ACCF/AHA Practice Guideline

2011 ACCF/AHA Guideline for Coronary Artery BypassGraft Surgery

A Report of the American College of Cardiology Foundation/American HeartAssociation Task Force on Practice Guidelines

Developed in Collaboration With the American Association for Thoracic Surgery, Society ofCardiovascular Anesthesiologists, and Society of Thoracic Surgeons

WRITING COMMITTEE MEMBERS*L. David Hillis, MD, FACC, Chair; Peter K. Smith, MD, FACC, Vice Chair*;

Jeffrey L. Anderson, MD, FACC, FAHA*; John A. Bittl, MD, FACC;Charles R. Bridges, MD, SCD, FACC, FAHA*; John G. Byrne, MD, FACC;

Joaquin E. Cigarroa, MD, FACC; Verdi J. DiSesa, MD, FACC;Loren F. Hiratzka, MD, FACC, FAHA; Adolph M. Hutter, Jr, MD, MACC, FAHA;

Michael E. Jessen, MD, FACC*; Ellen C. Keeley, MD, MS; Stephen J. Lahey, MD;Richard A. Lange, MD, FACC, FAHA; Martin J. London, MD;

Michael J. Mack, MD, FACC*; Manesh R. Patel, MD, FACC; John D. Puskas, MD, FACC*;Joseph F. Sabik, MD, FACC*#; Ola Selnes, PhD; David M. Shahian, MD, FACC, FAHA**;

Jeffrey C. Trost, MD, FACC*; Michael D. Winniford, MD, FACC

ACCF/AHA TASK FORCE MEMBERSAlice K. Jacobs, MD, FACC, FAHA, Chair; Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect;

Nancy Albert, PhD, CCNS, CCRN, FAHA; Mark A. Creager, MD, FACC, FAHA;Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC;

Jonathan L. Halperin, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA;Frederick G. Kushner, MD, FACC, FAHA; E. Magnus Ohman, MD, FACC;

William Stevenson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationship with industry and otherentities may apply; see Appendix 1 for recusal information.

ACCF/AHA Representative.ACCF/AHA Task Force on Practice Guidelines Liaison.Joint Revascularization Section Author.Society of Cardiovascular Anesthesiologists Representative.American Association for Thoracic Surgery Representative.#Society of Thoracic Surgeons Representative.**ACCF/AHA Task Force on Performance Measures Liaison.This document was approved by the American Heart Association Science Advisory and Coordinating Committee in July 2011, and by the American

College of Cardiology Foundation Board of Trustees in July 2011.The American Heart Association requests that this document be cited as follows: Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG,

Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, SabikJF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the AmericanCollege of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:e652e735.

This article has been copublished in the Journal of the American College of Cardiology.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American

Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the ByTopic link or the By Publication Date link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,visit http://my.americanheart.org/statements and select the Policies and Development link.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page.

(Circulation. 2011;124:e652e735.) 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31823c074e

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Table of Contents

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e6541. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e656

1.1. Methodology and Evidence Review . . . . . . . .e6561.2. Organization of the Writing Committee . . . . .e6571.3. Document Review and Approval. . . . . . . . . . .e657

2. Procedural Considerations. . . . . . . . . . . . . . . . . . . .e6572.1. Intraoperative Considerations . . . . . . . . . . . . .e657

2.1.1. Anesthetic Considerations:Recommendations. . . . . . . . . . . . . . . . .e657

2.1.2. Use of CPB . . . . . . . . . . . . . . . . . . . . .e6592.1.3. Off-Pump CABG Versus Traditional

On-Pump CABG . . . . . . . . . . . . . . . . .e6592.1.4. Bypass Graft Conduit:

Recommendations. . . . . . . . . . . . . . . . .e6602.1.4.1. Saphenous Vein Grafts . . . . . .e6612.1.4.2. Internal Mammary Arteries . . .e6612.1.4.3. Radial, Gastroepiploic, and

Inferior Epigastric Arteries . . .e6612.1.5. Incisions for Cardiac Access. . . . . . . . .e6612.1.6. Anastomotic Techniques. . . . . . . . . . . .e6622.1.7. Intraoperative TEE:

Recommendations. . . . . . . . . . . . . . . . .e6622.1.8. Preconditioning/Management of

Myocardial Ischemia:Recommendations. . . . . . . . . . . . . . . . .e663

2.2. Clinical Subsets. . . . . . . . . . . . . . . . . . . . . . . .e6642.2.1. CABG in Patients With Acute MI:

Recommendations. . . . . . . . . . . . . . . . .e6642.2.2. Life-Threatening Ventricular Arrhythmias:

Recommendations . . . . . . . . . . . . . . . . .e6662.2.3. Emergency CABG After Failed PCI:

Recommendations. . . . . . . . . . . . . . . . .e6662.2.4. CABG in Association With Other

Cardiac Procedures:Recommendations. . . . . . . . . . . . . . . . .e667

3. CAD Revascularization. . . . . . . . . . . . . . . . . . . . . .e6673.1. Heart Team Approach to Revascularization

Decisions: Recommendations . . . . . . . . . . . . .e6683.2. Revascularization to Improve Survival:

Recommendations . . . . . . . . . . . . . . . . . . . . . .e6683.3. Revascularization to Improve Symptoms:

Recommendations . . . . . . . . . . . . . . . . . . . . . .e6713.4. CABG Versus Contemporaneous Medical

Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e6713.5. PCI Versus Medical Therapy . . . . . . . . . . . . .e6713.6. CABG Versus PCI . . . . . . . . . . . . . . . . . . . . .e672

3.6.1. CABG Versus Balloon Angioplasty orBMS . . . . . . . . . . . . . . . . . . . . . . . . . . .e672

3.6.2. CABG Versus DES . . . . . . . . . . . . . . .e6723.7. Left Main CAD. . . . . . . . . . . . . . . . . . . . . . . .e673

3.7.1. CABG or PCI Versus Medical Therapyfor Left Main CAD . . . . . . . . . . . . . . .e673

3.7.2. Studies Comparing PCI Versus CABGfor Left Main CAD. . . . . . . . . . . . . . .e673

3.7.3. Revascularization Considerations forLeft Main CAD . . . . . . . . . . . . . . . . .e674

3.8. Proximal LAD Artery Disease . . . . . . . . . . .e6743.9. Clinical Factors That May Influence the Choice

of Revascularization . . . . . . . . . . . . . . . . . . .e6743.9.1. Diabetes Mellitus . . . . . . . . . . . . . . . .e6743.9.2. Chronic Kidney Disease . . . . . . . . . . .e6753.9.3. Completeness of

Revascularization . . . . . . . . . . . . . . . .e6753.9.4. LV Systolic Dysfunction. . . . . . . . . . .e6753.9.5. Previous CABG . . . . . . . . . . . . . . . . .e6753.9.6. Unstable Angina/NonST-Elevation

Myocardial Infarction . . . . . . . . . . . . .e6763.9.7. DAPT Compliance and Stent

Thrombosis: Recommendation . . . . . .e6763.10. TMR as an Adjunct to CABG. . . . . . . . . . . .e6763.11. Hybrid Coronary Revascularization:

Recommendations . . . . . . . . . . . . . . . . . . . . .e6764. Perioperative Management . . . . . . . . . . . . . . . . . . .e677

4.1. Preoperative Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . . . . . . . .e677

4.2. Postoperative Antiplatelet Therapy:Recommendations . . . . . . . . . . . . . . . . . . . . .e677

4.3. Management of Hyperlipidemia:Recommendations . . . . . . . . . . . . . . . . . . . . .e6784.3.1. Timing of Statin Use and CABG

Outcomes . . . . . . . . . . . . . . . . . . . . . .e6794.3.1.1. Potential Adverse Effects of

Perioperative StatinTherapy . . . . . . . . . . . . . . . . .e679

4.4. Hormonal Manipulation:Recommendations . . . . . . . . . . . . . . . . . . . . .e6794.4.1. Glucose Control . . . . . . . . . . . . . . . . .e6794.4.2. Postmenopausal Hormone

Therapy. . . . . . . . . . . . . . . . . . . . . . . .e6804.4.3. CABG in Patients With

Hypothyroidism . . . . . . . . . . . . . . . . .e6804.5. Perioperative Beta Blockers:

Recommendations . . . . . . . . . . . . . . . . . . . . .e6804.6. ACE Inhibitors/ARBs:

Recommendations . . . . . . . . . . . . . . . . . . . . .e6814.7. Smoking Cessation: Recommendations . . . . .e6824.8. Emotional Dysfunction and Psychosocial

Considerations: Recommendation . . . . . . . . .e6834.8.1. Effects of Mood Disturbance and

Anxiety on CABG Outcomes . . . . . . .e6834.8.2. Interventions to Treat Depression

in CABG Patients . . . . . . . . . . . . . . . .e6834.9. Cardiac Rehabilitation:

Recommendation . . . . . . . . . . . . . . . . . . . . . .e6834.10. Perioperative Monitoring . . . . . . . . . . . . . . . .e684

Hillis et al 2011 ACCF/AHA CABG Guideline e653

4.10.1. Electrocardiographic Monitoring:Recommendations . . . . . . . . . . . . . . .e684

4.10.2. Pulmonary Artery Catheterization:Recommendations . . . . . . . . . . . . . . .e684

4.10.3. Central Nervous System Monitoring:Recommendations . . . . . . . . . . . . . . .e684

5. CABG-Associated Morbidity and Mortality:Occurrence and Prevention . . . . . . . . . . . . . . . . . . .e6855.1. Public Reporting of Cardiac Surgery

Outcomes: Recommendation . . . . . . . . . . . . . .e6855.1.1. Use of Outcomes or Volume as

CABG Quality Measures:Recommendations . . . . . . . . . . . . . . .e686

5.2. Adverse Events . . . . . . . . . . . . . . . . . . . . . . . .e6875.2.1. Adverse Cerebral Outcomes . . . . . . .e687

