2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

90 Pages·2011·1.79 MB·English

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A
Report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines Developed in Collaboration
With the American Association for Thoracic Surgery, Society of
Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons
L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R.
Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka,
Adolph M. Hutter, Jr, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard
A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas,
Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, and Michael D.
Winniford
J. Am. Coll. Cardiol. 2011;58;e123-e210; originally published online Nov 7, 2011;
doi:10.1016/j.jacc.2011.08.009
This information is current as of May 21, 2012
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://content.onlinejacc.org/cgi/content/full/58/24/e123
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JournaloftheAmericanCollegeofCardiology Vol.58,No.24,2011
©2011bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/$36.00
PublishedbyElsevierInc. doi:10.1016/j.jacc.2011.08.009
PRACTICE GUIDELINE
2011 ACCF/AHA Guideline for
Coronary Artery Bypass Graft Surgery
A Report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the American Association for Thoracic Surgery,
Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons
Writing L. David Hillis, MD, FACC, Chair† Michael J. Mack, MD, FACC*¶
Committee
Peter K. Smith, MD, FACC, Vice Chair*† Manesh R. Patel, MD, FACC†
Members*
John D. Puskas, MD, FACC*†
Jeffrey L. Anderson, MD, FACC, FAHA*‡ Joseph F. Sabik, MD, FACC*#
John A. Bittl, MD, FACC§ Ola Selnes, PHD†
CharlesR.Bridges,MD,SCD,FACC,FAHA*† David M. Shahian, MD, FACC, FAHA**
John G. Byrne, MD, FACC† Jeffrey C. Trost, MD, FACC*†
Joaquin E. Cigarroa, MD, FACC† Michael D. Winniford, MD, FACC†
Verdi J. DiSesa, MD, FACC†
Loren F. Hiratzka, MD, FACC, FAHA† *Writingcommitteemembersarerequiredtorecusethemselvesfrom
Adolph M. Hutter, JR, MD, MACC, FAHA† votingonsectionstowhichtheirspecificrelationshipswithindustryand
other entities may apply; see Appendix 1 for recusal information.
Michael E. Jessen, MD, FACC*†
†ACCF/AHARepresentative.‡ACCF/AHATaskForceonPractice
Ellen C. Keeley, MD, MS† GuidelinesLiaison.§JointRevascularizationSectionAuthor.(cid:1)Society
Stephen J. Lahey, MD† ofCardiovascularAnesthesiologistsRepresentative.¶AmericanAsso-
ciation for Thoracic Surgery Representative. #Society of Thoracic
Richard A. Lange, MD, FACC, FAHA†§
SurgeonsRepresentative.**ACCF/AHATaskForceonPerformance
Martin J. London, MD(cid:1) MeasuresLiaison.
ACCF/AHA Alice K. Jacobs, MD, FACC, FAHA, Chair Robert A. Guyton, MD, FACC
TaskForce
Jeffrey L. Anderson, MD, FACC, FAHA, Jonathan L. Halperin, MD, FACC, FAHA
Members
Chair-Elect Judith S. Hochman, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA
Nancy Albert, PHD, CCNS, CCRN, FAHA E. Magnus Ohman, MD, FACC
Mark A. Creager, MD, FACC, FAHA William Stevenson, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC Clyde W. Yancy, MD, FACC, FAHA
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundation College of Cardiology Foundation/American Heart Association Task Force on
Board of Trustees and the American Heart Association Science Advisory and PracticeGuidelines.JAmCollCardiol2011;58:e123–210.
CoordinatingCommitteeinJuly2011,bytheSocietyofCardiovascularAnesthesi- ThisarticleiscopublishedinCirculation.
ologistsandtheSocietyofThoracicSurgeonsinAugust2011,andbytheAmerican Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmerican
AssociationforThoracicSurgeryinSeptember2011. CollegeofCardiology(www.cardiosource.org)andtheAmericanHeartAssociation
TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocument (my.americanheart.org).Forcopiesofthisdocument,pleasecontacttheElsevierInc.
becitedasfollows:HillisLD,SmithPK,AndersonJL,BittlJA,BridgesCR, ReprintDepartment,fax[phone],[email protected].
Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Permissions:Multiplecopies,modification,alteration,enhancement,and/ordis-
KeeleyEC,LaheySJ,LangeRA,LondonMJ,MackMJ,PatelMR,PuskasJD, tributionofthisdocumentarenotpermittedwithouttheexpresspermissionofthe
SabikJF,SelnesO,ShahianDM,TrostJC,WinnifordMD.2011ACCF/AHA American College of Cardiology Foundation. Please contact healthpermissions@
guideline for coronary artery bypass graft surgery: a report of the American elsevier.com.
