincoronaryartery,andnumberofmajorcoronaryarterieswithsignificantstenoses)arethemostconsistentpredictorsofmortalityaftercoronaryarterysurgery.Thegreatestriskiscorrelatedwiththeurgencyofoperation,advancedage,and1ormorepriorcoronarybypasssurgeries.Additionalvariablesthatarerelatedtomortalityincludecoronaryangioplastyduringindexadmission;recentmyocardialinfarction(MI);historyofangina,ventriculararrhythmias,congestiveheartfailure,ormitralregurgitation;andcomorbiditiessuchasdiabetes,cerebrovasculardisease,peripheralvasculardisease,chronicobstructivepulmonarydisease,andrenaldysfunction.Table1showsamethodbywhichkeypatientvariablescanbeusedtopredictanindividualpatient’soperativeriskofdeath,stroke,ormediastinitis.B.MorbidityAssociatedWithBypassSurgery1.NeurologicalEventsNeurologicalimpairmentafterbypasssurgerymaybeattributabletohypoxia,emboli,hemorrhage,and/ormetabolicabnormalities.Postoperativeneurologicaldeficitshavebeendividedinto2types:type1,associatedwithmajor,focalneurologicaldeficits,stupor,orcoma;andtype2,inwhichdeteriorationinintellectualfunctionisevident.Adversecerebraloutcomesareobservedin≈6%ofpatientsafterbypasssurgeryandareequallydividedbetweentype1andtype2deficits.Predictorsofcerebralcomplicationsafterbypasssurgeryincludeadvancedageandahistoryofhypertension.Particularpredictorsoftype1deficitsincludeproximalaorticatherosclerosisasdefinedbythesurgeonatoperation,historyofpriorneurologicaldisease,useoftheintra-aorticballoonpump,diabetes,hypertension,unstableangina,andincreasedage.Predictorsoftype2deficitsincludeahistoryofexcessalcoholconsumption;dysrhythmias,includingatrialfibrillation;hypertension;priorbypasssurgery;peripheralvasculardisease;andcongestiveheartfailure.Estimationofapatient’sriskforpostoperativestrokecanbecalculatedfromTable1.2.MediastinitisDeepsternalwoundinfectionoccursin1%to4%ofpatientsafterbypasssurgeryandcarriesamortalityof≈25%.Predictorsofthiscomplicationincludeobesity,reoperation,useofbothinternalmammaryarteriesatsurgery,durationandcomplexityofsurgery,anddiabetes.Anindividualpatient’sriskofpostoperativemediastinitiscanbeestimatedfromTable1.3.RenalDysfunctionPostoperativerenaldysfunctionoccursinasmanyas8%ofpatients.Amongpatientswhodeveloppostoperativerenaldysfunction(definedasapostoperativeserumcreatininelevel>2.0mg/dLoranincreaseinbaselinecreatininelevelof>0.7mg/dL),18%requiredialysis.Overallmortalityamongpatientswhodeveloppostoperativerenaldysfunctionis19%andapproachestwothirdsamongpatientsrequiringdialysis.Predictorsofrenaldysfunctionincludeadvancedage,ahistoryofmoderateorseverecongestiveheartfailure,priorbypasssurgery,type1diabetes,andpriorrenaldisease.Table2canbeusedtoestimatetheriskforanindividualpatient.PatientswithadvancedpreoperativerenaldysfunctionwhoundergoCABGsurgeryhaveanextraordinarilyhighrateofrequiringpostoperativedialysis.Amongpatientswithapreoperativecreatininelevel>2.5mg/dL,40%to50%requirehemodialysis.C.Long-TermOutcomesPredictorsofpoorlong-termsurvivalafterbypasssurgeryincludeadvancedage,poorLVEF,diabetes,numberofdiseasedvessels,andfemalesex.Insomestudies,additionalpredictorsincludeanginaclass,hypertension,priorMI,renaldysfunction,andclinicalcongestiveheartfailure.Predictorsoftherecurrenceofangina,lateMI,oranycardiaceventalsoincludeobesityandlackofuseofaninternalmammaryartery,aswellasthosefactorsidentifiedabove.Oftheseevents,thereturnofanginaisthemostcommonandisprimarilyrelatedtolatevein-graftatherosclerosisandocclusion.III.ComparisonofMedicalTherapyVersusSurgicalRevascularizationThecomparisonofmedicaltherapywithcoronarysurgicalrevascularizationisprimarilybasedonrandomized,clinicaltrialsandlargeregistries.Althoughclinicaltrialshaveprovidedvaluableinsights,therearelimitationstotheirinterpretationinthecurrentera.Patientselectionhadprimarilyincludedindividuals≤65yearsofage,veryfewincludedlargecohortsofwomen,andforthemostpart,thestudiesevaluatedpatientsatlowriskwhowereclinicallystable.Inaddition,becausethestudiesweredoneinthelate1970sandearly1980s,only1ofthetrialsusedarterialgrafts,andeventhattrialhadnoarterialgraftsin86%ofpatients.Newermodalitiesofcardioprotectionduringcardiopulmonarybypasswerenotused,norwereminimallyinvasiveoroff-bypasstechniques.Finally,medicaltherapywasnotoptimizedinthetrials.Lipid-loweringtherapyhadnotyetbecomestandard,aspirinwasnotwidelyused,andβ-blockerswereusedinjusthalfofthepatients.Angiotensin-convertingenzymeinhibitorswerenotbeingroutinelyusedinpatientswithcongestiveheartfailureordilatedcardiomyopathy.Accordingly,althoughtheclinicaltrialshaveprovidedimportantinsights,theirinterpretationmustbeviewedwithcaution,giventheevolutioninalltypesofcoronarytherapies.Forthemostpart,stratificationofpatientsinthetrialswasbasedonthenumberofvesselswithanatomicallysignificantdisease,whetherornotthemajorepicardialobstructionwasproximal,andtheextentofLVdysfunctionasdeterminedbyglobalEF.Theendpointofthetrialswasprimarilysurvival.Overview:RandomizedTrialsTherewere3major,randomizedtrialsandseveralsmallerones.Acollaborativemeta-analysisof7trialswithatotalenrollmentof2649patientshasallowedcomparisonofoutcomesat5and10years(Tables3,4,and5andtheFigure).Amongallpatients,theextensionsurvivalofCABGsurgicalpatientscomparedwithmedicallytreatedpatientswas4.3monthsat10yearsoffollow-up.ThebenefitofCABGcomparedwithmedicaltherapyinvariousclinicalsubsetsispresentedbelow.1.LeftMainCoronaryArteryDiseaseThetrialsdefinedsignificantleftmaincoronaryarterystenosisasa>50%reductioninlumendiameter.Mediansurvivalforsurgicallytreatedpatientswas13.3yearsversus6.6yearsinmedicallytreatedpatients.Leftmainequivalentdisease(≥70%stenosisinboththeproximalleftanteriordescending[LAD]andproximalleftcircumflexarteries)appearedtobehavesimilarlytotrueleftmaincoronaryarterydisease.Mediansurvivalforsurgicalpatientswas13.1yearsversus6.2yearsformedicallyassignedpatients.Thebenefitofsurgeryforleftmaincoronaryarterydiseasepatientscontinuedwellbeyond10years.By15years,itwasestimatedthattwothirdsofpatientsoriginallyassignedtomedicaltherapyandwhosurvivedwouldhavehadsurgery.The15-yearcumulativesurvivalforleftmaincoronaryarterydiseasepatientshavingCABGsurgerywas44%versus31%formedicalpatients.2.Three-VesselDiseaseIfonedefines3-vesseldiseaseasstenosisof50%ormoreinall3majorcoronaryterritories,theoverallextensionofsurvivalwas7monthsinCABGpatientscomparedwithmedicallytreatedpatients.PatientswithclassIIIorIVangina,thosewithmoreproximalandsevereLADstenosis,thosewithworseLVfunction,and/orthosewithmorepositivestresstestsderivedmorebenefitfromsurgery.3.ProximalLADDiseaseInpatientswithsevere,proximalLADstenosis,therelativeriskreductionduetobypasssurgerycomparedwithmedicaltherapywas42%at5yearsand22%at10years.ThiswasevenmorestrikinginpatientswithdepressedLVfunction.4.LVFunctionInpatientswithmildlytomoderatelydepressedLVfunction,thepoorertheLVfunction,thegreaterwasthepotentialadvantageofCABGsurgery.Althoughtherelativebenefitwassimilar,theabsolutebenefitwasgreaterbecauseofthehigh-riskprofileofthesepatients.5.SymptomsandQualityofLifeImprovementinsymptomsandqualityoflifeafterbypasssurgeryparallelstheoutcomedataregardingsurvival.Beyondsurvival,bypasssurgerymaybeindicatedtoalleviatesymptomsofanginaaboveandbeyondmedicaltherapyortoreducetheincidenceofnonfatalcomplicationslikeMI,congestiveheartfailure,andhospitalization.RegistrystudieshaveshownareductioninlateMIamonghighest-riskpatients,suchasthosewith3-vesseldisease,and/orthosewithsevereangina.Inpooledanalyses,abenefitontheincidenceofMIwasnotevident.ThisresultlikelyreflectedanearlyincreaseinMIperioperativelyafterCABG,whichwasbalancedbyfewerMIsoverthelongtermamongCABGrecipients.Antianginalmedicationswererequiredlessfrequentlyafterbypasssurgery.At5years,twothirdsofbypasspatientsweresymptom-freecomparedwith38%ofmedicallyassignedpatients.By10years,however,thesedifferenceswerenolongersignificant.Thisresultisrelatedtotheattritionofveingraftsinthebypassgroupaswellascrossoverofmedicallyassignedpatientstobypasssurgery.6.LossofBenefitofSurgeryAfter10to12yearsoffollow-up,therewasatendencyforthebypasssurgeryandmedicaltherapycurvestoconverge,inregardtobothsurvivalaswellasnonfataloutcomes.Thisconvergenceisduetoanumberoffactors.First,thereducedlifeexpectancyofpatientswithcoronarydisease(regardlessoftreatment)leadstoasteadyattrition.Second,theincreasedeventrateinthelatefollow-upperiodofsurgicallyassignedpatientswaslikelyrelatedtotheprogressionofnativecoronarydiseaseandgraftdiseaseovertime.Finally,medicallyassignedpatientscrossedovertosurgerylate,thusallowingthehighest-riskmedicallyassignedpatientstogainfromthebenefitofsurgerylaterinthecourseoffollow-up.By10years,37%to50%ofmedicallyassignedpatientshadcrossedovertosurgery.Tables3,4,and5andtheFigureprovideestimatesoflong-termoutcomesamongpatientsrandomizedinthetrials.ThesetablesandtheFigurecanbeusedtoestimatethegeneralsurvivalexpectationsinvariousanatomiccategories.IV.ComparisonofBypassSurgeryWithPercutaneousRevascularizationTheresultsofanumberofrandomized,clinicaltrialscomparingangioplastyandbypasssurgeryhavebeenpublished.Thetrialsexcludedpatientsinwhomsurvivalhadalreadybeenshowntobelongerwithbypasssurgerythanwithmedicaltherapy.Also,noneofthetrialswassufficientlylargetodetectrelativelymodestdifferencesinsurvivalbetweenthe2techniques.Mostofthetrialsdidnothavealong-termfollow-up,ie,5to10years,andthereforewereunabletoprovideclearinferencesregardinglong-termbenefitofthe2techniquesinsimilarpopulations.Also,andperhapsmostnotably,only≈5%ofscreenedpatientswithmultivesseldiseaseatenrollinginstitutionswereincludedinthetrials.Halfofthepatientsapproachedwereineligibleowingtoleftmaincoronaryarterydisease,insufficientsymptoms,orotherreasons.Evenamongalargegroupofpatientswithmultivesseldiseasesuitableforenrollment,onlyhalfwereactuallyrandomized.Itappearedthatphysicianselectednottoenrollmanypatientswith3-vesseldiseaseinthetrialsbutratherreferthemforbypasssurgery,whereaspatientswith2-vesseldiseasetendedtobereferredforangioplastyratherthanbeenrolledinthetrials.Overall,proceduralcomplicationswerelowforbothproceduresbuttendedtobehigherwithCABGsurgery(Table6).Forpatientsrandomizedtoangioplasty,CABGwasneededin≈6%duringtheindexhospitalizationandinnearly20%by1year.TheinitialcostandlengthofstaywerelowerforangioplastythanforCABG.Patientshavingangioplastyreturnedtoworksoonerandwereabletoexercisemoreat1month.Theextentofrevascularizationachievedbybypasssurgerywasgenerallyhigherthanwithangioplasty.Long-termsurvivalwasdifficulttoevaluateowingtotheshortperiodoffollow-upandthesmallsamplesizeofthetrials.However,fortheBypassAngioplastyRevascularizationInvestigation(BARI)trial,bypasspatientshada5-yearsurvivalof89.3%comparedwith86.3%forangioplasty.SecondaryanalysisrevealedthatintreateddiabeticpatientsintheBARItrials,CABGledtosignificantlysuperiorsurvivalcomparedwithpercutaneoustransluminalcoronaryangioplasty(PTCA).However,thisfindingwasnotevidentinothertrials.Inlong-termfollow-up,themoststrikingdifferencewasthe4-to10-fold-higherlikelihoodofreinterventionafterinitialPTCA.Qualityoflife,physicalactivity,employment,andcostweresimilarby3to5yearsafterbothprocedures.TheBARItrialsuggestedhighermortalityassociatedwithPTCAinseveralhigh-riskgroups,includingthosewithdiabetes,unstableangina,and/ornon–QwaveMI,andinpatientswithheartfailure.Ananalysisofregistriesgenerallyshowsdatasimilartothoseofthetrials.However,arecentanalysisof≈60000patientswhoweretreatedinNewYorkStateintheearly1990sprovidesa3-yearsurvivalanalysisofpatientsundergoingCABGandPTCA.Afteradjustmentforvariouscovariates,bypasssurgeryintheNewYorkStateregistryexperiencewasassociatedwithlongersurvivalinpatientswithsevereproximalLADstenosisand/or3-vesseldisease.Contrariwise,patientswith1-vesseldiseasenotinvolvingtheproximalLADhadimprovedsurvivalwithPTCA.Table7summarizessurvivaldatafromtheNewYorkStateregistrywithrespecttovariouscohortsofpatientsundergoingangioplastyorbypasssurgery.Thesedatacanbeusedtoestimate3-yearsurvivalexpectationsforpatientswithvariousanatomicfeatures.V.ManagementStrategiesReductionofPerioperativeMortalityandMorbidity1.ReducingtheRiskofType1BrainInjuryAfterCABGPostoperativeneurologicalcomplicationsrepresent1ofthemostdevastatingconsequencesofCABGsurgery.Type1injury,inwhichasignificant,permanent,neurologicalinjuryissustained,occursin≈3%ofpatientsoverallandisresponsiblefora21%mortality.AtheroscleroticAscendingAortaAnimportantpredictorofthiscomplicationisthesurgeon’sidentificationofaseverelyatherosclerotic,ascendingaortabeforeorduringthebypassoperation.PerioperativeatheroembolismfromaorticplaqueisthoughttoberesponsibleforapproximatelyonethirdofstrokesafterCABG.Atherosclerosisoftheascendingaortaisstronglyrelatedtoincreasedage.Thus,strokeriskisparticularlyincreasedinpatientsbeyond75to80yearsofage.Preoperative,noninvasivetestingtoidentifyhigh-riskpatientshasvariableaccuracy.Computedtomographyidentifiesthemostseverelyinvolvedaortasbutunderestimatesmildormoderateinvolvement.Transesophagealechocardiographyisusefulforaorticarchexamination,butexaminationoftheascendingaortamaybelimitedbytheinterveningtrachea.Intraoperativeassessmentwithepiaorticimagingissuperiortobothmethods.Intraoperativepalpationunderestimatesthehigh-riskaorta.Thehighest-riskaorticpatternisaprotrudingormobileaorticarchplaque.Anaggressiveapproachtothemanagementofpatientswithseverelydiseasedascendingaortasidentifiedbyintraoperativeechocardiographicimagingreducestheriskofpostoperativestroke.Forpatientswithaorticwalls≤3mmthick,standardtreatmentisused.Foraortas>3mmthick,thecannulation,clamp,orproximalanastomoticsitesmaybechanged,orano-clamp,fibrillatoryarreststrategymaybeused.Forhigh-riskpatientswithmultipleorcircumferentialinvolvementorthosewithextensivemiddleascendingaorticinvolvement,replacementoftheascendingaortaunderhypothermiccirculatoryarrestmaybeindicated.Alternatively,acombinedapproachwithoff-bypass,insituinternalmammarygraftingtotheLADandpercutaneouscoronaryinterventiontotreatothervesselstenoseshasconceptualmerit.AtrialFibrillationandStrokeChronicatrialfibrillationisahazardforperioperativestroke.Intraoperativesurgicalmanipulationorspontaneousresumptionofsinusrhythmduringtheearlypostoperativeperiodmayleadtoembolismofaleftatrialclot.Oneapproachtoreducethisriskistheperformanceofpreoperative,transesophagealechocardiography.Theabsenceofaleftatrialclotwouldsuggestthattheoperationmayproceedwithacceptablerisk.Forelectivepatients,ifaleftatrialclotisidentified,3to4weeksofanticoagulationtherapyfollowedbyrestudyandthensubsequentsurgeryisreasonable.Fewclinicaltrialdataareavailabletoassistcliniciansinthiscircumstance.New-onsetpostoperativeatrialfibrillationoccursin≈30%ofpost-CABGpatients,particularlyonthesecondandthirdpostoperativedays,andisassociatedwitha2-to3-foldincreasedriskofpostoperativestroke.Riskfactorsincludeadvancedage,chronicobstructivepulmonarydisease,proximalrightcoronarydisease,prolongedoperation,atrialischemia,andwithdrawalofβ-blockers.Theroleofanticoagulantsinpatientswhodeveloppost-CABGatrialfibrillationisunclear.Aggressiveanticoagulationandcardioversionmayreducetheneurologicalcomplicationsassociatedwiththisarrhythmia.Earlycardioversionwithin24hoursoftheonsetofatrialfibrillationcanprobablybeperformedsafelywithoutanticoagulation.However,persistenceofthearrhythmiabeyondthistimearguesfortheuseoforalanticoagulantstoreducestrokeriskinpatientswhoremaininatrialfibrillationand/orinthoseforwhomlatercardioversionisplanned.RecentMI,LVThrombus,andStrokePatientswitharecent,anteriorMIandresidualwall-motionabnormalityareatincreasedriskforthedevelopmentofanLVmuralthrombusanditspotentialforembolization.ForpatientsundergoingsurgicalrevascularizationaftersustainingananteriorMI,preoperativescreeningwithechocardiographymaybeappropriatetoidentifythepresenceofaclot.DetectionofanacuteLVmuralthrombusmaycallforlong-termanticoagulationandreevaluationbyechocardiographytoensureresolutionororganizationofthethrombusbeforecoronarybypasssurgery.Additionally,3to6monthsofanticoagulationtherapyisappropriateforpatientswithpersistent,anteriorwall–motionabnormalitiesaftercoronarybypasssurgery.Recent,AntecedentCerebrovascularEventArecent,preoperativecerebrovascularaccidentrepresentsasituationinwhichdelayingsurgerymayreducetheperioperativeneurologicalrisk.Inparticular,evidenceofahemorrhagiccomponentbasedoncomputedtomographicscanidentifieshighriskfortheextensionofneurologicaldamagewithcardiopulmonarybypass.Itisgenerallybelievedthatadelayof4weeksormoreafteracerebrovascularaccidentisprudent,ifcoronaryanatomyandsymptomspermit,beforeproceedingwithCABG.CarotidDiseaseandNeurologicalRiskReductionHemodynamicallysignificantcarotidstenosesarethoughttoberesponsibleforupto30%ofearlypostoperativestrokes.Thetrendforcoronarysurgerytobeperformedinanincreasinglyelderlypopulationandtheincreasingprevalenceofcarotiddiseaseinthissamegroupofpatientsunderscoretheimportanceofthisissue.Perioperativestrokeriskisthoughttobe<2%whencarotidstenosesare<50%,10%whenstenosesare50%to80%,and11%to19%inpatientswithstenoses>80%.Patientswithuntreated,bilateral,high-gradestenosesand/orocclusionshavea20%chanceofstroke.Carotidendarterectomyforpatientswithhigh-gradestenosisisgenerallydoneprecedingorcoincidentwithcoronarybypasssurgeryand,withproperteamworkinhigh-volumecenters,isassociatedwithalowriskforbothshort-andlong-termneurologicalsequelae.Carotidendarterectomyperformedinthisfashioncarriesalowmortality(3.5%)andreducesearlypostoperativestrokeriskto<4%,withaconcomitant5-yearfreedomfromstrokeof88%to96%.Thedecisionaboutwhoshouldundergopreoperativecarotidscreeningiscontroversial.Predictorsofimportantcarotidstenosisincludeadvancedage,femalesex,knownperipheralvasculardisease,previoustransientischemicattackorstroke,ahistoryofsmoking,andleftmaincoronaryarterydisease.Manycentersscreenallpatients>65yearsold.Patientswithleftmaincoronarydiseaseareoftenscreened,asarethosewithaprevioustransientischemicattackorstroke.PreoperativecentralnervoussystemsymptomssuggestiveofvertebralbasilarinsufficiencyshouldleadtoanevaluationbeforeelectiveCABG.Whensurgeryofbothcarotidandcoronarydiseaseisplanned,themostcommonapproachistoperformtheoperationinastagedmanner,inwhichthepatientfirsthascarotidsurgeryfollowedbycoronarybypassin1to5days.Alternatively,especiallyifthepatienthascompellingcardiacsymptomsorcoronaryanatomy,theoperationsmaybeperformedduringasingleperiodofanesthesia,withthecarotidendarterectomyimmediatelyprecedingcoronarybypass.Neitherstrategyhasbeenestablishedasbeingsuperior.Strokeriskisincreasedifareversed-stageprocedureisused,inwhichthecoronarybypassoperationprecedesthecarotidendarterectomyby≥1day.2.ReducingtheRiskofType2BrainInjuryType2neurologicalcomplicationsareseenin≈3%ofpatientsandarecorrelatedwitha10%riskofpostoperativedeath,with40%ofpatientsrequiringadditionalcareinatransitionalfacilityafterhospitaldischarge.MicroembolizationisthoughttobeamajorcontributortothepostoperativecerebraldysfunctionafterCABG.Thereleaseofmicroemboliduringextracorporealcirculation,involvingsmallgaseousorlipidemboli,mayberesponsible.Theuseofa40-μmarterial-linefilterontheheart-lungmachinecircuitandroutineuseofmembraneoxygenatorsratherthanbubbleoxygenatorsmayreducesuchneurologicalinjury.Additionalmaneuverstoreducetype2neurologicalinjuryincludethemaintenanceofsteady,cerebralbloodflowduringcardiopulmonarybypass,avoidanceofcerebralhyperthermiaduringandaftercardiopulmonarybypass,meticulouscontrolofperioperativehyperglycemia,andavoidanceandlimitationofpostoperativecerebraledema.3.ReducingtheRiskofPerioperativeMyocardialDysfunctionProtectioninPatientsWithNormalLVFunctionThereisnouniversallyapplicablemyocardialprotectiontechnique.Amongpatientswithpreservedpreoperativecardiacfunction,nostrongargumentcancurrentlybemadeforwarmversuscoldandcrystalloidversusbloodcardioplegia.However,certaintechniquesmayofferawidermarginofsafetyforspecialpatientsubsets.MyocardialProtectionforAcutelyDepressedCardiacFunctionSeveralstudieshavesuggestedthatbloodcardioplegia(comparedwithcrystalloid)mayofferagreatermarginofsafetyduringCABGperformedonpatientswithacutecoronaryocclusion,failedangioplasty,urgentrevascularizationforunstableangina,and/orchronicallyimpairedLVfunction.ProtectionforChronicallyDepressedLVFunctionTheuseofaprophylacticintra-aorticballoonpumpasanadjuncttomyocardialprotectionmayreducemortalityinpatientshavingCABGinthesettingofsevereLVdysfunction(eg,LVEF<0.25).Placementoftheintra-aorticballoonpumpimmediatelybeforeoperationappearstobeaseffectiveasplacementonthedayprecedingbypasssurgery.AdjunctstoMyocardialProtectionAlthoughitiswidelyappreciatedthatuseoftheinternalmammaryarteryleadstoimprovedlong-termsurvivalaftercoronarybypasssurgery,ithasalsobeendocumentedthatuseoftheinternalmammaryarteryinfluencesoperativemortalityitself.Thus,internalmammaryarteryuseshouldbeencouragedintheelderly,emergent,oracutelyischemicpatientandotherpatientgroups.InferiorInfarctWithRightVentricularInvolvementAnacutelyinfarctedrightventricleisatgreatriskforsevere,postoperativedysfunctionandpredisposesthepatienttoahigherpostoperativemortality.Duringoperation,lossofthepericardialconstraintmayleadtoacutedilatationofthedysfunctionalrightventricle,whichthenfailstorecoverevenwithoptimalmyocardialprotectionandrevascularization.Thebestdefenseagainstrightventriculardysfunctionisitsrecognitionduringpreoperativeevaluation.Whenpossible,CABGshouldbedelayedfor≥4weekstoallowtherightventricletorecover.4.ReducingtheSystemicConsequencesofCardiopulmonaryBypassAvarietyofmeasureshavebeentriedtoreducethesystemicconsequencesofcardiopulmonarybypass,whichelicitsadiffuseinflammatoryresponsethatmaycausetransientorprolongedmultisystemorgandysfunction.Administrationofcorticosteroidsbeforecardiopulmonarybypassmayreducecomplementactivationandreleaseofproinflammatorycytokines.Propertiminganddurationofcorticosteroidapplicationareincompletelyresolved.Theadministrationoftheserineproteaseinhibitoraprotininmayattenuatecomplementactivationandcytokinereleaseduringextracorporealcirculation.Unfortunately,aprotininisrelativelyexpensive.Anothermethodtoreducetheinflammatoryresponseisperioperativeleukocytedepletionthroughhematologicfiltration.5.ReducingtheRiskofPerioperativeInfectionsSeveralmethodsexisttoreducetheriskofwoundinfectionsinpatientsundergoingCABG.Thesebeginwithintervalreportingtoindividualsurgeonsregardingtheirrespectivewoundinfectionratesandadherencetosterileoperativetechniques.Additionalstrategiesincludeskinpreparationwithtopicalantiseptics,clippingratherthanshavingtheskin,avoidanceofhairremoval,reductionofoperatingroomtraffic,laminar-flowventilation,shorteroperation,minimizationofelectrocautery,avoidanceofbonewax,useofdouble-glovebarriertechniquesfortheoperatingroomteam,androutineuseofapleuralpericardialflap.Aggressive,perioperativeglucosecontrolindiabeticsthroughtheuseofcontinuous,intravenousinsulininfusionreducesperioperativehyperglycemiaanditsassociatedinfectionrisk.AvoidanceofhomologousbloodtransfusionsafterCABGmayreducetheriskofbothviralandbacterialinfections.Thisisduetoanimmunosuppressiveeffectoftransfusion.Leukodepletionoftransfusedbloodalsoreducesthiseffect.Thiscanbeaccomplishedbyregionalbloodblanksatthetimeofdonationoratthebedsidebyuseofatransfusionfilter.Preoperativeantibioticadministrationreducestheriskofpostoperativeinfection5-fold.Efficacyisdependentonadequatedrugtissuelevelsbeforemicrobialexposure.Cephalosporinsarecurrentlytheagentsofchoice.Table8identifiesappropriatechoices,doses,androutesoftherapy.A1-daycourseofintravenousantimicrobialsisaseffectiveas48hoursormore.Therapyshouldbeadministeredwithin30minutesofincisionandagainintheoperatingroomiftheoperationexceeds3hours.Manycentersdeliverantibioticsjustbeforeincision.Onefail-safemethodistohavetheanesthesiologistadministerthecephalosporinafterinductionbutbeforeskinincision.Ifdeepsternalwoundinfectiondoesoccur,aggressivesurgicaldebridementandearlyvascularizedmuscleflapcoveragearethemosteffectivemethodsfortreatment,alongwithlong-termsystemicantibiotics.6.PreventionofPostoperativeDysrhythmiasPostoperativeatrialfibrillationincreasesthelengthofstay,cost,andmostimportant,theriskofstroke.Atrialfibrillationoccursinupto30%ofpatients,usuallyonthesecondorthirdpostoperativeday.Methodstoavoidatrialfibrillationareseveral.First,withdrawalofpreoperativeβ-blockersinthepostoperativeperioddoublestheriskofatrialfibrillationafterCABG.Thus,earlyreinitiationofβ-blockersiscriticalforavoidanceofthiscomplication.Virtuallyeverystudyofpatientsreceivingβ-blockersprophylacticallyhasshownbenefitinloweringthefrequencyofatrialfibrillation.Mosthaveusedthedruginthepostoperativeperiod,butgreaterbenefitmayoccurifβ-blockadeisbegunbeforetheoperation.Morerecently,smallstudiesofpropafenone,sotalol,andamiodaronehavealsoshowneffectivenessinreducingtheriskofpostoperativeatrialfibrillation.Table9providesareviewofpharmacologicalapproachesintherandomizedtrials.DigoxinandcalciumchannelblockershavenoconsistentbenefitforpreventingatrialfibrillationafterCABG,althoughtheyarefrequentlyusedtocontrolitsrateafteritdoesoccur.Currently,theroutinepreoperativeorearlypostoperativeadministrationofβ-blockersisconsideredstandardtherapytoreducetheriskofatrialfibrillationafterCABG.7.StrategiestoReducePerioperativeBleedingandTransfusionRiskTransfusionRiskDespitetheincreasingsafetyofhomologousbloodtransfusion,concernssurroundingviraltransmissionduringtransfusionremain.Currently,therisksarelikelyverylowandhavebeenestimatedtobe1/493000forhumanimmunodeficiencyvirus,1/641000forhumanT-celllymphotrophicvirus,1/103000forhepatitisCvirus,and1/63000forhepatitisBvirus.PerioperativeBleedingRiskfactorsforbloodtransfusionafterCABGincludeadvancedage,lowpreoperativeredbloodcellvolume,preoperativeaspirintherapy,urgentoperation,durationofcardiopulmonarybypass,recentthrombolytictherapy,reoperation,anddifferencesinheparinmanagement.Institutionalprotocolsthatestablishminimumthresholdsfortransfusionleadtoareducednumberofunitstransfusedandthepercentageofpatientsrequiringblood.AdditionalstrategiescanreducethetransfusionrequirementafterCABG.Forstablepatients,aspirinandotherantiplateletdrugsmaybediscontinued7daysbeforeelectiveCABG.Aprotinin,aserumproteaseinhibitorwithantifibrinolyticactivity,alsodecreasespostoperativebloodlossandtransfusionrequirementsinhigh-riskpatients.Althoughtherehasbeensomeconcernthataprotininmayreduceearlygraftpatency,recentstudieshavefailedtodocumentthiseffect.Routineuseofaprotininislimitedbyitshighcost.Multidisciplinaryapproachestoconservebloodinsingleinstitutionsappeartobeeffective.Forpatientswithoutexclusions,suchaslowhemoglobinvalues,heartfailure,unstableangina,leftmaincoronaryarterydisease,oradvancedanginalsymptoms,self-donationof1to3unitsofredbloodcellsover30daysbeforeoperationreducestheneedforhomologoustransfusionduringorafteroperation.Donationimmediatelybeforecardiopulmonarybypassyieldsahigherplateletandhemoglobincountcomparedwithsimplehemodilutionwithoutpre–cardiopulmonarybypassbloodharvesting.8.AntiplateletTherapyforSaphenousVeinGraftPatencyAspirinsignificantlyreducesveingraftclosureduringthefirstpostoperativeyear.Theaspirinshouldbestartedwithin24hoursaftersurgerybecauseitsbenefitonsaphenousveingraftpatencyislostwhenbegunlater.Dosingregimensfromaslittleas100mg/dtoasmuchas325mgTIDappeartobeefficacious.Ticlopidineoffersnoadvantageoveraspirinbutisanalternativeintrulyaspirin-allergicpatients.Life-threateningneutropeniaisararebutrecognizedsideeffect.Clopidogreloffersthepotentialforfewersideeffectscomparedwithticlopidineasanalternativeinaspirin-allergicpatients.Itsincidenceofsevereleukopeniaisrare.9.PharmacologicalManagementofHyperlipidemiaAggressivetreatmentofhypercholesterolemiareducesprogressionofatheroscleroticveingraftdiseaseinpatientsafterbypasssurgery.Statintherapyhasbeenshowntoreducesaphenousveingraftdiseaseprogressionovertheensuingyearsafterbypass.Patientswithunknownlow-densitylipoprotein(LDL)cholesterollevelsafterbypassshouldhavecholesterollevelsdeterminedandtreatedpharmacologicallyiftheLDLexceeds100mg/dL.PatientswithtreatedLDLcholesterolshouldhavetheirlow-fatdietandcholesterol-loweringmedicationscontinuedafterbypasssurgerytoreducesubsequentgraftattrition.DataregardingthebenefitofcholesterolloweringafterbypasssurgeryaremostsupportedbystudiesthathaveusedHMGCoA(3-hydroxy-3-methylglutarylcoenzymeA)reductaseinhibitors,particularlytargetingLDLlevelsto<100mg/dL.10.HormonalManipulationWhileobservationalstudieshavesuggestedthathormonereplacementtherapyinpostmenopausalwomenleadstoareductioninall-causemortality,arecent,randomizedtrialforsecondarycoronarypreventionfailedtoshowabeneficialeffectontheoverallrateofcoronaryevents.Thus,hormonereplacementtherapyshouldbeconsideredinpostmenopausalwomenafterbypasswhen,inthephysician’sjudgment,thepotentialcoronarybenefitisnotoffsetbyanincreasedriskofuterineorbreastcancer.11.SmokingCessationSmokingcessationisthesingle,mostimportantrisk-modificationgoalafterCABGinpatientswhosmoke.Smokingcessationleadstolessrecurrentangina,improvedphysicalfunction,feweradmissions,maintenanceofemployment,andimprovedsurvival.Treatmentindividualizedtothepatientiscrucial.Depressionmaybeanimportantcomplicatingfactorandshouldbeapproachedwithbehavioralanddrugtherapy.Nicotinereplacementwithatransdermalpatch,nasalspray,gum,orinhalerisbeneficial.Asustained-releaseformofbupropion,anantidepressantsimilartoselectiveserotoninreuptakeinhibitors,reducesthenicotinecravingandanxietyofsmokerswhoquit.AllsmokersshouldreceiveeducationalcounselingandbeofferedsmokingcessationtherapyafterCABG(Table10).12.CardiacRehabilitationCardiacrehabilitation,includingearlyambulationduringhospitalization,outpatientprescriptiveexercise,familyeducation,anddietaryandsexualcounseling,hasbeenshowntoimproveoutcomesafterCABG.Thebenefitsincludebetterphysicalmobilityandperceivedhealth.Ahigherproportionofrehabilitatedpatientsareworkingat3yearsafterCABG.Thebenefitsofrehabilitationextendtotheelderlyandtowomen.CardiacrehabilitationreinforcespharmacologicaltherapyandsmokingcessationandshouldbeofferedtoalleligiblepatientsafterCABG.13.EmotionalDysfunctionandPsychosocialConsiderationsLackofsocialparticipationandlowreligiousstrengthareindependentpredictorsofdeathinelderlypatientsundergoingCABG.Althoughcontroversial,thehighprevalenceofdepressionafterbypasssurgerymayreflectahighprevalencepreoperatively.Cardiacrehabilitationhasahighlybeneficialeffectinpatientswhoaremoderatelyorseverelydepressed.Evaluationofsocialsupportsandattemptstoidentifyandtreatunderlyingdepressionshouldbepartofroutinepost-CABGcare.14.RapidSustainedRecoveryAfterOperationRapidrecoveryandearlydischargearestandardgoalsafterCABG.Theshortestin-hospitalpostoperativestaysarefollowedbythefewestrehospitalizations.Importantcomponentsof“fast-track”carearecarefulpatientselection,patientandfamilyeducation,earlyextubation,prophylacticantiarrhythmictherapy,dietaryconsiderations,earlyambulation,earlyoutpatienttelephonefollow-up,andcarefulcoordinationwithotherphysiciansandhealthcareproviders.15.CommunicationBetweenCaregiversMaintenanceofappropriateandtimelycommunicationbetweentreatingphysiciansregardingcareofthepatientiscrucial.Whenpossible,theprimarycarephysicianshouldfollowupthepatientduringtheperioperativecourse.Thereferralphysicianneedstoprovideclear,writtenreportsofthefindingsandrecommendationstotheprimarycarephysician,includingdischargemedicationsanddosagesalongwithlong-termgoals.VI.ImpactofEvolvingTechnologyA.Less-InvasiveCoronaryBypassSurgeryTechnicalmodificationsofCABGhavebeendevelopedtodecreasethemorbidityoftheoperation,eitherbyusinglimitedincisionorbyeliminatingcardiopulmonarybypass.Currently,“less-invasive”CABGsurgerycanbedividedinto3categories:(1)off-bypassCABGperformedthroughamediansternotomywithasmallerskinincision,(2)minimallyinvasivedirectCABG(MID-CAB)performedthroughaleftanteriorthoracotomywithoutcardiopulmonarybypass,and(3)port-accessCABGwithfemoral-to-femoralcardiopulmonarybypassandcardioplegicarrestwithlimitedincision.Off-bypasscoronarysurgeryisperformedonabeatingheartafterreductionofcardiacmotionwithavarietyofpharmacologicalandmechanicaldevices.Theseincludeslowingtheheartwithβ-blockersandcalciumchannelblockersanduseofamechanicalstabilizingdevicetoisolateandstabilizethetargetvessel.Retractiontechniquesmayelevatethehearttoallowaccesstovesselsonthelateralandinferiorsurfacesoftheheart.Becausethistechniquegenerallyusesamediansternotomy,itsprimarybenefitistheavoidanceofcardiopulmonarybypass,notalessextensiveincision.MID-CABreferstobypasssurgerywithoutmediansternotomyandwithouttheuseofcardiopulmonarybypass.Generally,thisisperformedwithasmallleftanteriorthoracotomy,exposingtheheartthroughthefourthintercostalinterspacewithaccesstotheLADanddiagonalbranchesandoccasionally,theanteriormarginalvessels.Therightcoronaryarterycanbeapproachedbyusingarightanteriorthoracotomy.MID-CABproceduresaregenerallyperformedononly1or2coronarytargets.ObservationalstudieshavesuggestedthatMID-CABisassociatedwithareducedaveragelengthofstayandanearlierreturntowork.Althoughinitialreportsof2-yearactuarialandevent-freesurvivalareencouraging,thedatamustbeviewedwithcaution.Becausethenumberofanastomosesperformedonabeatingheartisusually1oroccasionally2,thepotentiallong-termeffectsofincompleterevascularizationareunknown.Theclosed-chest,port-access,video-assistedCABGoperationusescardiopulmonarybypassandcardioplegiaofagloballyarrestedheart.Vascularaccessforcardiopulmonarybypassisachievedviathefemoralarteryandvein.Atriple-lumencatheterwithaninflatableballoonatitsdistalendisusedtoachieveendovascularaorticocclusion,cardioplegiadelivery,andLVdecompression.Withcardiopulmonarybypassandcardioplegicarrest,CABGcanbeperformedwithvideoassistanceonastillanddecompressedheartthroughseveralsmallports.IncomparisonwiththeMID-CAB,portaccessallowsaccesstodifferentareasoftheheart,thusfacilitatingmorecompleterevascularization,andthemotionlessheartmayallowamoreaccurateanastomosis.ComparedwithconventionalCABG,mediansternotomyisavoided.However,potentialmorbidityoftheport-accessoperationincludesmultiplewoundsatportsites,thelimitedthoracotomy,andthegroindissectionforfemoral-femoralbypass.Vigorousscrutinyofthelong-termbenefitsversusrisksofportaccessisrequired.B.ArterialandAlternateConduitsAnotherareaofevolvingtechnologyistheuseofarterialandalternateconduits.The5-yearpatencyofcoronaryartery–veinbypassgraftsis74%,andat10years,just41%.Contrariwise,patencyratesoftheinternalmammaryarteryimplantedintotheLADareashighas83%at10years.Asaconsequenceofimprovedpatency,patientsreceivinganLADgraftwithaninternalmammaryarteryhaveimprovedsurvivalcomparedwithpatientsreceivingonlyveingrafts.Currently,routineuseoftheleftinternalmammaryarteryforLADgraftingwithsupplementalsaphenousveingraftstoothercoronarylesionsisgenerallyacceptedasastandardgraftingmethod.Theuseofbilateralinternalmammaryarteriesappearstobesafeandefficacious.However,thereisahigherrateofdeepsternalwoundinfectionwhenbothinternalmammaryarteriesareused.Thisisparticularlytrueforpatientswithobesityanddiabetesandperhapsforthoserequiringprolongedventilatorysupport.Thebenefitsofbilateralinternalmammaryarteryuseincludelowerratesofrecurrentangina,MI,andneedforreoperationandatrendforbettersurvival.Recently,theradialarteryhasbeenusedmorefrequentlyasaconduitforcoronarybypasssurgery.Five-yearpatencyappearstobeintherangeof85%(comparedwithnearly90%fortheinternalmammarygraft).Inpatientsforwhommammaryartery,radialartery,andstandardveinconduitsareunavailable,theinsiturightgastroepiploicartery,theinferiorepigastricfreearterygraft,andeitherlessersaphenousorupper-extremityveinconduitshavebeenused.Long-termpatencyofthesealternativegraftshasnotbeenextensivelystudied.C.PercutaneousTechnologyTechnologicalimprovementsinpercutaneouscoronaryangioplastyhaveincludedtheintroductionofnewdevicesandimprovedmedicaltherapyofpatientsinwhomangioplastyisperformed.ThemostnotableimprovementhasbeentheintroductionofintracoronarystentsthathavereducedlaterestenosisandthefrequencywithwhichemergencybypasssurgeryisrequiredafterPTCA.IntracoronarystentshavebeenusedtotreatsaphenousveingraftstenosisinpatientswithpreviousCABG.However,stentedpatientsstillhavean≈25%combinedrateofdeath,MI,needforrepeatCABG,orre-revascularizationofthetargetvessel.Forsomepatients,hybridproceduresmaybethebestchoice,suchasthecombineduseofCABGsurgeryandcoronaryangioplasty.Suchanapproachisrelevanttothepatientwhoseascendingaortaisinvolvedwithsevereatherosclerosis,forwhichtheimplantationoffreeveingraftsorarterialgraftsleadstoriskforatheroembolism.Insuchapatient,theuseofinsituinternalmammaryarterygraftingwithoutcardiopulmonarybypasscombinedwithadditionalcoronaryangioplastyinotherdiseasedvesselsrepresentsastrategytoprovidecompleterevascularizationwithouttheconcomitantrisksofcardiopulmonarybypassand/ormanipulationoftheascendingaorta.D.TransmyocardialRevascularizationAfourthareathatisrapidlyevolvingistransmyocardialrevascularization.Theuseoftransmyocardiallaserrevascularizationhasgenerallybeenperformedsurgicallyforpatientswithsevereanginarefractorytomedicaltherapyandwhoarenotsuitablecandidatesforstandardsurgicalrevascularization,PTCA,orhearttransplant.Whileseveralstudieshavesuggestedimprovementinanginaseveritywithtransmyocardiallaserrevascularization,themechanismbywhichanginaimprovesandtheoverallbenefitonlong-termanginaand/orsurvivalawaitfurtherclarification.VII.SpecialPatientSubsetsA.ElderlyPatientsElderlypatientsbeingconsideredforCABGhaveahigheraverageriskformortalityandmorbidityinadirectrelationtoage,LVfunction,extentofcoronarydisease,andcomorbidconditionsandwhethertheprocedureisurgent,emergent,orareoperation.Nonetheless,functionalrecoveryandsustainedimprovementinthequalityoflifecanbeachievedinthemajorityofsuchpatients.Thepatientandphysiciantogethermustexplorethepotentialbenefitsofimprovedqualityoflifewiththeattendantrisksofsurgeryversusalternativetherapiesthattakeintoaccountbaselinefunctionalcapacitiesandpatientpreferences.AgealoneshouldnotbeacontraindicationtoCABGifitisthoughtthatlong-termbenefitsoutweightheproceduralrisk.B.WomenAnumberofearlierreportshadsuggestedthatfemalesexwasanindependentriskfactorformortalityandmorbidityafterCABG.Morerecentstudieshavesuggestedthatwomenonaveragehaveadisadvantageous,preoperativeclinicalprofilethataccountsformuchofthisperceiveddifference.Thus,theissueisnotnecessarilysexitselfbutthecomorbidconditionsthatareparticularlyassociatedwiththelaterageatwhichwomenpresentforcoronarysurgery.Thus,CABGshouldnotbedelayedinordeniedtowomenwhohaveappropriateindications.C.DiabeticPatientsCoronaryheartdiseaseistheleadingcauseofdeathamongadultdiabeticsandaccountsfor3timesasmanydeathsamongdiabeticsasamongnondiabetics.WhileCABGcarriesanincreasedmorbidityandmortalityindiabetics,datasuggestthatinappropriatecandidates,theabsoluteriskreductionprovidedbysuccessfulrevascularizationremainshigh.TheBARItrialsuggestedthatdiabeticswithmultivesselcoronarydiseasederivedadvantagefrombypasssurgerycomparedwithangioplasty.Severaloftheotherrandomizedtrials,albeitwithsmallernumbersofpatients,failedtoshowthistrend.Diabeticswhoarecandidatesforrenaltransplantationhaveaparticularlyhighincidenceofcoronaryarterydisease,evenintheabsenceofsymptomsorsigns.Inappropriatecandidates,CABGappearstooffermorbidityandmortalitybenefitinsuchpatients.D.PatientsWithChronicObstructivePulmonaryDiseaseBecauseCABGisassociatedwithvariabledegreesofpostoperativerespiratoryinsufficiency,itisimportanttoidentifypatientsatparticularriskforpulmonarycomplications.Theintentistotreatreversibleproblemsthatmaycontributetorespiratoryinsufficiencyinhigh-riskpatients,withthehopeofavoidingprolongedperiodsofmechanicalventilationafterCABG.High-riskpatientsoftenbenefitfrompreoperativeantibiotics,bronchodilatortherapy,aperiodofcessationfromsmoking,perioperativeincentivespirometry,deep-breathingexercises,andchestphysiotherapy.Ifpulmonaryvenouscongestionorpleuraleffusionsareidentified,diuresisoftenimproveslungperformance.Althoughpreoperativespirometrydirectedtoidentifyingpatientswithalow(eg,<1L)1-secondforcedexpiratoryvolumehasbeenusedbysometoqualifyordisqualifycandidatesforCABG,clinicalevaluationoflungfunctionislikelyasimportantifnotmoreso.Patientswithadvancedchronicobstructivepulmonarydiseaseareatparticularriskforpostoperativearrhythmiasthatmaybefatal.WhilemoderatetoseveredegreesofobstructivepulmonarydiseaserepresentasignificantriskfactorforearlymortalityandmorbidityafterCABG,itisalsotruethatwithcarefulpreoperativeassessmentandtreatmentoftheunderlyingpulmonaryabnormality,manysuchpatientsaresuccessfullycarriedthroughtheoperativeprocedure.E.PatientsWithEnd-StageRenalDiseaseCoronaryarterydiseaseisthemostimportantcauseofmortalityinpatientswithend-stagerenaldisease.Manyofsuchpatientshavediabetesandothercoronaryriskfactors,includinghypertension,myocardialdysfunction,abnormallipids,anemia,andincreasedplasmahomocysteinelevels.Althoughpatientsonchronicdialysisareathigherriskwhenundergoingcoronaryangioplastyorbypass,theyareatevenhigherriskwithconservativemedicalmanagement.Thus,inpatientswithmodestreductionsinLVfunction,significantleftmainor3-vesseldisease,and/orunstableangina,coronaryrevascularizationcanleadtoreliefofcoronarysymptoms,improvementinoverallfunctionalstatus,andimprovedlong-termsurvivalinthisselecthigh-riskpatientpopulation.F.ReoperativePatientsOperativesurvivalandlong-termbenefitofreoperativeCABGaredistinctlyinferiortofirst-timeoperations.PatientsundergoingrepeatedCABGhavehigherratesofpostoperativebleeding,perioperativeMI,andneurologicalandpulmonarycomplications.Nevertheless,reasonable5-and10-yearsurvivalratesafterreoperationforcoronarydiseasecanbeachieved,andtheoperationisappropriateiftheseverityofsymptomsandanticipatedbenefitjustifytheimmediaterisk.DatasuggestthattheneedforreoperationislesscommoninpatientsundergoinginternalmammaryarterygraftingtotheLAD.Morerecently,short-termfollow-upstudiessuggestthatpatientsundergoingmultiplearterialgraftshaveevenlowerratesofreoperation.Theseearlyresultsareconsistentwiththeknownsuperiorgraftpatencyofarterialconduitscomparedwithveingrafts.G.ConcomitantPeripheralVascularDiseaseThepresenceofclinicalandsubclinicalperipheralvasculardiseaseisastrongpredictorofincreasedhospitalandlong-termmortalityratesinpatientsundergoingCABG.However,theabsolutebenefitofferedbycoronaryrevascularizationiselevatedinpatientswithperipheralvasculardisease,particularlythosewith3-vesselcoronarydisease,moreadvancedangina,and/oradepressedLVEF.Excessperioperativemortalityinsuchpatientsisrelatedtoanincreasedincidenceofheartfailureanddysrhythmiasratherthanperipheralarterialcomplications.H.PoorLVFunctionPatientswithsevereLVdysfunctionhaveincreasedperioperativeandlong-termmortalitycomparedwithpatientswithnormalLVfunction.However,studiessuggestthatthebeneficialeffectsofmyocardialrevascularizationinpatientswithischemicheartdiseaseandsevereLVdysfunctionaresizeablewhencomparedwithmedicallytreatedpatientsofsimilarstatusintermsofsymptomrelief,exercisetolerance,andsurvival.I.CABGinAcuteCoronarySyndromesCoronarybypasssurgeryoffersasurvivaladvantagecomparedwithmedicaltherapyinpatientswithunstableanginaandLVdysfunction,particularlyinthepresenceof3-vesseldisease.However,theriskofbypasssurgeryinpatientswithunstableorpostinfarctionanginaorearlyafternon–QwaveinfarctionandduringacuteMIisincreasedseveralfoldcomparedwithpatientswithstableangina.Althoughthisriskisnotnecessarilyhigherthanthatwithmedicaltherapy,ithasledtotheargumenttoconsiderangioplastyortodelayCABGinsuchpatientsifmedicalstabilizationcanbeeasilyaccomplished.VIII.InstitutionalandOperatorCompetenceStudiessuggestthatmortalityafterCABGishigherwhencarriedoutininstitutionsthatannuallyperformfewerthanaminimumnumberofcases.Similarconclusionshavebeendrawnregardingindividualsurgeons’volumes.Thisobservationstrengthenstheargumentforcarefuloutcometrackingandsupportsthemonitoringofinstitutionsorindividualswhoannuallyperform<100cases.Itisalsotruethatthereisawidevariationinrisk-adjustedmortalityratesinlow-volumesituations.Thus,someinstitutionsandpractitionersmaintainexcellentoutcomesdespiterelativelylowvolumes.Outcomereportingintheformofrisk-adjustedmortalityratesafterbypasshasbeeneffectiveinreducingmortalityratesnationwide.Publicreleaseofhospitalandphysician-specificmortalityrateshasnotbeenshowntodrivethisimprovementandhasfailedtoeffectivelyguideconsumersoralterphysicianreferralpatterns.IX.Cost-EffectivenessofBypassSurgeryAvarietyofstudiesofCABGhavefoundthetechniquetobecost-effectiveinpatientsforwhomsurvivaland/orsymptomaticbenefitisdemonstrable.Withinthesesubsets,thecost-effectivenessofCABGcomparesfavorablywiththatofotheracceptedmedicaltherapies.WhencomparedwithPTCA,theinitialhospitalcostofCABGissignificantlyhigher.However,by5years,thecumulativecostofPTCAcomparedwithinitialsurgicaltherapyiswithin5%ofCABG,oradifferenceof1.4<70y70–79y≥80y0−−−−1.9%(n=909)7.0%(n=330)11.8%(n=68)1−−−+5.0%(n=80)18.4%(n=76)12.5%(n=16)−−+−5.9%(n=68)4.8%(n=81)0.0%(n=1)−+−−6.2%(n=130)14.3%(n=56)25.0%(n=4)+−−−7.6%(n=144)12.3%(n=73)29.4%(n=17)2−−++22.2%(n=9)0%(n=7)0%(n=0)−+−+20.0%(n=25)30.8%(n=13)0%(n=0)−++−37.6%(n=8)33.3%(n=3)0%(n=1)+−−+47.4%(n=19)7.7%(n=26)44.4%(n=9)+−+−25.9%(n=27)18.2%(n=11)0%(n=0)++−−31.6%(n=19)7.1%(n=14)100.0%(n=1)3−+++100%(n=1)100%(n=1)0%(n=0)+−++8.3%(n=12)25%(n=4)0%(n=1)++−+0.0%(n=2)33.3%(n=9)0%(n=2)+++−33.3%(n=3)0%(n=0)0%(n=0)4++++50.0%(n=2)0%(n=0)0%(n=0)CHFindicatespriorcongestiveheartfailure;Reop,redocoronarybypassoperation;DM,type1diabetesmellitus;Creat>1.4,preoperativeserumcreatininelevel>1.4mg/dL;n,observednumberofpatientswithineachclinicalstratum;−,riskfactorabsent;and+,riskfactorpresent.ReprintedwithpermissionfromManaganoCM,DiamondstoneLS,RamsayJG,AggarwalA,HerskowitzA,ManaganoDT.Renaldysfunctionaftermyocardialrevascularization:riskfactors,adverseoutcomes,andhospitalresourceutilization:theMulticenterStudyofPerioperativeIschemiaResearchGroup.AnnInternMed.1998;128:194. Table3. TotalMortalityat5and10YearsTrialNo.ofPatientsRandomized5-YearMortality10-YearMortalityCABGMedicalTreatmentCABGMedicalTreatmentOddsRatio(95%CI)CABGMedicalTreatmentOddsRatio(95%CI)VA33235458790.74(0.50–1.08)1181410.83(0.61–1.14)European39437330630.40(0.26–0.64)911090.72(0.52–0.99)CASS39039020320.60(0.34–1.08)72830.84(0.59–1.19)Texas566010130.79(0.31–1.97)23250.97(0.46–2.04)Oregon5149480.44(0.12–1.56)14140.94(0.39–2.26)NewZealand5149570.65(0.19–2.20)15160.94(0.38–2.31)NewZealand5050881.00(0.34–2.91)17161.15(0.50–2.65)Total132413251352100.61(0.48–0.77)3504040.83(0.70–0.98)(10.2%)(15.8%)P<0.0001(26.4%)(30.5%)P=0.03CABGindicatescoronaryarterybypassgraft;CI,confidenceinterval;VA,VeteransAdministration;andCASS,CoronaryArterySurgeryStudy.Pvaluesforheterogeneityacrossstudieswere0.49,0.84,and0.95at5,7,and10years,respectively.PleaserefertoTable7inthefulltextoftheseguidelines(JAmCollCardiol.1999;34:1275)fordetailedinformationconcerningthetrialslistedhereincolumn1. Table4. SubgroupResultsat5YearsSubgroupOverallNumbersMortalityRates,%OddsRatio(95%CI)PforCABGSurgeryvsMedicalTherapyDeathsPatientsSurgicalMedicalNo.ofdiseasedvessels1212715.49.90.54(0.22–1.33)0.182928599.711.70.84(0.54–1.32)0.453189134110.717.60.58(0.42–0.80)<0.001Leftmainartery3915015.836.50.32(0.15–0.70)0.004NoLADdisease1or2Vessels506068.38.31.05(0.58–1.90)0.883Vessels464107.714.50.47(0.25–0.89)0.02Leftmainartery165118.545.80.27(0.08–0.90)0.03Overall11210678.612.30.66(0.44–1.00)0.05LADdiseasepresent1or2Vessels635249.214.60.58(0.34–1.01)0.053Vessels14392912.019.10.61(0.42–0.88)0.009Leftmainartery229612.832.70.30(0.11–0.84)0.02Overall228154911.218.30.58(0.43–0.77)0.001LVfunctionNormal22820958.513.30.61(0.46–0.81)<0.001Abnormal11554916.525.20.59(0.39–0.91)0.02ExerciseteststatusMissing10266413.117.40.69(0.45–1.07)0.10Normal605859.011.60.78(0.45–1.35)0.38Abnormal18314009.416.80.52(0.37–0.72)<0.001SeverityofanginaClassI,II17817168.312.50.63(0.46–0.87)0.005ClassIII,IV16792413.822.40.57(0.40–0.81)0.001CIindicatesconfidenceinterval;CABG,coronaryarterybypassgraft;LAD,leftanteriordescendingcoronaryartery;andLV,leftventricular.Fordetailedinformationconcerningprobabilityvaluedata,pleaseseeTable8inthefulltextoftheseguidelines(JAmCollCardiol.1999;34:1276). Table5. SubgroupAnalysisof5-YearMortalitybyRiskStratumDeaths,nPatients,nMedicalTreatmentMortalityRate,%OddsRatio(95%CI)PforCABGvsMedicalTreatmentRiskstrataderivedbyriskscore1Lowesttertile234065.51.18(0.51–2.71)0.70Middletertile9093011.50.63(0.39–1.01)0.05Highesttertile15384923.00.50(0.35–0.72)0.001Riskstratabystepwiseriskscore2Lowesttertile527836.31.17(0.66–2.07)0.60Middletertile8578413.90.55(0.34–0.88)0.01Highesttertile15778325.20.54(0.37–0.77)0.001CIindicatesconfidenceinterval;CABG,coronaryarterybypassgraft.ModifiedwithpermissionfromYusufS,ZuckerD,PeduzziP,FisherLD,TakaroT,KennedyJW,DavisK,KillipT,PassamaniE,NorrisR,etal.Effectofcoronaryarterybypassgraftsurgeryonsurvival:overviewof10-yearresultsfromrandomisedtrialsbytheCoronaryArteryBypassGraftSurgeryTrialistsCollaboration.Lancet.1994;344:563–570.1VeteransAdministration–typeriskscore=(0.70×presenceofclassIII/IVangina)+(0.37×historyofhypertension)+(0.83×ST-segmentdepressionatrest)+(0.39×historyofmyocardialinfarction).2Stepwiseriskscore=(0.015×age)+(0.56×presenceofclassIII/IVangina)+(0.35×historyofmyocardialinfarction)+(0.62×abnormalejectionfraction)+(0.53×proximallesion>50%intheleftanteriordescendingcoronaryartery)+(0.29×rightcoronaryarterylesion>50%)+(0.43×historyofdiabetes)+(0.37×historyofhypertension). Table6. CABGvsPTCA:RandomizedControlledTrialsTrial1Age,y(%Female)CADNAcuteOutcome,%LateOutcome,%PrimaryEndPointPrimaryEndPoint,%F/U,yDeath:CABGPTCAQW-MI:CABGPTCAHospCABGDeathQW-MIAnginaRRTotal/PTCA/CABG,%BARI61(26%)MV17921.34.6…10.719.6…8/7/1D10.751.12.16.313.721.3…54/34/3113.7EAST61(26%)MV3921.010.3…6.219.61213/13/1D+MI+T27.331.03.0210.17.116.62054/41/2228.8GABI…(20%)MV3592.58.0…6.59.4266/5/1A2611.12.328.52.64.52944/27/2129Toulouse67(23%)MV1521.36.6…10.51.35.39/9/0A5.251.33.93.913.25.321.1229/15/1521.12RITA57(19%)SV+10111.22.4…3.65.221.54/3/1D+MI8.62.54MV30.83.54.53.16.731.331/18/199.8ERACI58(13%)MV1274.66.2…4.77.83.26/3/3D+MI+A+RR2311.56.31.59.57.84.837/14/22532MASS56(42%)SV1421.41.4………20/0/0D+MI+RR33(LAD)1.4011……1822/29/14242Lausanne56(20%)SV13400…1.51.553/3/0D+MI+RR7.624(LAD)002.902.9625/12/1336.82CABRI60(22%)MV10541.3……2.73.510.19/6/1D2.711.3……3.94.913.9236/21/183.9Weightedaverage60(23%)1.31.04.12.3…5.96.57.711.311.010.4>15.5>7.342.3CABGindicatescoronaryarterybypassgraft;PTCA,percutaneoustransluminalcoronaryangioplasty;CAD,coronaryarterydisease;QW,Qwave;MI,myocardialinfarction;