5.2.1.1. Stroke . . . . . . . . . . . . . . . . .e6875.2.1.1.1. Use of Epiaortic Ultra-

sound Imaging to ReduceStroke Rates: Recom-mendation . . . . . . .e687

5.2.1.1.2. The Role of PreoperativeCarotid Artery Noninva-sive Screening in CABGPatients: Recommenda-tions . . . . . . . . . . .e687

5.2.1.2. Delirium . . . . . . . . . . . . . . .e6895.2.1.3. Postoperative Cognitive

Impairment . . . . . . . . . . . . .e6895.2.2. Mediastinitis/Perioperative Infection:

Recommendations . . . . . . . . . . . . . . .e6895.2.3. Renal Dysfunction:

Recommendations . . . . . . . . . . . . . . .e6915.2.4. Perioperative Myocardial Dysfunction:

Recommendations . . . . . . . . . . . . . . .e6925.2.4.1. Transfusion:

Recommendation . . . . . . . . .e6925.2.5. Perioperative Dysrhythmias:

Recommendations . . . . . . . . . . . . . . .e6925.2.6. Perioperative Bleeding/Transfusion:

Recommendations . . . . . . . . . . . . . . .e6936. Specific Patient Subsets . . . . . . . . . . . . . . . . . . . . .e694

6.1. Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e6946.2. Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e6946.3. Patients With Diabetes Mellitus . . . . . . . . . . .e6956.4. Anomalous Coronary Arteries:

Recommendations . . . . . . . . . . . . . . . . . . . . . .e6966.5. Patients With Chronic Obstructive Pulmonary

Disease/Respiratory Insufficiency:Recommendations . . . . . . . . . . . . . . . . . . . . . .e696

6.6. Patients With End-Stage Renal Disease onDialysis: Recommendations. . . . . . . . . . . . . . .e697

6.7. Patients With Concomitant Valvular Disease:Recommendations . . . . . . . . . . . . . . . . . . . . . .e697

6.8. Patients With Previous Cardiac Surgery:Recommendation . . . . . . . . . . . . . . . . . . . . . .e6976.8.1. Indications for Repeat CABG. . . . . . .e6976.8.2. Operative Risk . . . . . . . . . . . . . . . . . .e6986.8.3. Long-Term Outcomes . . . . . . . . . . . . .e698

6.9. Patients With Previous Stroke . . . . . . . . . . . .e6986.10. Patients With PAD . . . . . . . . . . . . . . . . . . . .e698

7. Economic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .e6987.1. Cost-Effectiveness of CABG and PCI. . . . . .e698

7.1.1. Cost-Effectiveness of CABGVersus PCI . . . . . . . . . . . . . . . . . . . . .e699

7.1.2. CABG Versus PCI With DES . . . . . .e6998. Future Research Directions . . . . . . . . . . . . . . . . . . .e699

8.1. Hybrid CABG/PCI . . . . . . . . . . . . . . . . . . . .e7008.2. Protein and Gene Therapy. . . . . . . . . . . . . . .e7008.3. Teaching CABG to the Next Generation:

Use of Surgical Simulators . . . . . . . . . . . . . .e700References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e701Appendix 1. Author Relationships With Industry and

Other Entities (Relevant) . . . . . . . . . . . . .e731Appendix 2. Reviewer Relationships With Industry

and Other Entitites (Relevant) . . . . . . . . .e733Appendix 3. Abbreviation List . . . . . . . . . . . . . . . . . . .e735

PreambleThe medical profession should play a central role in evaluatingthe evidence related to drugs, devices, and procedures for thedetection, management, and prevention of disease. When prop-erly applied, expert analysis of available data on the benefits andrisks of these therapies and procedures can improve the qualityof care, optimize patient outcomes, and favorably affect costs byfocusing resources on the most effective strategies. An organizedand directed approach to a thorough review of evidence hasresulted in the production of clinical practice guidelines thatassist physicians in selecting the best management strategy foran individual patient. Moreover, clinical practice guidelines canprovide a foundation for other applications, such as performancemeasures, appropriate use criteria, and both quality improvementand clinical decision support tools.

The American College of Cardiology Foundation (ACCF)and the American Heart Association (AHA) have jointlyproduced guidelines in the area of cardiovascular diseasesince 1980. The ACCF/AHA Task Force on Practice Guide-lines (Task Force), charged with developing, updating, andrevising practice guidelines for cardiovascular diseases andprocedures, directs and oversees this effort. Writing commit-tees are charged with regularly reviewing and evaluating allavailable evidence to develop balanced, patientcentric recom-mendations for clinical practice.

Experts in the subject under consideration are selected bythe ACCF and AHA to examine subject-specific data andwrite guidelines in partnership with representatives fromother medical organizations and specialty groups. Writingcommittees are asked to perform a formal literature review;weigh the strength of evidence for or against particular tests,treatments, or procedures; and include estimates of expectedoutcomes where such data exist. Patient-specific modifiers,

e654 Circulation December 6, 2011

comorbidities, and issues of patient preference that mayinfluence the choice of tests or therapies are considered.When available, information from studies on cost is consid-ered, but data on efficacy and outcomes constitute theprimary basis for the recommendations contained herein.

In analyzing the data and developing recommendations andsupporting text, the writing committee uses evidence-basedmethodologies developed by the Task Force.1 The Class ofRecommendation (COR) is an estimate of the size of thetreatment effect considering risks versus benefits in additionto evidence and/or agreement that a given treatment orprocedure is or is not useful/effective or in some situationsmay cause harm. The Level of Evidence (LOE) is an estimateof the certainty or precision of the treatment effect. The

writing committee reviews and ranks evidence supportingeach recommendation with the weight of evidence ranked asLOE A, B, or C according to specific definitions that areincluded in Table 1. Studies are identified as observational,retrospective, prospective, or randomized where appropriate.For certain conditions for which inadequate data are avail-able, recommendations are based on expert consensus andclinical experience and are ranked as LOE C. When recommen-dations at LOE C are supported by historical clinical data,appropriate references (including clinical reviews) are cited ifavailable. For issues for which sparse data are available, a surveyof current practice among the clinicians on the writing commit-tee is the basis for LOE C recommendations, and no referencesare cited. The schema for COR and LOE is summarized in Table

Table 1. Applying Classification of Recommendations and Level of Evidence

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelinesdo not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy isuseful or effective.

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of prior myocardial infarction,history of heart failure, and prior aspirin use.

For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involvedirect omparisons of the treatments or strategies being evaluated.

Hillis et al 2011 ACCF/AHA CABG Guideline e655

1, which also provides suggested phrases for writing recommen-dations within each COR. A new addition to this methodology isseparation of the Class III recommendations to delineate if therecommendation is determined to be of no benefit or isassociated with harm to the patient. In addition, in view of theincreasing number of comparative effectiveness studies, com-parator verbs and suggested phrases for writing recommenda-tions for the comparative effectiveness of one treatment orstrategy versus another have been added for COR I and IIa, LOEA or B only.

In view of the advances in medical therapy across thespectrum of cardiovascular diseases, the Task Force hasdesignated the term guideline-directed medical therapy(GDMT) to represent optimal medical therapy as defined byACCF/AHA guidelinerecommended therapies (primarilyClass I). This new term, GDMT, will be used herein andthroughout all future guidelines.

Because the ACCF/AHA practice guidelines address pa-tient populations (and healthcare providers) residing in NorthAmerica, drugs that are not currently available in NorthAmerica are discussed in the text without a specific COR. Forstudies performed in large numbers of subjects outside NorthAmerica, each writing committee reviews the potential influ-ence of different practice patterns and patient populations onthe treatment effect and relevance to the ACCF/AHA targetpopulation to determine whether the findings should inform aspecific recommendation.

The ACCF/AHA practice guidelines are intended to assisthealthcare providers in clinical decision making by describing arange of generally acceptable approaches to the diagnosis,management, and prevention of specific diseases or conditions.The guidelines attempt to define practices that meet the needs ofmost patients in most circumstances. The ultimate judgmentregarding the care of a particular patient must be made by thehealthcare provider and patient in light of all the circumstancespresented by that patient. As a result, situations may arise forwhich deviations from these guidelines may be appropriate.Clinical decision making should involve consideration of thequality and availability of expertise in the area where care isprovided. When these guidelines are used as the basis forregulatory or payer decisions, the goal should be improvement inquality of care. The Task Force recognizes that situations arise inwhich additional data are needed to inform patient care moreeffectively; these areas will be identified within each respectiveguideline when appropriate.

Prescribed courses of treatment in accordance with theserecommendations are effective only if followed. Because lackof patient understanding and adherence may adversely affectoutcomes, physicians and other healthcare providers shouldmake every effort to engage the patients active participationin prescribed medical regimens and lifestyles. In addition,patients should be informed of the risks, benefits, andalternatives to a particular treatment and be involved inshared decision making whenever feasible, particularly forCOR IIa and IIb, where the benefit-to-risk ratio may be lower.

The Task Force makes every effort to avoid actual,potential, or perceived conflicts of interest that may arise as aresult of industry relationships or personal interests amongthe members of the writing committee. All writing committee

members and peer reviewers of the guideline are required todisclose all such current relationships, as well as thoseexisting 12 months previously. In December 2009, the ACCFand AHA implemented a new policy for relationships withindustry and other entities (RWI) that requires the writingcommittee chair plus a minimum of 50% of the writingcommittee to have no relevant RWI (Appendix 1 for theACCF/AHA definition of relevance). These statements arereviewed by the Task Force and all members during eachconference call and meeting of the writing committee and areupdated as changes occur. All guideline recommendationsrequire a confidential vote by the writing committee and mustbe approved by a consensus of the voting members. Membersare not permitted to write, and must recuse themselves fromvoting on, any recommendation or section to which their RWIapply. Members who recused themselves from voting areindicated in the list of writing committee members, andsection recusals are noted in Appendix 1. Authors and peerreviewers RWI pertinent to this guideline are disclosed inAppendixes 1 and 2, respectively. Additionally, to ensurecomplete transparency, writing committee members comprehen-sive disclosure informationincluding RWI not pertinent to thisdocumentis available as an online supplement. Comprehensivedisclosure information for the Task Force is also available online atwww.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing com-mittee was supported exclusively by the ACCF and AHA withoutcommercial support. Writing committee members volunteered theirtime for this activity.