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e124 Hillisetal. JACCVol.58,No.24,2011
2011ACCF/AHACABGGuideline December6,2011:e123–210
3.9.2. ChronicKidneyDisease.....................e146
TABLE OF CONTENTS
3.9.3. CompletenessofRevascularization..........e147
3.9.4. LVSystolicDysfunction....................e147
Preamble.....................................................e125 3.9.5. PreviousCABG.............................e147
3.9.6. UnstableAngina/Non(cid:1)ST-Elevation
1. Introduction .............................................e127 MyocardialInfarction.......................e147
3.9.7. DAPTComplianceandStentThrombosis:
1.1. MethodologyandEvidenceReview ............e127 Recommendation............................e147
1.2. OrganizationoftheWritingCommittee........e128 3.10. TMRasanAdjuncttoCABG.....................e148
3.11. HybridCoronaryRevascularization:
1.3. DocumentReviewandApproval................e128 Recommendations................................e148
2. ProceduralConsiderations............................e128 4. PerioperativeManagement...........................e148
2.1. IntraoperativeConsiderations..................e128 4.1. PreoperativeAntiplateletTherapy:
2.1.1. AnestheticConsiderations:
Recommendations................................e148
Recommendations...........................e128
4.2. PostoperativeAntiplateletTherapy:
2.1.2. UseofCPB.................................e130
2.1.3. Off-PumpCABGVersus Recommendations................................e149
TraditionalOn-PumpCABG...............e131 4.3. ManagementofHyperlipidemia:
2.1.4. BypassGraftConduit:Recommendations.......e132 Recommendations................................e150
2.1.4.1. SAPHENOUSVEINGRAFTS..................e132 4.3.1. TimingofStatinUseandCABGOutcomes....e150
2.1.4.2. INTERNALMAMMARYARTERIES.............e132 4.3.1.1. POTENTIALADVERSEEFFECTSOF
2.1.4.3. RADIAL,GASTROEPIPLOIC,AND PERIOPERATIVESTATINTHERAPY............e150
2.1.5. IncisionINsFfEoRrIOCREaPrdIGiAaScTRAICccAeRsTsE.R.IE.S...........................ee113323 4.4. HormonalManipulation:Recommendations...e151
2.1.6. AnastomoticTechniques....................e133 4.4.1. GlucoseControl.............................e151
2.1.7. IntraoperativeTEE:Recommendations.....e133 4.4.2. PostmenopausalHormoneTherapy.........e152
2.1.8. Preconditioning/Managementof 4.4.3. CABGinPatientsWithHypothyroidism.....e152
MyocardialIschemia:Recommendations......e135 4.5. PerioperativeBetaBlockers:
2.2. ClinicalSubsets..................................e136 Recommendations................................e152
2.2.1. CABGinPatientsWithAcuteMI: 4.6. ACEInhibitors/ARBs:Recommendations......e153
Recommendations...........................e136 4.7. SmokingCessation:Recommendations........e154
2.2.2. Life-ThreateningVentricularArrhythmias:
4.8. EmotionalDysfunctionand
Recommendations...........................e137 PsychosocialConsiderations:Recommendation..e155
2.2.3. EmergencyCABGAfterFailedPCI:
4.8.1. EffectsofMoodDisturbanceandAnxietyon
Recommendations...........................e138
CABGOutcomes...........................e155
2.2.4. CABGinAssociationWithOther
4.8.2. InterventionstoTreatDepressionin
CardiacProcedures:Recommendations......e138
CABGPatients.............................e155
3. CADRevascularization ................................e139 4.9. CardiacRehabilitation:Recommendation.......e155
4.10. PerioperativeMonitoring........................e156
3.1. HeartTeamApproachtoRevascularization
4.10.1. ElectrocardiographicMonitoring:
Decisions:Recommendations...................e139 Recommendations...........................e156
3.2. RevascularizationtoImproveSurvival: 4.10.2. PulmonaryArteryCatheterization:
Recommendations................................e141 Recommendations...........................e156
3.3. RevascularizationtoImproveSymptoms: 4.10.3. CentralNervousSystemMonitoring:
Recommendations................................e142 Recommendations...........................e156
3.4. CABGVersusContemporaneousMedical 5. CABG-AssociatedMorbidityandMortality:
Therapy............................................e142 OccurrenceandPrevention...........................e157
3.5. PCIVersusMedicalTherapy.....................e143
3.6. CABGVersusPCI.................................e143 5.1. PublicReportingofCardiacSurgeryOutcomes:
3.6.1. CABGVersusBalloonAngioplastyorBMS....e143 Recommendation.................................e157
3.6.2. CABGVersusDES.........................e144 5.1.1. UseofOutcomesorVolumeasCABG
3.7. LeftMainCAD ....................................e144 QualityMeasures:Recommendations.......e158
3.7.1. CABGorPCIVersusMedicalTherapyfor 5.2. AdverseEvents...................................e159
LeftMainCAD............................e144 5.2.1. AdverseCerebralOutcomes.................e159
3.7.2. StudiesComparingPCIVersusCABGfor 5.2.1.1. STROKE................................e159
5.2.1.1.1. USEOFEPIAORTICULTRASOUND
LeftMainCAD............................e145
IMAGINGTOREDUCESTROKERATES:
3.7.3. RevascularizationConsiderationsfor
LeftMainCAD............................e145 RECOMMENDATION..............e159
5.2.1.1.2. THEROLEOFPREOPERATIVECAROTID
3.8. ProximalLADArteryDisease ...................e146 ARTERYNONINVASIVESCREENINGIN
3.9. ClinicalFactorsThatMayInfluencetheChoice CABGPATIENTS:RECOMMENDATIONS..e160
ofRevascularization.............................e146 5.2.1.2. DELIRIUM...............................e161
3.9.1. DiabetesMellitus ...........................e146 5.2.1.3. POSTOPERATIVECOGNITIVEIMPAIRMENT......e161
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5.2.2. Mediastinitis/PerioperativeInfection: When properly applied, expert analysis of available data on
Recommendations...........................e161 thebenefitsandrisksofthesetherapiesandprocedurescan
5.2.3. RenalDysfunction:Recommendations........e163 improvethequalityofcare,optimizepatientoutcomes,and
5.2.4. PerioperativeMyocardialDysfunction:
favorably affect costs by focusing resources on the most
Recommendations...........................e164
5.2.4.1. TRANSFUSION:RECOMMENDATION...........e165 effectivestrategies.Anorganizedanddirectedapproachtoa
5.2.5. PerioperativeDysrhythmias: thorough review of evidence has resulted in the production
Recommendations...........................e165 ofclinicalpracticeguidelinesthatassistphysiciansinselect-
5.2.6. PerioperativeBleeding/Transfusion:
ingthebestmanagementstrategyforanindividualpatient.