HospCABG,requiredCABGafterPTCAandbeforehospitaldischarge;RR,repeatedrevascularization;F/U,follow-up;BARI,BypassAngioplastyRevascularizationInvestigation;EAST,EmoryAngioplastySurgeryTrial;GABI,GermanAngioplastyBypass-surgeryInvestigation;RITA,RandomisedInterventionTreatmentofAngina;ERACI,EstudioRandomizadoArgentinodeAngioplastiavsCirugia;MASS,Medicine,Angioplasty,orSurgeryStudy;CABRI,CoronaryAngioplastyversusBypassRevascularizationInvestigation;MV,multivessel;D,death;T,thalliumdefect;A,angina;SV,singlevessel;andLAD,leftanteriordescendingcoronaryartery.1ReferencesfoundinthecompleteguidelinespublishedinJAmCollCardiol.1999;34:1262–1341.2P<0.05comparingCABGandPTCAcohorts.3Includedtotalocclusion.4Planned5-yearfollow-up(interimresults). Table7. Three-YearSurvivalbyTreatmentinEachAnatomicSubgroupCoronaryAnatomyGroupPatients,nSurvivalPObserved,%Adjusted,%1-Vessel,noLADCABG50789.292.40.003PTCA1123395.495.31-Vessel,nonproximalLADCABG15395.896.00.857PTCA413095.795.71-Vessel,proximalLADCABG191795.896.60.010PTCA586895.595.22-Vessel,noLADCABG112091.093.00.664PTCA272993.492.62-Vessel,nonproximalLADCABG85091.392.30.438PTCA230093.393.12-Vessel,proximalLADCABG724293.593.8<0.001PTCA237692.891.73-Vessel,nonproximalLADCABG198490.190.30.002PTCA66086.786.03-Vessel,proximalLADCABG1587390.190.3<0.001PTCA63488.286.1LADindicatesleftanteriordescendingcoronaryartery;CABG,coronaryarterybypassgraft;andPTCA,percutaneoustransluminalcoronaryangioplasty.Comparativeobservedandadjusted3-yearsurvivalofpatientstreatedwithPTCAorCABGinvariousanatomicsubgroups.ReprintedwithpermissionfromtheNewYorkStateRegistryaspublishedinHannanEL,RaczMJ,McCallisterBD,RyanTJ,AraniDT,IsomOW,JonesRH.Acomparisonofthree-yearsurvivalaftercoronaryarterybypassgraftsurgeryandpercutaneoustransluminalcoronaryangioplasty.JAmCollCardiol.1999;33:67. Table8. ProphylacticAntimicrobialsforCoronaryArteryBypassGraftSurgeryCephalosporinsEquivalentEfficacyIVDosingRegimensDoseandIntervalCostperDoseCommentsCefuroxime1.5gpreoperatively1.5gafterCPB1.5gQ12×48$6.33/1.5gFirst-lineagents;lowtoxicity;pharmacokineticsvary;shorterprophylaxisduration<24hmaybeequallyefficaciousforcefuroximeCefamandole,cefazolin1gpreoperatively$6.27/g1gatsternotomy$0.90/g1gafterCPB1gQ6×48(Initialdosetobegiven30–60minutesbeforeskinincision)Vancomycin1gQ12/h/untillines/tubesoutAtleast2doses$5.77/gReservedforpenicillin-allergic;justified(During30–60-minuteinfusiontimedtoendbeforeskinincision)inperiodsofmethicillin-resistantStaphylococcusspeciesoutbreaks;vancomycin-resistantEnterococcusproblemisonhorizon;morelikelytorequirevasopressoragentperioperatively\CPBindicatescardiopulmonarybypass.Datatakenfrom(1)TownsendTR,ReitzBA,BilkerWB,BartlettJG.Clinicaltrialofcefamandole,cefazolin,andcefuroximeforantibioticprophylaxisincardiacoperations.JThoracCardiovascSurg.1993;106:664–670.(2)Antimicrobialprophylaxisinsurgery.MedLettDrugsTher.1997;39:97–101.(3)VuorisaloS,PokelaR,SyrjalaH.Comparisonofvancomycinandcefuroximeforinfectionprophylaxisincoronaryarterybypasssurgery.InfectControlHospEpidemiol.1998;19:234–239.(4)RomanelliVA,HowieMB,MyerowitzPD,ZvaraDA,RezaeiA,JackmanDL,SinclairDS,McSweenyTD.Intraoperativeandpostoperativeeffectsofvancomycinadministrationincardiacsurgerypatients:aprospective,double-blind,randomizedtrial.CritCareMed.1993;21:1124–1131. Table9. PharmacologicalStrategiesforPreventionofAtrialFibrillation(AF)AfterCoronaryArteryBypassGraftSurgeryTreatmentTimingDose/RouteAFIncidence,%CommentsFrontlinestrategiesResumptionofpatient’spreoperativeβ-blockerPostoperativeresumptionSameaspreoperativeβ-Blockerstopped;38.1%ContinuedP=0.0217.1%Resumptionofβ-blockerreducedAFby45%β-Blockerstopped;28%ContinuedP=0.016%Nearly5-folddecreaseinincidence;ifnolongerneededafterrevascularization,maytaperasoutpatientβ-Blockers(propranololprototypical)Postoperativeinitiation(10±7hpostoperatively)5mgorally4timesperdayControl23%Propranolol9.8%P=0.02ReducedAFby43%;inexpensive,lowdoseAlmostallβ-blockersevaluatedPostoperativelyVariesSignificantlyreducedvsplaceboOddsratio0.17;confidenceinterval0.03–0.98infavorofβ-blockerovercontrolsinmeta-analysisAtenololPreoperatively(begun72hbeforeoperation)50mgOrallytwiceadayControl37%Atenolol3%P=0.001ExcellentoptionifpreoperativephasepracticalSotalolPreoperativelythroughpostoperatively160mgamofoperation,then160mgBIDPOControl29%Sotalol10%ClassIIIproperties;sotalolnottoleratedin10%ofpatientsMagnesiumsulfatePostoperativelyContinuousIVinfusionforatotalof178mEqoverfirst4postoperativedaysControl28%Mgsupplement14%P=0.02Goalisnormalserummagnesium:≥1mmol/L,<2mEq/L,whichisusuallylowaftercardiopulmonarybypassAlternative/nichestrategiesAmiodaronePreoperativelythroughpostoperatively600mgOrallydailyfor7dayspreoperatively;then200mgPOdailypostoperatively;stopatdischarge;total=4.8gControl53%Amiodarone25%P=0.003Mixedgroupofcoronaryandvalvepatients,explainingveryhighAFincidenceAmiodaronePostoperatively300mgIntravenousbolus;then1.2gover24hfor2days;then900mgevery24hfor2days,foratotalof4.5gControl21%Amiodarone5%P=0.05CoronarybypasspatientsonlyinthisstudyPropafenonePostoperatively300mgOrallytwiceadayfor7daysPropafenone12%Atenolol11%P=NSPropafenoneoffersalessnegativeinotropicoptionforpoorleftventricularfunctionpopulationFordetailsaboutthetrialsfromwhichthesedatawerederived,pleaserefertoTable13ofthefulltextoftheseguidelines(JAmCollCardiol.1999;34:1294). Table10. ProvenManagementStrategiestoReducePerioperativeandLateMorbidityandMortalityTimingClassIndicationInterventionCommentsPreoperativeCarotidscreeningICarotidduplexultrasoundindefinedpopulationCarotidendarterectomyifstenosis≥80%PerioperativeAntimicrobialsIProphylacticantimicrobialsTable8AntifibrinolyticsIIaAprotinininselectedgroupsSignificantreductioninbloodtransfusionrequirementAntiarrhythmicsIβ-BlockerstopreventpostoperativeatrialfibrillationPropafenoneoramiodaronearealternativesifcontraindicationtoβ-blocker(Table9)Anti-inflammatorydrugsIIaMinimizediffuseinflammatoryresponsetocardiopulmonarybypassPostoperativeAntiplateletagentsIAspirintopreventearlyvein-graftattritionTiclopidineorclopidogrelarealternativesifcontraindicationstoaspirinLipid-loweringtherapyICholesterol-loweringagentpluslow-fatdietiflow-densitylipoproteincholesterol>100mg/dL3-Hydroxy-3-methyglutaryl/coenzymeAreductaseinhibitorspreferredifelevatedlow-densitylipoproteinismajoraberrationSmokingcessationISmokingcessationeducation,andoffercounselingandpharmacotherapies Table1. Previous Backtotop Next FiguresReferencesRelatedDetailsCitedByTianM,WangX,SunH,FengW,SongY,LuF,WangL,WangY,XuB,WangH,LiuS,LiuZ,ChenY,MiaoQ,SuP,YangY,GuoS,LuB,SunZ,LiuK,ZhangC,WuY,XuH,ZhaoW,HanC,ZhouX,WangE,HuoXandHuS(2021)No-TouchVersusConventionalVeinHarvestingTechniquesat12MonthsAfterCoronaryArteryBypassGraftingSurgery:MulticenterRandomized,ControlledTrial,Circulation,144:14,(1120-1129),Onlinepublicationdate:5-Oct-2021. September28,1999Vol100,Issue13ArticleInformationMetrics Copyright©1999byAmericanHeartAssociationhttps://doi.org/10.1161/01.CIR.100.13.1464 OriginallypublishedSeptember28,1999 KeywordsmorbidityACC/AHAPracticeGuidelinesmortalityangioplastyriskfactorsbypassrevascularizationPDFdownload Advertisement TitleCaptionTitleCaptionTitleCaptionTitleCaption