In an effort to maintain relevance at the point of care forpracticing physicians, the Task Force continues to oversee anongoing process improvement initiative. As a result, inresponse to pilot projects, evidence tables (with referenceslinked to abstracts in PubMed) have been added.

In April 2011, the Institute of Medicine released 2 reports:Finding What Works in Health Care: Standards for SystematicReviews and Clinical Practice Guidelines We Can Trust.2,3 It isnoteworthy that the ACCF/AHA guidelines are cited as beingcompliant with many of the proposed standards. A thoroughreview of these reports and of our current methodology is underway, with further enhancements anticipated.

The recommendations in this guideline are consideredcurrent until they are superseded by a focused update or thefull-text guideline is revised. Guidelines are official policy ofboth the ACCF and AHA.

Alice K. Jacobs, MD, FACC, FAHAChair ACCF/AHA Task Force on Practice Guidelines

1. Introduction1.1. Methodology and Evidence ReviewWhenever possible, the recommendations listed in this docu-ment are evidence based. Articles reviewed in this guidelinerevision covered evidence from the past 10 years throughJanuary 2011, as well as selected other references through April2011. Searches were limited to studies, reviews, and otherevidence conducted in human subjects that were published inEnglish. Key search words included but were not limited to thefollowing: analgesia, anastomotic techniques, antiplatelet

e656 Circulation December 6, 2011

agents, automated proximal clampless anastomosis device,asymptomatic ischemia, Cardica C-port, cost effectiveness, de-pressed left ventricular (LV) function, distal anastomotic tech-niques, direct proximal anastomosis on aorta, distal anastomoticdevices, emergency coronary artery bypass graft (CABG) andST-elevation myocardial infarction (STEMI), heart failure, in-terrupted sutures, LV systolic dysfunction, magnetic connectors,PAS-Port automated proximal clampless anastomotic device,patency, proximal connectors, renal disease, sequential anasto-mosis, sternotomy, symmetry connector, symptomatic ischemia,proximal connectors, sequential anastomosis, T grafts, thoracot-omy, U-clips, Ventrica Magnetic Vascular Port system, Y grafts.Additionally, the committee reviewed documents related to thesubject matter previously published by the ACCF and AHA.References selected and published in this document are repre-sentative but not all-inclusive.

To provide clinicians with a comprehensive set of data,whenever deemed appropriate or when published, the absoluterisk difference and number needed to treat or harm are providedin the guideline, along with confidence interval (CI) and datarelated to the relative treatment effects such as odds ratio (OR),relative risk (RR), hazard ratio (HR), or incidence rate ratio.

The focus of these guidelines is the safe, appropriate, andefficacious performance of CABG.

1.2. Organization of the Writing CommitteeThe committee was composed of acknowledged experts inCABG, interventional cardiology, general cardiology, andcardiovascular anesthesiology. The committee included rep-resentatives from the ACCF, AHA, American Association forThoracic Surgery, Society of Cardiovascular Anesthesiolo-gists, and Society of Thoracic Surgeons (STS).

1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers, eachnominated by both the ACCF and the AHA, as well as 1reviewer each from the American Association for ThoracicSurgery, Society of Cardiovascular Anesthesiologists, andSTS, as well as members from the ACCF/AHA Task Forceon Data Standards, ACCF/AHA Task Force on PerformanceMeasures, ACCF Surgeons Scientific Council, ACCF Inter-ventional Scientific Council, and Southern Thoracic SurgicalAssociation. All information on reviewers RWI was distrib-uted to the writing committee and is published in thisdocument (Appendix 2).

This document was approved for publication by the gov-erning bodies of the ACCF and the AHA and endorsed by theAmerican Association for Thoracic Surgery, Society of Car-diovascular Anesthesiologists, and STS.

2. Procedural Considerations2.1. Intraoperative Considerations2.1.1. Anesthetic Considerations: RecommendationsClass I

1. Anesthetic management directed toward early postop-erative extubation and accelerated recovery of low- tomedium-risk patients undergoing uncomplicatedCABG is recommended.46 (Level of Evidence: B)

2. Multidisciplinary efforts are indicated to ensure anoptimal level of analgesia and patient comfortthroughout the perioperative period.711 (Level ofEvidence: B)

3. Efforts are recommended to improve interdisciplin-ary communication and patient safety in the periop-erative environment (eg, formalized checklist-guidedmultidisciplinary communication).1215 (Level of Ev-idence: B)

4. A fellowship-trained cardiac anesthesiologist (or ex-perienced board-certified practitioner) credentialedin the use of perioperative transesophageal echocar-diography (TEE) is recommended to provide orsupervise anesthetic care of patients who are consid-ered to be at high risk.1618 (Level of Evidence: C)

Class IIa1. Volatile anesthetic-based regimens can be useful in

facilitating early extubation and reducing patientrecall.5,1921 (Level of Evidence: A)

Class IIb1. The effectiveness of high thoracic epidural anesthe-

sia/analgesia for routine analgesic use is uncer-tain.2225 (Level of Evidence: B)

Class III: HARM1. Cyclooxygenase-2 inhibitors are not recommended

for pain relief in the postoperative period afterCABG.26,27 (Level of Evidence: B)

2. Routine use of early extubation strategies in facilitieswith limited backup for airway emergencies oradvanced respiratory support is potentially harmful.(Level of Evidence: C)

See Online Data Supplement 1 for additional data on anes-thetic considerations.

Anesthetic management of the CABG patient mandates afavorable balance of myocardial oxygen supply and demand toprevent or minimize myocardial injury (Section 2.1.8). Histori-cally, the popularity of several anesthetic techniques for CABGhas varied on the basis of their known or potential adversecardiovascular effects (eg, cardiovascular depression with highdoses of volatile anesthesia, lack of such depression withhigh-dose opioids, or coronary vasodilation and concern for asteal phenomenon with isoflurane) as well as concerns aboutinteractions with preoperative medications (eg, cardiovasculardepression with beta blockers or hypotension with angiotensin-converting enzyme [ACE] inhibitors and angiotensin-receptorblockers [ARBs]2830) (Sections 2.1.8 and 4.5). Independent ofthese concerns, efforts to improve outcomes and to reduce costshave led to shorter periods of postoperative mechanical ventila-tion and even, in some patients, to prompt extubation in theoperating room (accelerated recovery protocols or fast-trackmanagement).5,31

High-dose opioid anesthesia with benzodiazepine supple-mentation was used commonly in CABG patients in theUnited States in the 1970s and 1980s. Subsequently, itbecame clear that volatile anesthetics are protective in thesetting of myocardial ischemia and reperfusion, and this, in

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combination with a shift to accelerated recovery or fast-track strategies, led to their ubiquitous use. As a result,opioids have been relegated to an adjuvant role.32,33 Despitetheir widespread use, volatile anesthetics have not beenshown to provide a mortality rate advantage when comparedwith other intravenous regimens (Section 2.1.8).

Optimal anesthesia care in CABG patients should include1) a careful preoperative evaluation and treatment of modifi-able risk factors; 2) proper handling of all medications givenpreoperatively (Sections 4.1, 4.3, and 4.5); 3) establishmentof central venous access and careful cardiovascular monitor-ing; 4) induction of a state of unconsciousness, analgesia, andimmobility; and 5) a smooth transition to the early postoper-ative period, with a goal of early extubation, patient mobili-zation, and hospital discharge. Attention should be directed atpreventing or minimizing adverse hemodynamic and hor-monal alterations that may induce myocardial ischemia orexert a deleterious effect on myocardial metabolism (as mayoccur during cardiopulmonary bypass [CPB]) (Section 2.1.8).This requires close interaction between the anesthesiologistand surgeon, particularly when manipulation of the heart orgreat vessels is likely to induce hemodynamic instability.During on-pump CABG, particular care is required duringvascular cannulation and weaning from CPB; with off-pumpCABG, the hemodynamic alterations often caused by dis-placement or verticalization of the heart and application ofstabilizer devices on the epicardium, with resultant changes inheart rate, cardiac output, and systemic vascular resistance,should be monitored carefully and managed appropriately.

In the United States, nearly all patients undergoing CABGreceive general anesthesia with endotracheal intubation uti-lizing volatile halogenated general anesthetics with opioidsupplementation. Intravenous benzodiazepines often aregiven as premedication or for induction of anesthesia, alongwith other agents such as propofol or etomidate. Nondepo-larizing neuromuscular-blocking agents, particularly nonva-golytic agents with intermediate duration of action, arepreferred to the longer-acting agent, pancuronium. Use of thelatter is associated with higher intraoperative heart rates anda higher incidence of residual neuromuscular depression inthe early postoperative period, with a resultant delay inextubation.23,34 In addition, low concentrations of volatileanesthetic usually are administered via the venous oxygenatorduring CPB, facilitating amnesia and reducing systemicvascular resistance.