Recommendations...........................e165
Moreover, clinical practice guidelines can provide a foun-
6. SpecificPatientSubsets..............................e166 dationforotherapplications,suchasperformancemeasures,
appropriate use criteria, and both quality improvement and
6.1. Elderly.............................................e166
clinical decision support tools.
6.2. Women.............................................e167
The American College of Cardiology Foundation
6.3. PatientsWithDiabetesMellitus................e167 (ACCF)andtheAmericanHeartAssociation(AHA)have
6.4. AnomalousCoronaryArteries:
jointly produced guidelines in the area of cardiovascular
Recommendations................................e168
disease since 1980. The ACCF/AHA Task Force on
6.5. PatientsWithChronicObstructivePulmonary
PracticeGuidelines(TaskForce),chargedwithdeveloping,
Disease/RespiratoryInsufficiency:
Recommendations................................e169 updating,andrevisingpracticeguidelinesforcardiovascular
diseases and procedures, directs and oversees this effort.
6.6. PatientsWithEnd-StageRenalDiseaseon
Dialysis:Recommendations.....................e169 Writing committees are charged with regularly reviewing
6.7. PatientsWithConcomitantValvularDisease: and evaluating all available evidence to develop balanced,
Recommendations................................e170 patient-centric recommendations for clinical practice.
6.8. PatientsWithPreviousCardiacSurgery: Expertsinthesubjectunderconsiderationareselectedby
Recommendation.................................e170 the ACCF and AHA to examine subject-specific data and
6.8.1. IndicationsforRepeatCABG ..............e170 write guidelines in partnership with representatives from
6.8.2. OperativeRisk..............................e170 other medical organizations and specialty groups. Writing
6.8.3. Long-TermOutcomes......................e170
committeesareaskedtoperformaformalliteraturereview;
6.9. PatientsWithPreviousStroke..................e171 weighthestrengthofevidencefororagainstparticulartests,
6.10. PatientsWithPAD................................e171 treatments,orprocedures;andincludeestimatesofexpected
7. EconomicIssues........................................e171 outcomes where such data exist. Patient-specific modifiers,
comorbidities, and issues of patient preference that may
7.1. Cost-EffectivenessofCABGandPCI...........e172 influence the choice of tests or therapies are considered.
7.1.1. Cost-EffectivenessofCABGVersusPCI.......e172 When available, information from studies on cost is con-
7.1.2. CABGVersusPCIWithDES.............e172
sidered, but data on efficacy and outcomes constitute the
8. FutureResearchDirections...........................e172 primary basis for the recommendations contained herein.
In analyzing the data and developing recommendations
8.1. HybridCABG/PCI.................................e173 and supporting text, the writing committee uses evidence-
8.2. ProteinandGeneTherapy.......................e173 basedmethodologiesdevelopedbytheTaskForce(1).The
8.3. TeachingCABGtotheNextGeneration: ClassofRecommendation(COR)isanestimateofthesize
UseofSurgicalSimulators......................e173 of the treatment effect considering risks versus benefits in
References..................................................e174 addition to evidence and/or agreement that a given treat-
ment or procedure is or is not useful/effective or in some
Appendix1.AuthorRelationshipsWithIndustry situationsmaycauseharm.TheLevelofEvidence(LOE)is
andOtherEntities(Relevant)............................e204 an estimate of the certainty or precision of the treatment
effect. The writing committee reviews and ranks evidence
Appendix2.ReviewerRelationshipsWithIndustry supporting each recommendation with the weight of evi-
andOtherEntitites(Relevant)...........................e207 dence ranked as LOE A, B, or C according to specific
definitions that are included in Table 1. Studies are identi-
Appendix3.AbbreviationList............................e210 fiedasobservational,retrospective,prospective,orrandom-
ized where appropriate. For certain conditions for which
inadequate data are available, recommendations are based
Preamble
on expert consensus and clinical experience and are ranked
as LOE C. When recommendations at LOE C are sup-
The medical profession should play a central role in evalu- ported by historical clinical data, appropriate references
atingtheevidencerelatedtodrugs,devices,andprocedures (including clinical reviews) are cited if available. For issues
for the detection, management, and prevention of disease. for which sparse data are available, a survey of current
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e126 Hillisetal. JACCVol.58,No.24,2011
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Table1. ApplyingClassificationofRecommendationsandLevelofEvidence
ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials.
Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheart
failure,andprioraspirinuse.†Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirect
comparisonsofthetreatmentsorstrategiesbeingevaluated.
practice among the clinicians on the writing committee is In view of the advances in medical therapy across the
the basis for LOE C recommendations, and no references spectrum of cardiovascular diseases, the Task Force has
arecited.TheschemaforCORandLOEissummarizedin designated the term guideline(cid:1)directed medical therapy
Table 1, which also provides suggested phrases for writing (GDMT)torepresentoptimalmedicaltherapyasdefinedby
recommendationswithineachCOR.Anewadditiontothis ACCF/AHA guideline–recommended therapies (primarily
methodology is separation of the Class III recommenda- Class I). This new term, GDMT, will be used herein and
tionstodelineateiftherecommendationisdeterminedtobe throughout all future guidelines.
of“nobenefit”orisassociatedwith“harm”tothepatient.In Because the ACCF/AHA practice guidelines address
addition, in view of the increasing number of comparative patient populations (and healthcare providers) residing in
effectiveness studies, comparator verbs and suggested North America, drugs that are not currently available in
phrases for writing recommendations for the comparative North America are discussed in the text without a specific
effectiveness of one treatment or strategy versus another COR. For studies performed in large numbers of subjects
have been added for COR I and IIa, LOE A or B only. outsideNorthAmerica,eachwritingcommitteereviewsthe
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JACCVol.58,No.24,2011 Hillisetal. e127
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potentialinfluenceofdifferentpracticepatternsandpatient Additionally, to ensure complete transparency, writing com-
populations on the treatment effect and relevance to the mittee members’ comprehensive disclosure information—
ACCF/AHA target population to determine whether the includingRWInotpertinenttothisdocument—isavailableas
findings should inform a specific recommendation. an online supplement. Comprehensive disclosure information
TheACCF/AHApracticeguidelinesareintendedtoassist for the Task Force is also available online at www.
