INDICATIONS OF CABG
DR ALTAF HUSSAIN JATOIRESIDENT CARDIAC SURGERY CIVIL HOSPITAL KARACHI.
INTRODUCTION
1991 guidelines: the evidence is complete that the coronary artery bypass operation relieves angina in most patients.
Bypass surgery also relieved angina better than coronary stents in a randomized trial
Relief angina symptoms and prolongation of life
7~8 yrs survival superior for CABG compared with PTCA.
EARLY INTERVENTION OF CABG
Advantage Limitation of infarct expansion Avoidance of LV dysfunction, heart failure
Disadvantage Ischemia-reperfusion injury hemorrhagic
infarction
The best window for intervention is quite an art
2004 ACC/AHA GUIDELINES Class I:
procedure/treatment should be performed/ administered
Class IIa:
it is reasonable to perform/administer Class IIb:
procedure/treatment is considered Class III:
procedure/treatment is not helpful and may be harmful
ASYMPTOMATIC OR MILD ANGINA
Indications: class I Significant (50%) left main coronary artery stenosis. Significant (greater than or equal to 70%) stenosis of the
proximal LAD and proximal left circumflex artery. 3-vessel disease (EF less than 0.50)
Indications: class IIa proximal LAD stenosis with 1- or 2-vessel disease. ( Class I
if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.)
Indications: class IIb 1- or 2-vessel disease not involving the proximal LAD (If a
large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes Class I)
STABLE ANGINA Indications: Class I
Significant (50%) left main coronary artery stenosis. Significant (greater than or equal to 70%) stenosis of
the proximal LAD and proximal left circumflex artery.
3-vessel disease (benefits greater: EF less than 0.50 ) 2-vessel disease with significant proximal LAD
stenosis and either EF less than 0.50 or ischemia on noninvasive testing
1- or 2-vessel CAD without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing
Disabling angina despite maximal noninvasive therapy
Indications: class II Proximal LAD stenosis with 1-vessel disease
STABLE ANGINA
The patient factors most influencing a decision to recommend CABG Presence of severe proximal multivessel coronary
disease LV dysfunction Strongly positive stress test, Diabetes
PCA did not reduce the risk of death, myocardial infarction, stroke, or hospitalization when added to optimal medical therapy
UNSTABLE ANGINA/ NON-ST-SEGMENT ELEVATION (NSTEMI)
Indications: class I Significant (50%) left main coronary artery stenosis. Significant (greater than or equal to 70%) stenosis of the proximal LAD and LCX. Ongoing ischemia not responsive to maximal nonsurgical
therapy. Indications: class II
Proximal LAD stenosis with 1- or 2-vessel disease
UNSTABLE ANGINA/ NON-ST-SEGMENT ELEVATION (NSTEMI)
5-year overall survival: CABG (88.8%) or PTCA (86.1%, ) Cardiac mortality: PTCA (8.8%) vs CABG (4.9%)
The results for postoperative morbidity six predictors: sex, age, left ventricular function, timing
of surgery, extent of coronary artery disease and the type of myocardial protection used
ST-SEGMENT ELEVATION MI (STEMI)
Emergency or urgent CABG indication:Failed angioplasty (PTCA)Ventricular septal rupture or mitral valve
insufficiency In the early hours(6~12 hrs) of evolving STEMI Persistent or recurrent ischemia refractory to
medical therapyCardiogenic shock in <75 y/o, LBBBPost. MI developed shock within 36 hrs, CABG
should be performed within 18 hrs Life-threatening ventricular arrhythmias with
50% left mainstenosis and/or 3-vessels disease
ST-SEGMENT ELEVATION MI (STEMI)
Indications: Significant (50%) left main coronary artery stenosis. Significant (greater than or equal to 70%) stenosis
of the proximal LAD and LCX. Ongoing ischemia not responsive to maximal
nonsurgical therapy.
Risk factors: Besides time interval between MI and CABG Age renal insufficiency previous stroke LVEF< 40%
POOR LV FUNCTION
LVEF 0.31~0.35 0.26~0.30 <0.25
5 year-survival rate 73% 70% 62%
LVEF >50% <20%
Mortality rate 1.9% 6.7%
LVEF<0.25/0.35~0.5 Medical treatment CABG
5 year-survival rate 43%/ 50% 63%/ 62%
POOR LV FUNCTION
low EF and clinical heart failure are predictive of higher operative mortality rates with CABG
EFs less than 0.30: although having a higher immediate risk for
bypass surgery, may achieve a greater long-term gain in terms of survival advantage
CABG AFTER FAILED PTCA
Emergency bypass for failed PTCA a higher rate of death and subsequent MI compared with
elective bypass surgery Factors that influence the outcome of surgery
LV dysfunction, older age, and previous MI Extent of multivessel disease, collaterals Total ischemic time (a delay in transport to the operating
room) Cooperative interaction between the cardiologist,
cardiac surgeon, and anesthesia team are necessary to expedite resuscitation, transfer, and revascularization of patients with failed PTCA
PATIENTS WITH PREVIOUS CABG
Indication: Repeating angina despite optimal nonsurgical
therapy Vein grafts stenosis, native-vessel CAD
Percutaneous procedures have been ineffective in the treatment of atherosclerotic vein graft stenoses
Use of the left IMA to LAD graft, platelet
inhibitors and statin decreased reoperation rate
GETHOME MESSAGE
Indications for CABG: Significant (50%) left main coronary artery stenosis. Significant (greater than or equal to 70%) stenosis of
the proximal LAD and proximal left circumflex artery. 3-vessel disease (EF less than 0.50)
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