Outside the United States, alternative anesthetic tech-niques, particularly total intravenous anesthesia via propofoland opioid infusions with benzodiazepine supplementationwith or without high thoracic epidural anesthesia, are com-monly used. The use of high thoracic epidural anesthesiaexerts salutary effects on the coronary circulation as well asmyocardial and pulmonary function, attenuates the stressresponse, and provides prolonged postoperative analge-sia.24,25,35 In the United States, however, concerns about thepotential for neuraxial bleeding (particularly in the setting ofheparinization, platelet inhibitors, and CPB-induced throm-bocytopenia), local anesthetic toxicity, and logistical issuesrelated to the timing of epidural catheter insertion andmanagement have resulted in limited use of these tech-

niques.22 Their selective use in patients with severe pulmo-nary dysfunction (Section 6.5) or chronic pain syndromesmay be considered. Although meta-analyses of randomizedcontrolled trials (RCTs) of high thoracic epidural anesthesia/analgesia in CABG patients (particularly on-pump) haveyielded inconsistent results on morbidity and mortality rates,it does appear to reduce time to extubation, pain, andpulmonary complications.3638 Of interest, although none ofthe RCTs have reported the occurrence of epidural hematomaor abscess, these entities occur on occasion.38 Finally, the useof other regional anesthetic approaches for postoperativeanalgesia, such as parasternal block, has been reported.39

Over the past decade, early extubation strategies (fast-track anesthesia) often have been used in low- to medium-risk CABG patients. These strategies allow a shorter time toextubation, a decreased length of intensive care unit (ICU)stay, and variable effects on length of hospital stay.46Immediate extubation in the operating room, with or withoutmarkedly accelerated postoperative recovery pathways (eg,ultra-fast-tracking, rapid recovery protocol, short-stayintensive care) have been used safely, with low rates ofreintubation and no influence on quality of life.4044 Obser-vational data suggest that physician judgment in triaginglower-risk patients to early or immediate extubation workswell, with rates of reintubation1%.45 Certain factors appearto predict fast-track failure, including previous cardiacsurgery, use of intra-aortic balloon counterpulsation, andpossibly advanced patient age.

Provision of adequate perioperative analgesia is importantin enhancing patient mobilization, preventing pulmonarycomplications, and improving the patients psychologicalwell-being.9,11 The intraoperative use of high-dose morphine(40 mg) may offer superior postoperative pain relief andenhance patient well-being compared with fentanyl (despitesimilar times to extubation).46

The safety of nonsteroidal anti-inflammatory agents foranalgesia is controversial, with greater evidence for adversecardiovascular events with the selective cyclooxygenase-2inhibitors than the nonselective agents. A 2007 AHA Scien-tific statement presented a stepped-care approach to themanagement of musculoskeletal pain in patients with or atrisk for coronary artery disease (CAD), with the goal oflimiting the use of these agents to patients in whom safertherapies fail.47 In patients hospitalized with unstable angina(UA) and nonST-elevation myocardial infarction(NSTEMI), these agents should be discontinued promptly andreinstituted later according to the stepped-care approach.48

In the setting of cardiac surgery, nonsteroidal anti-inflammatory agents previously were used for perioperativeanalgesia. A meta-analysis of 20 trials of patients undergoingthoracic or cardiac surgery, which evaluated studies publishedbefore 2005, reported significant reductions in pain scores, withno increase in adverse outcomes.49 Subsequently, 2 RCTs, bothstudying the oral cyclooxygenase-2 inhibitor valdecoxib and itsintravenous prodrug, parecoxib, reported a higher incidence ofsternal infections in 1 trial and a significant increase in adversecardiovascular events in the other.26,27 On the basis of the resultsof these 2 studies (as well as other nonsurgical reports ofincreased risk with cyclooxygenase-2selective agents), the U.S.

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Food and Drug Administration in 2005 issued a black boxwarning for all nonsteroidal anti-inflammatory agents (exceptaspirin) immediately after CABG.50 The concurrent administra-tion of ibuprofen with aspirin has been shown to attenuate thelatters inhibition of platelet aggregation, likely because ofcompetitive inhibition of cyclooxygenase at the platelet-receptorbinding site.51

Observational analyses in patients undergoing noncardiacsurgery have shown a significant reduction in perioperativedeath with the use of checklists, multidisciplinary surgicalcare, intraoperative time-outs, postsurgical debriefings, andother communication strategies.14,15 Such methodology isbeing used increasingly in CABG patients.1214

In contrast to extensive literature on the role of the surgeon indetermining outcomes with CABG, limited data on the influenceof the anesthesiologist are available. Of 2 such reports fromsingle centers in the 1980s, 1 suggested that the failure to controlheart rate to110 beats per minute was associated with a highermortality rate, and the other suggested that increasing duration ofCPB adversely influenced outcome.52,53 Another observationalanalysis of data from vascular surgery patients suggested thatanesthetic specialization was independently associated with areduction in mortality rate.54

To meet the challenges of providing care for the increasinglyhigher-risk patients undergoing CABG, efforts have been di-rected at enhancing the experience of trainees, particularly in theuse of newer technologies such as TEE. Cardiac anesthesiolo-gists, in collaboration with cardiologists and surgeons, haveimplemented national training and certification processes forpractitioners in the use of perioperative TEE (Section2.1.7).164,165 Accreditation of cardiothoracic anesthesia fellow-ship programs from the Accreditation Council for GraduateMedical Education was initiated in 2004, and efforts are ongoingto obtain formal subspecialty certification.18

2.1.2. Use of CPBSeveral adverse outcomes have been attributed to CPB,including 1) neurological deficits (eg, stroke, coma, postop-erative neurocognitive dysfunction); 2) renal dysfunction;and 3) the Systemic inflammatory Response Syndrome(SIRS). The SIRS is manifested as generalized systemicinflammation occurring after a major morbid event, such astrauma, infection, or major surgery. It is often particularlyapparent after on-pump cardiac surgery, during which surgi-cal trauma, contact of blood with nonphysiological surfaces(eg, pump tubing, oxygenator surfaces), myocardial ischemiaand reperfusion, and hypothermia combine to cause a dra-matic release of cytokines (eg, interleukin [IL] 6 and IL8) andother mediators of inflammation.55 Some investigators haveused serum concentrations of S100 beta as a marker of braininjury56 and have correlated increased serum levels with thenumber of microemboli exiting the CPB circuit duringCABG. In contrast, others have noted the increased incidenceof microemboli with on-pump CABG (relative to off-pumpCABG) but have failed to show a corresponding worsening ofneurocognitive function 1 week to 6 months postopera-tively.57,58 Blood retrieved from the operative field duringon-pump CABG contains lipid material and particulate mat-ter, which have been implicated as possible causes of post-

operative neurocognitive dysfunction. Although a study59reported that CPB-associated neurocognitive dysfunction canbe mitigated by the routine processing of shed blood with acell saver before its reinfusion, another study60 failed to showsuch an improvement.

It has been suggested that CPB leads to an increasedincidence of postoperative renal failure requiring dialysis, buta large RCT comparing on-pump and off-pump CABGshowed no difference in its occurrence.61 Of interest, thisstudy failed to show a decreased incidence of postoperativeadverse neurological events (stroke, coma, or neurocognitivedeficit) in those undergoing off-pump CABG.

The occurrence of SIRS in patients undergoing CPB hasled to the development of strategies designed to prevent or tominimize its occurrence. Many reports have focused on theincreased serum concentrations of cytokines (eg, IL-2R, IL-6,IL-8, tumor necrosis factor alpha) and other modulators ofinflammation (eg, P-selectin, sE-selectin, soluble intercellularadhesion molecule-1, plasma endothelial cell adhesionmolecule-1, and plasma malondialdehyde), which reflectleukocyte and platelet activation, in triggering the onset ofSIRS. A study showed a greater upregulation of neutrophilCD11b expression (a marker of leukocyte activation) inpatients who sustained a 50% increase in the serumcreatinine concentration after CPB, thereby implicating acti-vated neutrophils in the pathophysiology of SIRS and theoccurrence of post-CPB renal dysfunction.62 Modulatingneutrophil activation to reduce the occurrence of SIRS hasbeen investigated; however, the results have been inconsis-tent. Preoperative intravenous methylprednisolone (10 mg/kg) caused a reduction in the serum concentrations of many ofthese cytokines after CPB, but this reduction was not associ-ated with improved hemodynamic variables, diminishedblood loss, less use of inotropic agents, shorter duration ofventilation, or shorter ICU length of stay.63 Similarly, the useof intravenous immunoglobulin G in patients with post-CPBSIRS has not been associated with decreased rates of short-term morbidity or 28-day mortality.64

Other strategies to mitigate the occurrence of SIRS afterCPB have been evaluated, including the use of 1) CPBcircuits (including oxygenators) coated with materials knownto reduce complement and leukocyte activation; 2) CPBtubing that is covalently bonded to heparin; and 3) CPBtubing coated with polyethylene oxide polymer or Poly(2-methoxyethylacrylate). Leukocyte depletion via special-ized filters in the CPB circuits has been shown to reduce theplasma concentrations of P-selectin, intercellular adhesionmolecule-1, IL-8, plasma endothelial cell adhesionmolecule-1, and plasma malondialdehyde after CPB.65

Finally, closed mini-circuits for CPB have been developed inan attempt to minimize the bloodair interface and blood contactwith nonbiological surfaces, both of which promote cytokineelaboration, but it is uncertain if these maneuvers and techniqueshave a discernible effect on outcomes after CABG.

2.1.3. Off-Pump CABG Versus Traditional On-Pump CABGSince the first CABG was performed in the late 1960s, thestandard surgical approach has included the use of cardiacarrest coupled with CPB (so-called on-pump CABG), thereby

Hillis et al 2011 ACCF/AHA CABG Guideline e659

optimizing the conditions for construction of vascular anas-tomoses to all diseased coronary arteries without cardiacmotion or hemodynamic compromise. Such on-pump CABGhas become the gold standard and is performed in about 80%of subjects undergoing the procedure in the United States.Despite the excellent results that have been achieved, the useof CPB and the associated manipulation of the ascendingaorta are linked with certain perioperative complications,including myonecrosis during aortic occlusion, cerebrovascu-lar accidents, generalized neurocognitive dysfunction, renaldysfunction, and SIRS. In an effort to avoid these complica-tions, off-pump CABG was developed.58,66 Off-pump CABGis performed on the beating heart with the use of stabilizingdevices (which minimize cardiac motion); in addition, itincorporates techniques to minimize myocardial ischemia andsystemic hemodynamic compromise. As a result, the need forCPB is obviated. This technique does not necessarily de-crease the need for manipulation of the ascending aortaduring construction of the proximal anastomoses.