healthcareprovidersinclinicaldecisionmakingbydescribinga cardiosource.org/ACC/About-ACC/Leadership/Guidelines-
range of generally acceptable approaches to the diagnosis, and-Documents-Task-Forces.aspx. The work of the writing
management,andpreventionofspecificdiseasesorconditions. committeewassupportedexclusivelybytheACCFandAHA
Theguidelinesattempttodefinepracticesthatmeettheneeds without commercial support. Writing committee members
of most patients in most circumstances. The ultimate judg- volunteeredtheirtimeforthisactivity.
mentregardingthecareofaparticularpatientmustbemadeby Inanefforttomaintainrelevanceatthepointofcarefor
thehealthcareproviderandpatientinlightofallthecircum- practicing physicians, the Task Force continues to oversee
stances presented by that patient. As a result, situations may an ongoing process improvement initiative. As a result, in
arise for which deviations from these guidelines may be response to pilot projects, evidence tables (with references
appropriate. Clinical decision making should involve consid- linked to abstracts in PubMed) have been added.
eration of the quality and availability of expertise in the area In April 2011, the Institute of Medicine released 2
wherecareisprovided.Whentheseguidelinesareusedasthe reports: Finding What Works in Health Care: Standards for
basis for regulatory or payer decisions, the goal should be Systematic Reviews and Clinical Practice Guidelines We Can
improvementinqualityofcare.TheTaskForcerecognizesthat Trust (2,3). It is noteworthy that the ACCF/AHA guide-
situations arise in which additional data are needed to inform linesarecitedasbeingcompliantwithmanyoftheproposed
patientcaremoreeffectively;theseareaswillbeidentifiedwithin standards. A thorough review of these reports and of our
eachrespectiveguidelinewhenappropriate. current methodology is under way, with further enhance-
Prescribed courses of treatment in accordance with these ments anticipated.
recommendationsareeffectiveonlyiffollowed.Becauselackof The recommendations in this guideline are considered
patient understanding and adherence may adversely affect currentuntiltheyaresupersededbyafocusedupdateorthe
outcomes, physicians and other healthcare providers should full-textguidelineisrevised.Guidelinesareofficialpolicyof
makeeveryefforttoengagethepatient’sactiveparticipationin both the ACCF and AHA.
prescribedmedicalregimensandlifestyles.Inaddition,patients
Alice K. Jacobs, MD, FACC, FAHA Chair
shouldbeinformedoftherisks,benefits,andalternativestoa
ACCF/AHA Task Force on Practice Guidelines
particulartreatmentandbeinvolvedinshareddecisionmaking
wheneverfeasible,particularlyforCORIIaandIIb,wherethe
1. Introduction
benefit-to-riskratiomaybelower.
The Task Force makes every effort to avoid actual,
potential,orperceivedconflictsofinterestthatmayariseas
1.1. Methodology and Evidence Review
aresultofindustryrelationshipsorpersonalinterestsamong
the members of the writing committee. All writing com- Wheneverpossible,therecommendationslistedinthisdocu-
mittee members and peer reviewers of the guideline are ment are evidence based. Articles reviewed in this guideline
requiredtodiscloseallsuchcurrentrelationships,aswellas revision covered evidence from the past 10 years through
thoseexisting12monthspreviously.InDecember2009,the January2011,aswellasselectedotherreferencesthroughApril
ACCF and AHA implemented a new policy for relation- 2011. Searches were limited to studies, reviews, and other
ships with industry and other entities (RWI) that requires evidenceconductedinhumansubjectsthatwerepublishedin
thewritingcommitteechairplusaminimumof50%ofthe English.Keysearchwordsincludedbutwerenotlimitedtothe
writing committee to have no relevant RWI (Appendix 1 following: analgesia, anastomotic techniques, antiplatelet agents,
for the ACCF/AHA definition of relevance). These state- automated proximal clampless anastomosis device, asymptomatic
ments are reviewed by the Task Force and all members ischemia,Cardica C-port,cost effectiveness,depressed left ventric-
during each conference call and meeting of the writing ular(LV)function,distalanastomotictechniques,directproximal
committee and are updated as changes occur. All guideline anastomosis on aorta, distal anastomotic devices, emergency coro-
recommendationsrequireaconfidentialvotebythewriting nary artery bypass graft (CABG) and ST-elevation myocardial
committee and must be approved by a consensus of the infarction(STEMI),heartfailure,interruptedsutures,LVsystolic
voting members. Members are not permitted to write, and dysfunction, magnetic connectors, PAS-Port automated proximal
must recuse themselves from voting on, any recommenda- clampless anastomotic device, patency, proximal connectors, renal
tion or section to which their RWI apply. Members who disease, sequential anastomosis, sternotomy, symmetry connector,
recused themselves from voting are indicated in the list of symptomaticischemia,proximalconnectors,sequentialanastomosis,
writingcommitteemembers,andsectionrecusalsarenotedin T grafts, thoracotomy, U-clips, Ventrica Magnetic Vascular Port
Appendix 1. Authors’ and peer reviewers’ RWI pertinent to system, Y grafts. Additionally, the committee reviewed docu-
thisguidelinearedisclosedinAppendixes1and2,respectively. mentsrelatedtothesubjectmatterpreviouslypublishedbythe
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e128 Hillisetal. JACCVol.58,No.24,2011
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ACCF and AHA. References selected and published in this superviseanestheticcareofpatientswhoareconsideredtobeat
documentarerepresentativebutnotall-inclusive. highrisk(16–18).(LevelofEvidence:C)
To provide clinicians with a comprehensive set of data,
CLASSIIa
wheneverdeemedappropriateorwhenpublished,theabsolute 1. Volatile anesthetic-based regimens can be useful in facilitating
risk difference and number needed to treat or harm are early extubation and reducing patient recall (5,19–21). (Level of
providedintheguideline,alongwithconfidenceinterval(CI) Evidence:A)
and data related to the relative treatment effects such as odds
ratio(OR),relativerisk(RR),hazardratio(HR),orincidence CLASSIIb
1. Theeffectivenessofhighthoracicepiduralanesthesia/analgesiafor
rateratio.