To date, the results of several RCTs comparing on-pump andoff-pump CABG in various patient populations have beenpublished.61,67,68 In addition, registry data and the results ofmeta-analyses have been used to assess the relative efficacies ofthe 2 techniques.69,70 In 2005, an AHA Scientific statementcomparing the 2 techniques concluded that both proceduresusually result in excellent outcomes and that neither techniqueshould be considered superior to the other.71 At the same time,several differences were noted. Off-pump CABG was associatedwith less bleeding, less renal dysfunction, a shorter length ofhospital stay, and less neurocognitive dysfunction. The inci-dence of perioperative stroke was similar with the 2 techniques.On-pump CABG was noted to be less technically complex andallowed better access to diseased coronary arteries in certainanatomic locations (eg, those on the lateral LV wall) as well asbetter long-term graft patency.

In 2009, the results of the largest RCT to date comparingon-pump CABG to off-pump CABG, the ROOBY (Random-ized On/Off Bypass) trial, were published, reporting theoutcomes for 2203 patients (99% men) at 18 Veterans AffairsMedical Centers.61 The primary short-term endpoint, a com-posite of death or complications (reoperation, new mechani-cal support, cardiac arrest, coma, stroke, or renal failure)within 30 days of surgery, occurred with similar frequency(5.6% for on-pump CABG; 7.0% for off-pump CABG;P0.19). The primary long-term endpoint, a composite ofdeath from any cause, a repeat revascularization procedure, ora nonfatal myocardial infarction (MI) within 1 year ofsurgery, occurred more often in those undergoing off-pumpCABG (9.9%) than in those having on-pump CABG (7.4%;P0.04). Neuropsychological outcomes and resource utiliza-tion were similar between the 2 groups. One year aftersurgery, graft patency was higher in the on-pump group(87.8% versus 82.6%; P0.01). In short, the ROOBY inves-tigators failed to show an advantage of off-pump CABGcompared with on-pump CABG in a patient populationconsidered to be at low risk. Instead, use of the on-pumptechnique was associated with better 1-year composite out-comes and 1-year graft patency rates, with no difference inneuropsychological outcomes or resource utilization.

Although numerous investigators have used single-center registries, the STS database, and meta-analyses inan attempt to identify patient subgroups in whom off-pumpCABG is the preferred procedure, even these analyses havereached inconsistent conclusions about off-pump CABGsability to reduce morbidity and mortality rates.69,72 83 Aretrospective cohort study of 14 766 consecutive patientsundergoing isolated CABG identified a mortality benefit(OR: 0.45) for off-pump CABG in patients with a pre-dicted risk of mortality 2.5%,82 but a subsequent ran-domized comparison of off-pump CABG to traditionalon-pump CABG in 341 high-risk patients (a Euroscore5) showed no difference in the composite endpoint ofall-cause death, acute MI, stroke, or a required reinterven-tion procedure.78 An analysis of data from the New YorkState Cardiac Surgery Reporting system did not demon-strate a reduction in mortality rate with off-pump CABG inany patient subgroup, including the elderly (age 80years) or those with cerebrovascular disease, azotemia, oran extensively calcified ascending aorta.69

Despite these results, off-pump CABG is the preferredapproach by some surgeons who have extensive experiencewith it and therefore are comfortable with its technicalnuances. Recently, published data suggested that theavoidance of aortic manipulation is the most importantfactor in reducing the risk of neurological complica-tions.84,85 Patients with extensive disease of the ascendingaorta pose a special challenge for on-pump CABG; forthese patients, cannulation or cross-clamping of the aortamay create an unacceptably high risk of stroke. In suchindividuals, off-pump CABG in conjunction with avoid-ance of manipulation of the ascending aorta (includingplacement of proximal anastomoses) may be beneficial.Surgeons typically prefer an on-pump strategy in patientswith hemodynamic compromise because CPB offers sup-port for the systemic circulation. In the end, most surgeonsconsider either approach to be reasonable for the majorityof subjects undergoing CABG.2.1.4. Bypass Graft Conduit: RecommendationsClass I

1. If possible, the left internal mammary artery(LIMA) should be used to bypass the left anteriordescending (LAD) artery when bypass of the LADartery is indicated.8689 (Level of Evidence: B)

Class IIa1. The right internal mammary artery (IMA) is prob-

ably indicated to bypass the LAD artery when theLIMA is unavailable or unsuitable as a bypassconduit. (Level of Evidence: C)

2. When anatomically and clinically suitable, use of asecond IMA to graft the left circumflex or rightcoronary artery (when critically stenosed and per-fusing LV myocardium) is reasonable to improve thelikelihood of survival and to decrease reinterven-tion.9094 (Level of Evidence: B)

e660 Circulation December 6, 2011

Class IIb1. Complete arterial revascularization may be reason-

able in patients less than or equal to 60 years of agewith few or no comorbidities. (Level of Evidence: C)

2. Arterial grafting of the right coronary artery may bereasonable when a critical (>90%) stenosis is pres-ent.89,93,95 (Level of Evidence: B)

3. Use of a radial artery graft may be reasonable whengrafting left-sided coronary arteries with severestenoses (>70%) and right-sided arteries with criti-cal stenoses (>90%) that perfuse LV myocardi-um.96101 (Level of Evidence: B)

Class III: HARM1. An arterial graft should not be used to bypass the

right coronary artery with less than a critical steno-sis (

hasten postoperative recovery, and 3) enhance cosmesis. Theutility and benefit of these smaller incisions has been evidentin subjects undergoing valvular surgery, for which onlylimited access to the heart is required.

The most minimally invasive access incisions for CABGare seen with robotically assisted totally endoscopic CABG.A study showed that totally endoscopic CABG with robotictechnology was associated with improved physical health,shorter hospital stay, and a more rapid return to the activitiesof daily living compared with traditional techniques. Atpresent, direct comparisons of robotically assisted and con-ventional CABG are lacking.135

The use of minimally invasive cardiac access incisions forCABG is limited. The need for adequate exposure of theascending aorta and all surfaces of the heart to accomplishfull revascularization usually precludes the use of minimalaccess incisions, such as upper sternotomy, lower sternotomy,or anterolateral thoracotomy. Nevertheless, use of limitedincisions may increase in the future with the advent of hybridstrategies that use a direct surgical approach (usually forgrafting the LAD artery through a small parasternal incision)and percutaneous coronary intervention (PCI) of the otherdiseased coronary arteries. The benefit of hybrid revascular-ization and hybrid operating rooms, in which PCI and CABGcan be accomplished in one procedure, is yet to be deter-mined. In patients with certain comorbid conditions, such assevere aortic calcification, previous chest irradiation, andobesity in combination with severe diabetes mellitus, fullmedian sternotomy may be problematic,136 and hybrid revas-cularization may be preferable.

2.1.6. Anastomotic TechniquesAt present, most coronary bypass grafts are constructed withhand-sewn suture techniques for the proximal and distalanastomoses, a practice that has resulted in good short- andintermediate-term patency rates. Because surgeons have dif-ferent preferences with regard to the technical aspects of theprocedure, a wide variety of suture configurations is used.Sewing of the proximal and distal anastomoses with acontinuous polypropylene suture is commonly done, buttechniques with interrupted silk sutures have been used, withsimilar results for graft patency and adverse events.

Certain clinical scenarios have precipitated an interest inalternative techniques of constructing coronary bypass anas-tomoses. Some surgeons and patients wish to avoid thepotential morbidity and cosmetic results of a median sternot-omy, yet the least invasive incisions usually are too small toallow hand-sewn anastomoses. To solve this problem, coro-nary connector devices have been developed for use witharterial or venous conduits to enable grafting without directsuturing. In addition, these devices have been used in subjectswith diseased ascending aortas, in whom a technique thatallows construction of a proximal anastomosis with minimalmanipulation of the ascending aorta (typically by eliminatingthe need for aortic cross-clamping) may result in less embo-lization of debris, thereby reducing the occurrence of adverseneurological outcomes. In this situation, the operation isperformed through a median sternotomy, and the proximalanastomoses are created with a connector (or may be hand-

sewn with the assistance of a device that provides a bloodlessoperative field) without partial or complete clamping of theascending aorta.

2.1.7. Intraoperative TEE: Recommendations

Class I1. Intraoperative TEE should be performed for evalu-

ation of acute, persistent, and life-threatening hemo-dynamic disturbances that have not responded totreatment.137,138 (Level of Evidence: B)

2. Intraoperative TEE should be performed in patientsundergoing concomitant valvular surgery.137,139(Level of Evidence: B)

Class IIa1. Intraoperative TEE is reasonable for monitoring of

hemodynamic status, ventricular function, regionalwall motion, and valvular function in patients un-dergoing CABG.138,140145 (Level of Evidence: B)

The use of intraoperative TEE in patients undergoing cardiacsurgery has increased steadily since its introduction in the late1980s. Although its utility is considered to be highest inpatients undergoing valvular and complex open great-vessel/aortic surgery, it is commonly used in subjects undergoingCABG. TEE is most often used,146 although epicardial andepiaortic imaging, performed under aseptic conditions, allowsvisualization of imaging planes not possible with TEE.147,148specifically, epiaortic imaging allows visualization of theblind spot of the ascending aorta (caused by interposition ofthe trachea with the esophagus), the site of aortic cannulationfor CPB, from which dislodgement of friable atheroma, amajor risk factor for perioperative stroke, may occur (Section5.2.1). In addition, epicardial probes allow imaging whenTEE is contraindicated, cannot be performed, or producesinadequate images. It can facilitate the identification ofintraventricular thrombi when TEE images are equivocal.

The 2003 ACC/AHA/ASE Guideline Update for theClinical Application of Echocardiography based its recom-mendations on those reported in the 1996 American Societyof Anesthesiologists/Society of Cardiovascular Anesthesiol-ogists practice guideline and considered the use of TEE inCABG patients.149 The latter document was updated in2010.139 Because of the use of different grading methodolo-gies in the American Society of Anesthesiologists/Society ofCardiovascular Anesthesiologists guideline relative to that ofthe ACCF/AHA, precise comparisons are difficult. However,it is noted that TEE should be considered in subjectsundergoing CABG, to confirm and refine the preoperativediagnosis, detect new or unsuspected pathology, adjust theanesthetic and surgical plan accordingly, and assess theresults of surgery. The strongest recommendation is given fortreatment of acute life-threatening hemodynamic instabilitythat has not responded to conventional therapies.

Observational cohort analyses and case reports have sug-gested the utility of TEE for diagnosing acute life-threateninghemodynamic or surgical problems in CABG patients, manyof which are difficult or impossible to detect or treat withoutdirect imaging. Evaluation of ventricular cross-sectional areas

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and ejection fraction (EF) and estimation or direct measure-ment of cardiac output by TEE may facilitate anesthetic,fluid, and inotropic/pressor management. The utility of echo-cardiography for the evaluation of LV end-diastolic area/volume and its potential superiority over pulmonary arteryocclusion or pulmonary artery diastolic pressure, particularlyin the early postoperative period, has been reported150,151(Section 4.10). In subjects without preoperative transthoracicimaging, intraoperative TEE may provide useful diagnosticinformation (over and above that detected during cardiaccatheterization) on valvular function as well as evidence ofpulmonary hypertension, intracardiac shunts, or other com-plications that may alter the planned surgery.

In patients undergoing CABG, intraoperative TEE is usedmost often for the detection of regional wall motion abnor-malities (possibly caused by myocardial ischemia or infarc-tion) and their effect on LV function. Observational studieshave suggested that regional wall motion abnormalities de-tected with TEE can guide surgical therapy, leading torevision of a failed or inadequate conduit or the placement ofadditional grafts not originally planned. The presence of newwall motion abnormalities after CPB correlates with adverseperioperative and long-term outcomes.143

Although the initial hope that an estimation of coronaryblood flow with intramyocardial contrast enhancement visu-alized by TEE would facilitate surgical intervention has notbeen realized, technical advances in imaging of coronaryarteries and grafts may ultimately provide reliable informa-tion. At present, the evaluation of graft flow with conven-tional nonimaging handheld Doppler probes appears adequate(Section 8). Intraoperative evaluation of mitral regurgitationmay facilitate detection of myocardial ischemia and provideguidance about the need for mitral valve annuloplasty (Sec-tion 6.7). Newer technologies, including nonimaging methodsfor analyzing systolic and diastolic velocity and direction andtiming of regional wall motion (Doppler tissue imaging andspeckle tracking), as well as real-time 3-dimensional im-aging, may facilitate the diagnosis of myocardial ischemiaand evaluation of ventricular function. At present, however,their cost-effectiveness has not been determined, and they aretoo complex for routine use.152154

Among different centers, the rate of intraoperative TEE usein CABG patients varies from none to routine; its use isinfluenced by many factors, such as institutional and practi-tioner preferences, the healthcare system and reimbursementstrategies, tertiary care status, and presence of training pro-grams.155 The efficacy of intraoperative TEE is likely influ-enced by the presence of 1) LV systolic and diastolicdysfunction, 2) concomitant valvular disease, 3) the plannedsurgical procedure (on pump versus off pump, primary versusreoperative), 4) the surgical approach (full sternotomy versuspartial sternotomy versus endoscopic or robotic), 5) its acuity(elective versus emergency); and 6) physician training andexperience.137,138,140142,144,145,156163

The safety of intraoperative TEE in patients undergoingcardiac surgery is uncertain. Retrospective analyses of datafrom patients undergoing diagnostic upper gastrointestinalendoscopy, nonoperative diagnostic TEE imaging, and intra-operative imaging by skilled operators in high-volume cen-

ters demonstrate a low frequency of complications related toinsertion or manipulation of the probe.164,165 Nevertheless,minor (primarily pharyngeal injury from probe insertion) andmajor (esophageal perforation, gastric bleeding, or late me-diastinitis) complications are reported.166,167 A more indolentcomplication is that of acquired dysphagia and possibleaspiration postoperatively. Although retrospective analyses ofpostoperative cardiac surgical patients with clinically mani-fest esophageal dysfunction have identified TEE use as a riskfactor,168170 such dysfunction also has been reported insubjects in whom TEE was not used.171 Advanced age,prolonged intubation, and neurological injury seem to be riskfactors for its development. The significance of the incidentalintraoperative detection and repair of a patent foramen ovale,a common occurrence, is controversial.172 A 2009 observa-tional analysis of 13 092 patients (25% isolated CABG; 29%CABG or other cardiac procedure), of whom 17% had apatent foramen ovale detected by TEE (28% of which wererepaired), reported an increase in postoperative stroke in thepatients who had patent foramen ovale repair (OR: 2.47; 95%CI: 1.02 to 6.0) with no improvement in long-termoutcome.173

2.1.8. Preconditioning/Management of MyocardialIschemia: Recommendations

Class I1. Management targeted at optimizing the determinants

of coronary arterial perfusion (eg, heart rate, diastolicor mean arterial pressure, and right ventricular or LVend-diastolic pressure) is recommended to reduce therisk of perioperative myocardial ischemia and infarc-tion.53,174177 (Level of Evidence: B)

Class IIa1. Volatile-based anesthesia can be useful in reducing

the risk of perioperative myocardial ischemia andinfarction.178181 (Level of Evidence: A)

Class IIb1. The effectiveness of prophylactic pharmacological

therapies or controlled reperfusion strategies aimedat inducing preconditioning or attenuating the ad-verse consequences of myocardial reperfusion injuryor surgically induced systemic inflammation is un-certain.182189 (Level of Evidence: A)

2. Mechanical preconditioning might be considered toreduce the risk of perioperative myocardial ischemiaand infarction in patients undergoing off-pumpCABG.190192 (Level of Evidence: B)

3. Remote ischemic preconditioning strategies using pe-ripheral-extremity occlusion/reperfusion might be con-sidered to attenuate the adverse consequences of myo-cardial reperfusion injury.193195 (Level of Evidence: B)

4. The effectiveness of postconditioning strategies to at-tenuate the adverse consequences of myocardial reper-fusion injury is uncertain.196,197 (Level of Evidence: C)

See Online Data Supplements 2 to 4 for additional data onpreconditioning.

Hillis et al 2011 ACCF/AHA CABG Guideline e663

Perioperative myocardial injury is associated with adverseoutcomes after CABG,198200 and available data suggest adirect correlation between the amount of myonecrosis and thelikelihood of an adverse outcome198,201204 (Section 5.2.4).

The etiologies of perioperative myocardial ischemia andinfarction and their complications (electrical or mechanical)range from alterations in the determinants of global orregional myocardial oxygen supply and demand to complexbiochemical and microanatomic, systemic, or vascular abnor-malities, many of which are not amenable to routine diagnos-tic and therapeutic interventions. Adequate surgical reperfu-sion is important in determining outcome, even though it mayinitially induce reperfusion injury. Various studies delineat-ing the major mediators of reperfusion injury have focusedattention on the mitochondrial permeability transition pore,the opening of which during reperfusion uncouples oxidativephosphorylation, ultimately leading to cell death.205 Althoughseveral pharmacological interventions targeting componentsof reperfusion injury have been tried, none has been found tobe efficacious for this purpose.182,184189,205207

The severity of reperfusion injury is influenced by numer-ous factors, including 1) the status of the patients coronarycirculation, 2) the presence of active ongoing ischemia orinfarction, 3) preexisting medical therapy (Sections 4.3 and4.5), 4) concurrent use of mechanical assistance to improvecoronary perfusion (ie, intra-aortic balloon counterpulsation),and 5) the surgical approach used (on pump or off pump).CPB with ischemic arrest is known to induce the release ofcytokines and chemokines involved in cellular homeostasis,thrombosis, and coagulation; oxidative stress; adhesion ofblood cell elements to the endothelium; and neuroendocrinestress responses; all of these may contribute to myocardialinjury.208,209 Controlled reperfusion strategies during CPB,involving prolonged reperfusion with warm-blood cardiople-gia in conjunction with metabolic enhancers, are rarely usedin lieu of more routine methods of preservation (eg, asystolicarrest, anterograde or retrograde blood cardioplegia duringaortic cross-clamping). Several studies suggest that the mag-nitude of SIRS is greater with on-pump CABG than withoff-pump CABG.201,208,210213

Initial studies of preconditioning used mechanical occlusionof arterial inflow followed by reperfusion via aortic cross-clamping immediately on institution of bypass or with coronaryartery occlusion proximal to the planned distal anastomosisduring off-pump CABG.190,191,214217 Because of concerns of thepotential adverse cerebral effects of aortic manipulation, enthu-siasm for further study of this technique in on-pump CABGpatients is limited (Section 5.2.1). Despite intense interest in thephysiology of postconditioning, few data are available.197 Asmall 2008 study in patients undergoing valve surgery, whichused repeated manipulation of the ascending aorta, reported areduction in surrogate markers of inflammation and myo-necrosis.196 In lieu of techniques utilizing mechanical occlusion,pharmacological conditioning agents are likely to be used. Analternative approach that avoids much (but not all) of the safetyconcerns related to potential vascular injury is remote precondi-tioning of arterial inflow to the leg or (more commonly) the armvia blood pressure cuff occlusion.218 Two studies of patientsundergoing on-pump CABG at a single center, the first of which

used 2 different myocardial protection strategies and the secondof which repeated the study with a standardized cold-bloodcardioplegia routine, reported similar amounts of troponin re-lease during the 72 hours postoperatively, with no apparentcomplications.193,195 A larger trial was unable to confirm anybenefits of a similar protocol, casting doubt on the utility of thisapproach.194

Volatile halogenated anesthetics and opioids have anti-ischemic or conditioning properties,32,33,219,220 and propofolhas antioxidant properties of potential value in subjects withreperfusion injury.221,222 The salutary properties of volatileanesthetics during myocardial ischemia are well known.Their negative inotropic and chronotropic effects are consid-ered to be beneficial, particularly in the setting of elevatedadrenergic tone that is common with surgical stimulation.Although contemporary volatile agents demonstrate somedegree of coronary arterial vasodilation (with isofluraneconsidered the most potent), the role of a steal phenomenain the genesis of ischemia is considered to be trivial.33 Incomparison to propofol/opioid infusions, volatile agents seemto reduce troponin release, preserve myocardial function, andimprove resource utilization (ie, ICU or hospital lengths ofstay) and 1-year outcome.223227 It is postulated that multiplefactors that influence myocardial preservation modulate thepotential impact of a specific anesthetic regimen.