routineanalgesicuseisuncertain(22–25).(LevelofEvidence:B)
Thefocusoftheseguidelinesisthesafe,appropriate,and
efficacious performance of CABG. CLASSIII:HARM
1. Cyclooxygenase-2inhibitorsarenotrecommendedforpainreliefin
1.2. Organization of the Writing Committee
thepostoperativeperiodafterCABG(26,27).(LevelofEvidence:B)
The committee was composed of acknowledged experts in 2. Routineuseofearlyextubationstrategiesinfacilitieswithlimited
CABG, interventional cardiology, general cardiology, and backupforairwayemergenciesoradvancedrespiratorysupportis
potentiallyharmful.(LevelofEvidence:C)
cardiovascularanesthesiology.Thecommitteeincludedrep-
resentatives from the ACCF, AHA, American Association
SeeOnlineDataSupplement1foradditionaldataonanesthetic
for Thoracic Surgery, Society of Cardiovascular Anesthesi-
considerations.
ologists, and Society of Thoracic Surgeons (STS).
Anesthetic management of the CABG patient mandates
1.3. Document Review and Approval
a favorable balance of myocardial oxygen supply and de-
This document was reviewed by 2 official reviewers, each
mand to prevent or minimize myocardial injury (Section
nominated by both the ACCF and the AHA, as well as 1
2.1.8). Historically, the popularity of several anesthetic
reviewer each from the American Association for Thoracic
techniques for CABG has varied on the basis of their
Surgery, Society of Cardiovascular Anesthesiologists, and
known or potential adverse cardiovascular effects (e.g.,
STS,aswellasmembersfromtheACCF/AHATaskForce
cardiovascular depression with high doses of volatile anes-
on Data Standards, ACCF/AHA Task Force on Perfor-
thesia, lack of such depression with high-dose opioids, or
mance Measures, ACCF Surgeons’ Scientific Council,
coronaryvasodilationandconcernfora“steal”phenomenon
ACCF Interventional Scientific Council, and Southern
with isoflurane) as well as concerns about interactions with
Thoracic Surgical Association. All information on review-
preoperative medications (e.g., cardiovascular depression
ers’ RWI was distributed to the writing committee and is
with beta blockers or hypotension with angiotensin-
published in this document (Appendix 2).
converting enzyme [ACE] inhibitors and angiotensin-
This document was approved for publication by the
receptorblockers[ARBs][28–30])(Sections2.1.8and4.5).
governingbodiesoftheACCFandtheAHAandendorsed
Independentoftheseconcerns,effortstoimproveoutcomes
by the American Association for Thoracic Surgery, Society
and to reduce costs have led to shorter periods of postop-
of Cardiovascular Anesthesiologists, and STS.
erativemechanicalventilationandeven,insomepatients,to
prompt extubation in the operating room (“accelerated
2. Procedural Considerations
recovery protocols” or “fast-track management”) (5,31).
High-dose opioid anesthesia with benzodiazepine sup-
2.1. Intraoperative Considerations plementationwasusedcommonlyinCABGpatientsinthe
United States in the 1970s and 1980s. Subsequently, it
2.1.1. Anesthetic Considerations: Recommendations
became clear that volatile anesthetics are protective in the
CLASSI settingofmyocardialischemiaandreperfusion,andthis,in
1. Anestheticmanagementdirectedtowardearlypostoperativeextu- combination with a shift to accelerated recovery or “fast-
bation and accelerated recovery of low- to medium-risk patients track” strategies, led to their ubiquitous use. As a result,
undergoinguncomplicatedCABGisrecommended(4–6).(Levelof
opioids have been relegated to an adjuvant role (32,33).
Evidence:B)
Despite their widespread use, volatile anesthetics have not
2. Multidisciplinaryeffortsareindicatedtoensureanoptimallevelof
been shown to provide a mortality rate advantage when
analgesiaandpatientcomfortthroughouttheperioperativeperiod
compared with other intravenous regimens (Section 2.1.8).
(7–11).(LevelofEvidence:B)
Optimal anesthesia care in CABG patients should in-
3. Effortsarerecommendedtoimproveinterdisciplinarycommunication
clude 1) a careful preoperative evaluation and treatment of
andpatientsafetyintheperioperativeenvironment(e.g.,formalized
modifiableriskfactors;2)properhandlingofallmedications
checklist-guidedmultidisciplinarycommunication)(12–15).(Levelof
Evidence:B) given preoperatively (Sections 4.1, 4.3, and 4.5); 3) estab-
4. Afellowship-trainedcardiacanesthesiologist(orexperiencedboard- lishmentofcentralvenousaccessandcarefulcardiovascular
certifiedpractitioner)credentialedintheuseofperioperativetrans- monitoring; 4) induction of a state of unconsciousness,
esophagealechocardiography(TEE)isrecommendedtoprovideor analgesia,andimmobility;and5)asmoothtransitiontothe
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early postoperative period, with a goal of early extubation, occurrence of epidural hematoma or abscess, these entities
patient mobilization, and hospital discharge. Attention occur on occasion (38). Finally, the use of other regional
should be directed at preventing or minimizing adverse anesthetic approaches for postoperative analgesia, such as
hemodynamic and hormonal alterations that may induce parasternal block, has been reported (39).