Observational analyses have reported an association be-tween elevated perioperative heart rates and adverse out-comes,228,229 but it is difficult to recommend a specific heartrate for all CABG patients. Instead, the heart rate may need tobe adjusted up or down to maintain an adequate cardiacoutput.230,231 Similarly, controversy exists about managementof blood pressure in the perioperative period,232 particularlywith regard to systolic pressure233 and pulse pressure.234Intraoperative hypotension is considered to be a risk factorfor adverse outcomes in patients undergoing many types ofsurgery. Unique to CABG are unavoidable periods of hypo-tension associated with surgical manipulation, cannulation forCPB, weaning from CPB, or during suspension and stabili-zation of the heart with off-pump CABG. Minimization ofsuch periods is desirable but is often difficult to achieve,particularly in patients who are unstable hemodynamically.

2.2. Clinical Subsets2.2.1. CABG in Patients With Acute MI: Recommendations

Class I1. Emergency CABG is recommended in patients with

acute MI in whom 1) primary PCI has failed orcannot be performed, 2) coronary anatomy is suit-able for CABG, and 3) persistent ischemia of asignificant area of myocardium at rest and/or hemo-dynamic instability refractory to nonsurgical ther-apy is present.235239 (Level of Evidence: B)

2. Emergency CABG is recommended in patients un-dergoing surgical repair of a postinfarction mechan-ical complication of MI, such as ventricular septalrupture, mitral valve insufficiency because of papil-lary muscle infarction and/or rupture, or free wallrupture.240244 (Level of Evidence: B)

e664 Circulation December 6, 2011

3. Emergency CABG is recommended in patients withcardiogenic shock and who are suitable for CABGirrespective of the time interval from MI to onset ofshock and time from MI to CABG.238,245247 (Level ofEvidence: B)

4. Emergency CABG is recommended in patients withlife-threatening ventricular arrhythmias (believed tobe ischemic in origin) in the presence of left mainstenosis greater than or equal to 50% and/or 3-vesselCAD.248 (Level of Evidence: C)

Class IIa1. The use of CABG is reasonable as a revasculariza-

tion strategy in patients with multivessel CAD withrecurrent angina or MI within the first 48 hours ofSTEMI presentation as an alternative to a moredelayed strategy.235,237,239,249 (Level of Evidence: B)

2. Early revascularization with PCI or CABG is rea-sonable for selected patients greater than 75 years ofage with ST-segment elevation or left bundle branchblock who are suitable for revascularization irre-spective of the time interval from MI to onset ofshock.250254 (Level of Evidence: B)

Class III: HARM1. Emergency CABG should not be performed in pa-

tients with persistent angina and a small area ofviable myocardium who are stable hemodynam-ically. (Level of Evidence: C)

2. Emergency CABG should not be performed in pa-tients with noreflow (successful epicardial reperfu-sion with unsuccessful microvascular reperfusion).(Level of Evidence: C)

See Online Data Supplement 5 for additional data on CABGin patients with acute myocardial infarction.

With the widespread use of fibrinolytic therapy or primaryPCI in subjects with STEMI, emergency CABG is nowreserved for those with 1) left main and/or 3-vessel CAD, 2)ongoing ischemia after successful or failed PCI, 3) coronaryanatomy not amenable to PCI, 4) a mechanical complicationof STEMI,241,255,256 and 5) cardiogenic shock (defined ashypotension [systolic arterial pressure 90 mm Hg for 30minutes or need for supportive measures to maintain asystolic pressure 90 mm Hg], evidence of end-organhypoperfusion, cardiac index 2.2 L/min/m2, and pulmonarycapillary wedge pressure 15 mm Hg).245,247 In the SHOCK(Should We Emergently Revascularize Occluded Coronariesfor Cardiogenic Shock) trial, 36% of patients randomlyassigned to early revascularization therapy underwent emer-gency CABG.245 Although those who underwent emergencyCABG were more likely to be diabetic and to have complexcoronary anatomy than were those who had PCI, the survivalrates of the 2 groups were similar.247 The outcomes ofhigh-risk STEMI patients with cardiogenic shock undergoingemergency CABG suggest that CABG may be preferred toPCI in this patient population when complete revasculariza-tion cannot be accomplished with PCI.236,238,246

The need for emergency CABG in subjects with STEMI isrelatively uncommon, ranging from 3.2% to 10.9%.257,258 Ofthe 1572 patients enrolled in the DANAMI-2 (Danish Mul-ticenter Randomized Study on Thrombolytic Therapy VersusAcute Coronary Angioplasty in Acute Myocardial Infarction)study, only 50 (3.2%) underwent CABG within 30 days (30patients initially treated with PCI and 20 given fibrinolysis),and only 3 patients (0.2%) randomly assigned to receiveprimary PCI underwent emergency CABG.257 Of the 1100patients who underwent coronary angiography in the PAMI-2(Primary Angioplasty in Myocardial Infarction) trial, CABGwas performed before hospital discharge in 120.258

The in-hospital mortality rate is higher in STEMI patientsundergoing emergency CABG than in those undergoing it ona less urgent or a purely elective basis.239,257,259264 In a studyof 1181 patients undergoing CABG, the in-hospital mortalityrate increased as the patients preoperative status worsened,ranging from 1.2% in those with stable angina to 26% inthose with cardiogenic shock.265

Although patients requiring emergency or urgent CABGafter STEMI are at higher risk than those undergoing itelectively, the optimal timing of CABG after STEMI iscontroversial. A retrospective study performed before thewidespread availability of fibrinolysis and primary PCI re-ported an overall in-hospital mortality rate of 5.2% in 440STEMI patients undergoing CABG as primary reperfusiontherapy. Those undergoing CABG 6 hours after symptomonset had a lower in-hospital and long-term (10 years)mortality rate than those undergoing CABG 6 hours aftersymptom onset.237 Other studies have provided conflictingresults, because of, at least in part, the lack of clear delinea-tion between STEMI and NSTEMI patients in these largedatabase reports.259,265 In an analysis of 9476 patients hospi-talized with an acute coronary syndrome (ACS) who under-went CABG during the index hospitalization, 1344 (14%)were STEMI patients with shock or intra-aortic balloonplacement preoperatively.264 These individuals had a mortal-ity rate of 4% when CABG was performed on the thirdhospital day, which was lower than the mortality ratesreported when CABG was performed earlier or later duringthe hospitalization.264 In studies in which the data fromSTEMI patients were analyzed separately with regard to theoptimal timing of CABG, however, the results appear to bedifferent. In 1 analysis of 44 365 patients who underwentCABG after MI (22 984 with STEMI; 21 381 with NSTEMI),the inhospital mortality rate was similar in the 2 groupsundergoing CABG 6 hours after diagnosis (12.5% and11.5%, respectively), but it was higher in STEMI patientsthan in NSTEMI patients when CABG was performed 6 to 23hours after diagnosis (13.6% versus 6.2%; P0.006).262 Thegroups had similar in-hospital mortality rates when CABGwas performed at all later time points (1 to 7 days, 8 to 14days, and 15 days after the acute event).262 Similarly, in astudy of 138 subjects with STEMI unresponsive to maximalnonsurgical therapy who underwent emergency CABG, theoverall mortality rate was 8.7%, but it varied according tothe time interval from symptom onset to time of operation.The mortality rate was 10.8% for patients undergoing CABGwithin 6 hours of the onset of symptoms, 23.8% in those

Hillis et al 2011 ACCF/AHA CABG Guideline e665

undergoing CABG 7 to 24 hours after symptom onset, 6.7%in patients undergoing CABG from 1 to 3 days, 4.2% in thosewho underwent surgery from 4 to 7 days, and 2.4% after 8days.266 In an analysis of data from 150 patients with STEMIwho did not qualify for primary PCI and required CABG, thein-hospital mortality rate increased according to the timeinterval between symptom onset and surgery.239 The mortal-ity rate was 6.1% for subjects who underwent CABG within6 hours of pain onset, 50% in those who underwent CABG 7to 23 hours after pain onset, and 7.1% in those whounderwent CABG after 15 days.239 Lastly, in another study,the time interval of 6 hours was also found to be important inSTEMI patients requiring CABG. The mean time fromsymptom onset to CABG was significantly shorter in survi-vors versus nonsurvivors (5.12.7 hours versus 11.43.2hours; P0.0007).235 In patients with cardiogenic shock, thebenefits of early revascularization were apparent across awide time interval between 1) MI and the onset of shock and2) MI and CABG. Therefore, although CABG exerts its mostprofound salutary effect when it is performed as soon aspossible after MI and the appearance of shock, the timewindow in which it is beneficial is quite broad.

Apart from the timing of CABG, the outcomes of STEMIpatients undergoing CABG depend on baseline demographicvariables. Those with mechanical complications of STEMI(eg, ventricular septal rupture or mitral regurgitation causedby papillary muscle rupture) have a high operative mortalityrate.240242,244,255,267 In a study of 641 subjects with ACS, 22with evolving STEMI and 20 with a mechanical complicationof STEMI were referred for emergency CABG; the 30-daymortality rate was 0% in those with evolving STEMI and25% in those with a mechanical complication of STEMI.268In those with mechanical complications, several variableswere predictive of death, including advanced age, female sex,cardiogenic shock, the use of intra-aortic balloon counterpul-sation preoperatively, pulmonary disease, renal insufficiency,and magnitude of elevation of the serum troponinconcentration.235,239,263,265,266,269,270

2.2.2. Life-Threatening VentricularArrhythmias: Recommendations

Class I1. CABG is recommended in patients with resuscitated

sudden cardiac death or sustained ventriculartachycardia thought to be caused by significant CAD(>50% stenosis of left main coronary artery and/or>70% stenosis of 1, 2, or all 3 epicardial coronaryarteries) and resultant myocardial ischemia.248,271,272(Level of Evidence: B)

Class III: HARM1. CABG should not be performed in patients with

ventricular tachycardia with scar and no evidence ofischemia. (Level of Evidence: C)

See Online Data Supplement 6 for additional data on life-threatening ventricular arrhythmias.

Most studies evaluating the benefits of CABG in patientswith ventricular arrhythmias have examined survivors of

out-of-hospital cardiac arrest as well as patients with induc-ible ventricular tachycardia or fibrillation during electro-physiological study.272274 In general, CABG has been moreeffective in reducing the occurrence of ventricular fibrillationthan of ventricular tachycardia, because the mechanism of thelatter is usually reentry with scarred endocardium rather thanischemia. Observational studies have demonstrated a favor-able prognosis of subjects undergoing CABG for ischemicventricular tachycardia/fibrillation.248

In survivors of cardiac arrest who have severe but operableCAD, CABG can suppress the appearance of arrhythmias,reduce subsequent episodes of cardiac arrest, and result in agood long-term outcome.271273 It is particularly effectivewhen an ischemic cause of the arrhythmia can be documented(for instance, when it occurs with exercise).275 Still, becauseCABG may not alleviate all the factors that predispose toventricular arrhythmias, concomitant insertion of an implant-able cardioverter-defibrillator is often warranted.276 Simi-larly, continued inducibility or clinical recurrence of ventric-ular tachycardia after CABG usually requires an implantablecardioverter-defibrillator implantation.

Patients with depressed LV systolic function, advancedage, female sex, and increased CPB time are at higher risk forlife-threatening arrhythmias in the early postoperative period.Given the poor short-term prognosis of those with thesearrhythmias, mechanical and ischemic causes should beconsidered in the postoperative setting.277279

2.2.3. Emergency CABG After Failed PCI: RecommendationsClass I

1. Emergency CABG is recommended after failed PCIin the presence of ongoing ischemia or threatenedocclusion with substantial myocardium at risk.280,281(Level of Evidence: B)

2. Emergency CABG is recommended after failed PCIfor hemodynamic compromise in patients withoutimpairment of the coagulation system and without aprevious sternotomy.280,282,283 (Level of Evidence: B)

Class IIa1. Emergency CABG is reasonable after failed PCI for

retrieval of a foreign body (most likely a fracturedguidewire or stent) in a crucial anatomic location.(Level of Evidence: C)

2. Emergency CABG can be beneficial after failed PCIfor hemodynamic compromise in patients with im-pairment of the coagulation system and withoutprevious sternotomy. (Level of Evidence: C)

Class IIb1. Emergency CABG might be considered after failed

PCI for hemodynamic compromise in patients withprevious sternotomy. (Level of Evidence: C)

Class III: HARM1. Emergency CABG should not be performed after

failed PCI in the absence of ischemia or threatenedocclusion. (Level of Evidence: C)

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2. Emergency CABG should not be performed afterfailed PCI if revascularization is impossible becauseof target anatomy or a no-reflow state. (Level ofEvidence: C)

See Online Data Supplement 7 for additional data on CABGafter failed PCI.

With widespread stent use as well as effective antiplate-let and antithrombotic therapies, emergency CABG afterfailed PCI is not commonly performed. In a 2009 analysisof data from almost 22 000 patients undergoing PCI at asingle center, only 90 (0.4%) required CABG within 24hours of PCI.281 A similarly low rate (0.8%) of emer-gency CABG after PCI has been reported by others.284 286The indications for emergency CABG after PCI include 1)acute (or threatened) vessel closure, 2) coronary arterialdissection, 3) coronary arterial perforation,281 and 4) mal-function of PCI equipment (eg, stent dislodgement, frac-tured guidewire). Subjects most likely to require emer-gency CABG after failed PCI are those with evolvingSTEMI, cardiogenic shock, 3-vessel CAD, or the presenceof a type C coronary arterial lesion (defined as 2 cm inlength, an excessively tortuous proximal segment, anextremely angulated segment, a total occlusion 3 monthsin duration, or a degenerated SVG that appears to befriable).281

In those in whom emergency CABG for failed PCI isperformed, morbidity and mortality rates are increased com-pared with those undergoing elective CABG,287289 resultingat least in part from the advanced age of many patients nowreferred for PCI, some of whom have multiple comorbidconditions and complex coronary anatomy. Several variableshave been shown to be associated with increased periop-erative morbidity and mortality rates, including 1) de-pressed LV systolic function,290 2) recent ACS,290,291 3)multivessel CAD and complex lesion morphology,291,292 4)cardiogenic shock,281 5) advanced patient age,293 6) ab-sence of angiographic collaterals,293 7) previous PCI,294and 8) a prolonged time delay in transfer to the operatingroom.293 In patients undergoing emergency CABG forfailed PCI, an off-pump procedure may be associated witha reduced incidence of renal failure, need for intra-aorticballoon use, and reoperation for bleeding.283,295

If complete revascularization is achieved with minimaldelay in patients undergoing emergency CABG after failedPCI, long-term prognosis is similar to that of subjectsundergoing elective CABG.280,282,296 In-hospital morbidityand mortality rates in women297 and the elderly298 undergoingemergency CABG for failed PCI are relatively high, but thelong-term outcomes in these individuals are comparable tothose achieved in men and younger patients.

2.2.4. CABG in Association With Other CardiacProcedures: Recommendations

Class I1. CABG is recommended in patients undergoing non-

coronary cardiac surgery with greater than or equalto 50% luminal diameter narrowing of the left maincoronary artery or greater than or equal to 70%

luminal diameter narrowing of other major coro-nary arteries. (Level of Evidence: C)

Class IIa1. The use of the LIMA is reasonable to bypass a signifi-

cantly narrowed LAD artery in patients undergoingnoncoronary cardiac surgery. (Level of Evidence: C)

2. CABG of moderately diseased coronary arteries(>50% luminal diameter narrowing) is reasonablein patients undergoing noncoronary cardiac sur-gery. (Level of Evidence: C)

3. CAD RevascularizationRecommendations and text in this section are the result ofextensive collaborative discussions between the PCI andCABG writing committees, as well as key members of theStable Ischemic Heart Disease (SIHD) and UA/NSTEMIwriting committees. Certain issues, such as older versus morecontemporary studies, primary analyses versus subgroupanalyses, and prospective versus post hoc analyses, have beencarefully weighed in designating COR and LOE; they areaddressed in the appropriate corresponding text. The goals ofrevascularization for patients with CAD are to 1) to improvesurvival and 2) to relieve symptoms.

Revascularization recommendations in this section arepredominantly based on studies of patients with symptomaticSIHD and should be interpreted in this context. As discussedlater in this section, recommendations on the type of revas-cularization are, in general, applicable to patients with UA/NSTEMI. In some cases (eg, unprotected left main CAD),specific recommendations are made for patients with UA/NSTEMI or STEMI.

Historically, most studies of revascularization have beenbased on and reported according to angiographic criteria.Most studies have defined a significant stenosis as 70%diameter narrowing; therefore, for revascularization decisionsand recommendations in this section, a significant stenosishas been defined as 70% diameter narrowing (50% forleft main CAD). Physiological criteria, such as an assessmentof fractional flow reserve, has been used in deciding whenrevascularization is indicated. Thus, for recommendations onrevascularization in this section, coronary stenoses withfractional flow reserve 0.80 can also be consideredsignificant.299,300

As noted, the revascularization recommendations havebeen formulated to address issues related to 1) improvedsurvival and/or 2) improved symptoms. When one method ofrevascularization is preferred over the other for improvedsurvival, this consideration, in general, takes precedence overimproved symptoms. When discussing options for revascu-larization with the patient, he or she should understand whenthe procedure is being performed in an attempt to improvesymptoms, survival, or both.

Although some results from the SYNTAX (Synergybetween Percutaneous Coronary Intervention with TAXUSand Cardiac Surgery) study are best characterized assubgroup analyses and hypothesis generating, SYNTAXnonetheless represents the latest and most comprehensivecomparison of contemporary PCI and CABG.301,302 There-

Hillis et al 2011 ACCF/AHA CABG Guideline e667

fore, the results of SYNTAX have been considered appro-priately when formulating our revascularization recom-mendations. Although the limitations of using theSYNTAX score for certain revascularization recommenda-tions are recognized, the SYNTAX score is a reasonablesurrogate for the extent of CAD and its complexity andserves as important information that should be consideredwhen making revascularization decisions. Recommenda-tions that refer to SYNTAX scores use them as surrogatesfor the extent and complexity of CAD.

Revascularization recommendations to improve survivaland symptoms are given in the following text and summa-rized in Tables 2 and 3. References to studies comparingrevascularization with medical therapy are presented whenavailable for each anatomic subgroup.

See Online Data Supplements 8 and 9 for additional dataregarding the survival and symptomatic benefits with CABGor PCI for different anatomic subsets.

3.1. Heart Team Approach to RevascularizationDecisions: Recommendations

Class I1. A Heart Team approach to revascularization is

recommended in patients with unprotected left mainor complex CAD.302304 (Level of Evidence: C)

Class IIa1. Calculation of the STS and SYNTAX scores is

reasonable in patients with unprotected left mainand complex CAD.301,30