myocardialischemiaorexertadeleteriouseffectonmyocar- Over the past decade, early extubation strategies (“fast-
dial metabolism (as may occur during cardiopulmonary track”anesthesia)oftenhavebeenusedinlow-tomedium-
bypass [CPB]) (Section 2.1.8). This requires close interac- riskCABGpatients.Thesestrategiesallowashortertimeto
tion between the anesthesiologist and surgeon, particularly extubation, a decreased length of intensive care unit (ICU)
when manipulation of the heart or great vessels is likely to stay, and variable effects on length of hospital stay (4–6).
induce hemodynamic instability. During on-pump CABG, Immediate extubation in the operating room, with or
particular care is required during vascular cannulation and without markedly accelerated postoperative recovery path-
weaning from CPB; with off-pump CABG, the hemody- ways (e.g., “ultra-fast-tracking,” “rapid recovery protocol,”
namic alterations often caused by displacement or vertical- “short-stay intensive care”) have been used safely, with low
ization of the heart and application of stabilizer devices on rates of reintubation and no influence on quality of life
theepicardium,withresultantchangesinheartrate,cardiac (40–44). Observational data suggest that physician judg-
output, and systemic vascular resistance, should be moni- ment in triaging lower-risk patients to early or immediate
tored carefully and managed appropriately. extubationworkswell,withratesofreintubation(cid:2)1%(45).
In the United States, nearly all patients undergoing Certainfactorsappeartopredictfast-track“failure,”includ-
CABG receive general anesthesia with endotracheal intu- ing previous cardiac surgery, use of intra-aortic balloon
bation utilizing volatile halogenated general anesthetics counterpulsation, and possibly advanced patient age.
with opioid supplementation. Intravenous benzodiazepines Provisionofadequateperioperativeanalgesiaisimportant
often are given as premedication or for induction of anes- in enhancing patient mobilization, preventing pulmonary
thesia, along with other agents such as propofol or etomi- complications, and improving the patient’s psychological
date.Nondepolarizingneuromuscular-blockingagents,par- well-being (9,11). The intraoperative use of high-dose
ticularly nonvagolytic agents with intermediate duration of morphine (40 mg) may offer superior postoperative pain
action, are preferred to the longer-acting agent, pancuro- reliefandenhancepatientwell-beingcomparedwithfenta-
nium. Use of the latter is associated with higher intraoper- nyl (despite similar times to extubation) (46).
ative heart rates and a higher incidence of residual neuro- The safety of nonsteroidal anti-inflammatory agents for
muscular depression in the early postoperative period, with analgesia is controversial, with greater evidence for adverse
a resultant delay in extubation (23,34). In addition, low cardiovascular events with the selective cyclooxygenase-2
concentrations of volatile anesthetic usually are adminis- inhibitors than the nonselective agents. A 2007 AHA
tered via the venous oxygenator during CPB, facilitating scientific statement presented a stepped-care approach to
amnesia and reducing systemic vascular resistance. themanagementofmusculoskeletalpaininpatientswithor
Outside the United States, alternative anesthetic tech- at risk for coronary artery disease (CAD), with the goal of
niques,particularlytotalintravenousanesthesiaviapropofol limiting the use of these agents to patients in whom safer
and opioid infusions with benzodiazepine supplementation therapies fail (47). In patients hospitalized with unstable
with or without high thoracic epidural anesthesia, are angina (UA) and non–ST-elevation myocardial infarction
commonlyused.Theuseofhighthoracicepiduralanesthe- (NSTEMI), these agents should be discontinued promptly
siaexertssalutaryeffectsonthecoronarycirculationaswell and reinstituted later according to the stepped-care ap-
asmyocardialandpulmonaryfunction,attenuatesthestress proach (48).
response, and provides prolonged postoperative analgesia In the setting of cardiac surgery, nonsteroidal anti-
(24,25,35). In the United States, however, concerns about inflammatory agents previously were used for perioperative
the potential for neuraxial bleeding (particularly in the analgesia. A meta-analysis of 20 trials of patients undergo-
setting of heparinization, platelet inhibitors, and CPB- ing thoracic or cardiac surgery, which evaluated studies
induced thrombocytopenia), local anesthetic toxicity, and published before 2005, reported significant reductions in
logistical issues related to the timing of epidural catheter pain scores, with no increase in adverse outcomes (49). Sub-
insertion and management have resulted in limited use of sequently, 2 RCTs, both studying the oral cyclooxygenase-2
these techniques (22). Their selective use in patients with inhibitorvaldecoxibanditsintravenousprodrug,parecoxib,
severepulmonarydysfunction(Section6.5)or chronicpain reported a higher incidence of sternal infections in 1 trial
syndromes may be considered. Although meta-analyses of andasignificantincreaseinadversecardiovasculareventsin
randomized controlled trials (RCTs) of high thoracic epi- the other (26,27). On the basis of the results of these 2
dural anesthesia/analgesia in CABG patients (particularly studies(aswellasothernonsurgicalreportsofincreasedrisk
on-pump) have yielded inconsistent results on morbidity withcyclooxygenase-2–selectiveagents),theU.S.Foodand
and mortality rates, it does appear to reduce time to Drug Administration in 2005 issued a “black box” warning
extubation,pain,andpulmonarycomplications(36–38).Of forallnonsteroidalanti-inflammatoryagents(exceptaspirin)
interest, although none of the RCTs have reported the immediatelyafterCABG(50).Theconcurrentadministration
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e130 Hillisetal. JACCVol.58,No.24,2011
2011ACCF/AHACABGGuideline December6,2011:e123–210
of ibuprofen with aspirin has been shown to attenuate the retrieved from the operative field during on-pump CABG
latter’s inhibition of platelet aggregation, likely because of contains lipid material and particulate matter, which have
competitive inhibition of cyclooxygenase at the platelet- been implicated as possible causes of postoperative neuro-
receptorbindingsite(51). cognitive dysfunction. Although a study (59) reported that
Observationalanalysesinpatientsundergoingnoncardiac CPB-associated neurocognitive dysfunction can be miti-
surgery have shown a significant reduction in perioperative gated by the routine processing of shed blood with a cell
death with the use of checklists, multidisciplinary surgical saverbeforeitsreinfusion,anotherstudy(60)failedtoshow
care, intraoperative time-outs, postsurgical debriefings, and such an improvement.
othercommunicationstrategies(14,15).Suchmethodology It has been suggested that CPB leads to an increased
is being used increasingly in CABG patients (12–14). incidence of postoperative renal failure requiring dialysis,
In contrast to extensive literature on the role of the butalargeRCTcomparingon-pumpandoff-pumpCABG
surgeonindeterminingoutcomeswithCABG,limiteddata showednodifferenceinitsoccurrence(61).Ofinterest,this
on the influence of the anesthesiologist are available. Of 2 study failed to show a decreased incidence of postoperative
such reports from single centers in the 1980s, 1 suggested adverseneurologicalevents(stroke,coma,orneurocognitive
that the failure to control heart rate to (cid:1)110 beats per deficit) in those undergoing off-pump CABG.
minutewasassociatedwithahighermortalityrate,andthe TheoccurrenceofSIRSinpatientsundergoingCPBhas
other suggested that increasing duration of CPB adversely led to the development of strategies designed to prevent or
influencedoutcome(52,53).Anotherobservationalanalysis to minimize its occurrence. Many reports have focused on
of data from vascular surgery patients suggested that anes- the increased serum concentrations of cytokines (e.g., IL-2R,
thetic specialization was independently associated with a IL-6, IL-8, tumor necrosis factor alpha) and other modu-
reduction in mortality rate (54). lators of inflammation (e.g., P-selectin, sE-selectin, soluble
Tomeetthechallengesofprovidingcarefortheincreas- intercellular adhesion molecule-1, plasma endothelial cell
ingly higher-risk patients undergoing CABG, efforts have adhesion molecule-1, and plasma malondialdehyde), which
been directed at enhancing the experience of trainees, reflect leukocyte and platelet activation, in triggering the
particularly in the use of newer technologies such as TEE. onset of SIRS. A study showed a greater upregulation of
Cardiac anesthesiologists, in collaboration with cardiolo- neutrophil CD11b expression (a marker of leukocyte acti-
gistsandsurgeons,haveimplementednationaltrainingand vation) in patients who sustained a (cid:2)50% increase in the
certificationprocessesforpractitionersintheuseofperiop- serum creatinine concentration after CPB, thereby impli-
erative TEE (Section 2.1.7) (164,165). Accreditation of catingactivatedneutrophilsinthepathophysiologyofSIRS
cardiothoracic anesthesia fellowship programs from the and the occurrence of post-CPB renal dysfunction (62).
AccreditationCouncilforGraduateMedicalEducationwas Modulating neutrophil activation to reduce the occurrence
initiated in 2004, and efforts are ongoing to obtain formal of SIRS has been investigated; however, the results have
subspecialty certification (18). been inconsistent. Preoperative intravenous methylpred-
nisolone (10 mg/kg) caused a reduction in the serum
2.1.2. Use of CPB
concentrations of many of these cytokines after CPB, but
Several adverse outcomes have been attributed to CPB, this reduction was not associated with improved hemody-
including 1) neurological deficits (e.g., stroke, coma, post- namicvariables,diminishedbloodloss,lessuseofinotropic
operativeneurocognitivedysfunction);2)renaldysfunction; agents, shorter duration of ventilation, or shorter ICU
and 3) the Systemic Inflammatory Response Syndrome lengthofstay(63).Similarly,theuseofintravenousimmu-
(SIRS). The SIRS is manifested as generalized systemic noglobulinGinpatientswithpost-CPBSIRShasnotbeen
inflammationoccurringafteramajormorbidevent,suchas associated with decreased rates of short-term morbidity or
trauma, infection, or major surgery. It is often particularly 28-day mortality (64).
apparent after on-pump cardiac surgery, during which OtherstrategiestomitigatetheoccurrenceofSIRSafter
surgical trauma, contact of blood with nonphysiological CPB have been evaluated, including the use of 1) CPB
surfaces (e.g., pump tubing, oxygenator surfaces), myocar- circuits (including oxygenators) coated with materials
dialischemiaandreperfusion,andhypothermiacombineto known to reduce complement and leukocyte activation;
cause a dramatic release of cytokines (e.g., interleukin [IL] 2) CPB tubing that is covalently bonded to heparin; and
6andIL8)andothermediatorsofinflammation(55).Some 3) CPB tubing coated with polyethylene oxide polymer or
investigators have used serum concentrations of S100 beta Poly(2-methoxyethylacrylate).Leukocytedepletionviaspe-
as a marker of brain injury (56) and have correlated cializedfiltersintheCPBcircuitshasbeenshowntoreduce
increased serum levels with the number of microemboli the plasma concentrations of P-selectin, intercellular adhe-
exiting the CPB circuit during CABG. In contrast, others sion molecule-1, IL-8, plasma endothelial cell adhesion
have noted the increased incidence of microemboli with molecule-1, and plasma malondialdehyde after CPB (65).
on-pump CABG (relative to off-pump CABG) but have Finally, closed mini-circuits for CPB have been devel-
failedtoshowacorrespondingworseningofneurocognitive opedinanattempttominimizetheblood–airinterfaceand
function1weekto6monthspostoperatively(57,58).Blood blood contact with nonbiological surfaces, both of which
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promote cytokine elaboration, but it is uncertain if these off-pump CABG; p(cid:3)0.19). The primary long-term end-
maneuvers and techniques have a discernible effect on out- point, a composite of death from any cause, a repeat
comesafterCABG. revascularizationprocedure,oranonfatalmyocardialinfarc-
tion (MI) within 1 year of surgery, occurred more often in
2.1.3. Off-Pump CABG Versus
those undergoing off-pump CABG (9.9%) than in those
Traditional On-Pump CABG
havingon-pumpCABG(7.4%;p(cid:3)0.04).Neuropsycholog-
SincethefirstCABGwasperformedinthelate1960s,the icaloutcomesandresourceutilizationweresimilarbetween
standard surgical approach has included the use of cardiac the 2 groups. One year after surgery, graft patency was
arrest coupled with CPB (so-called on-pump CABG), higher in the on-pump group (87.8% versus 82.6%;
thereby optimizing the conditions for construction of vas- p(cid:2)0.01).Inshort,theROOBYinvestigatorsfailedtoshow
cular anastomoses to all diseased coronary arteries without
anadvantageofoff-pumpCABGcomparedwithon-pump
cardiac motion or hemodynamic compromise. Such on-
CABGinapatientpopulationconsideredtobeatlowrisk.
pump CABG has become the gold standard and is per-
Instead, use of the on-pump technique was associated with
formed in about 80% of subjects undergoing the procedure
better 1-year composite outcomes and 1-year graft patency
intheUnitedStates.Despitetheexcellentresultsthathave
rates,withnodifferenceinneuropsychologicaloutcomesor
been achieved, the use of CPB and the associated manipu-
resource utilization.
lation of the ascending aorta are linked with certain peri-
Althoughnumerousinvestigatorshaveusedsingle-center
operative complications, including myonecrosis during aor-
registries, the STS database, and meta-analyses in an
tic occlusion, cerebrovascular accidents, generalized
attempt to identify patient subgroups in whom off-pump
neurocognitivedysfunction,renaldysfunction,andSIRS.In
CABGisthepreferredprocedure,eventheseanalyseshave
anefforttoavoidthesecomplications,off-pumpCABGwas
reached inconsistent conclusions about off-pump CABG’s
developed (58,66). Off-pump CABG is performed on the
ability to reduce morbidity and mortality rates (69,72–83).
beating heart with the use of stabilizing devices (which
A retrospective cohort study of 14,766 consecutive patients
minimizecardiacmotion);inaddition,itincorporatestech-
undergoing isolated CABG identified a mortality benefit
niques to minimize myocardial ischemia and systemic he-
(OR:0.45)foroff-pumpCABGinpatientswithapredicted
modynamic compromise. As a result, the need for CPB is
riskofmortality(cid:4)2.5%(82),butasubsequentrandomized
obviated. This technique does not necessarily decrease the
comparison of off-pump CABG to traditional on-pump
need for manipulation of the ascending aorta during con-
CABGin341high-riskpatients(aEuroscore(cid:4)5)showed
struction of the proximal anastomoses.
no difference in the composite endpoint of all-cause death,
Todate,theresultsofseveralRCTscomparingon-pump
acute MI, stroke, or a required reintervention procedure
and off-pump CABG in various patient populations have
(78).AnanalysisofdatafromtheNewYorkStateCardiac
beenpublished(61,67,68).Inaddition,registrydataandthe
Surgery Reporting system did not demonstrate a reduction
resultsofmeta-analyseshavebeenusedtoassesstherelative
in mortality rate with off-pump CABG in any patient
efficacies of the 2 techniques (69,70). In 2005, an AHA
subgroup, including the elderly (age (cid:4)80 years) or those
scientific statement comparing the 2 techniques concluded
with cerebrovascular disease, azotemia, or an extensively
that both procedures usually result in excellent outcomes
calcified ascending aorta (69).
andthatneithertechniqueshouldbeconsideredsuperiorto
Despite these results, off-pump CABG is the preferred
the other (71). At the same time, several differences were
approach by some surgeons who have extensive experience
noted.Off-pumpCABGwasassociatedwithlessbleeding,
with it and therefore are comfortable with its technical
lessrenaldysfunction,ashorterlengthofhospitalstay,and
nuances.Recently,publisheddatasuggestedthattheavoid-
lessneurocognitivedysfunction.Theincidenceofperioper-
ative stroke was similar with the 2 techniques. On-pump ance of aortic manipulation is the most important factor in
CABG was noted to be less technically complex and reducing the risk of neurological complications (84,85).
allowedbetteraccesstodiseasedcoronaryarteriesincertain Patientswithextensivediseaseoftheascendingaortaposea
anatomic locations (e.g., those on the lateral LV wall) as special challenge for on-pump CABG; for these patients,
well as better long-term graft patency. cannulation or cross-clamping of the aorta may create an
In2009,theresultsofthelargestRCTtodatecomparing unacceptably high risk of stroke. In such individuals, off-
on-pump CABG to off-pump CABG, the ROOBY (Ran- pump CABG in conjunction with avoidance of manipula-
domized On/Off Bypass) trial, were published, reporting tion of the ascending aorta (including placement of proxi-
the outcomes for 2,203 patients (99% men) at 18 Veterans mal anastomoses) may be beneficial. Surgeons typically
Affairs Medical Centers (61). The primary short-term end- prefer an on-pump strategy in patients with hemodynamic
point, a composite of death or complications (reoperation, compromise because CPB offers support for the systemic
new mechanical support, cardiac arrest, coma, stroke, or circulation. In the end, most surgeons consider either
renal failure) within 30 days of surgery, occurred with approach to be reasonable for the majority of subjects
similar frequency (5.6% for on-pump CABG; 7.0% for undergoing CABG.
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