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A Coronary Artery Bypass Grafting
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Coronary artery bypass grafting (CABG) can be accomplished with a very low mortality rate (1 3%) in otherwise healthy patients with preserved cardiac function However, the mortality rate of this procedure rises to 4 8% in older individuals and in patients who have had a prior CABG Increasingly, younger individuals with focal lesions of one or several vessels are undergoing coronary angioplasty as the initial revascularization procedure Grafts using one or both internal mammary arteries (usually to the left anterior descending artery or its branches) provide the best long-term results in terms of patency and flow Segments of the saphenous vein (or, less optimally, other veins) or the radial artery interposed between the aorta and the coronary arteries distal to the obstructions are also used One to five distal anastomoses are commonly performed After successful surgery, symptoms generally abate The need for antianginal medications diminishes, and LV function may improve Minimally invasive surgical techniques utilize different approaches to the heart than standard sternotomy and
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should have CK-MB and troponin measured after the procedure, and a new rise of greater than five times the upper limit of normal constitutes a significant periprocedural myocardial infarction Acute thrombosis after stent placement can largely be prevented by aggressive antithrombotic therapy (long-term aspirin plus clopidogrel for between 30 days and 1 year, and with acute use of platelet glycoprotein IIb/IIIa inhibitors) A major limitation with PCI has been restenosis, which occurs in the first 6 months in less than 10% of vessels treated with drug-eluting stents, 15 30% of vessels treated with bare metal stents, and 30 40% of vessels without stenting Factors associated with higher restenosis rates include diabetes, small luminal diameter, longer and more complex lesions, and lesions at coronary ostia or in the left anterior descending coronary artery Drug-eluting stents that elute antiproliferative agents such as sirolimus or paclitaxel have substantially reduced restenosis However, because prevention of tissue proliferation around the stent may leave exposed stent and predispose to thrombosis, drug-eluting stents are associated with a small but poorly defined incidence of late stent thrombosis, an event associated with high mortality Full stent deployment as well as use of clopidogrel are important to minimize risk of late stent thrombosis An advisory of cardiovascular professional societies has recommended 12 months of dual antiplatelet therapy after placement of a drug-eluting stent and educating patients about hazards of premature discontinuation Elective surgery should be postponed for 1 year, and if surgery cannot be delayed, consider the continuation of aspirin during the perioperative period in high-risk patients with drug-eluting stents In-stent restenosis is often treated with either brachytherapy or restenting with drug-eluting stents The nearly 2 million PCIs performed worldwide per year far exceeds the number of CABG operations, but the justification for many of the procedures performed in patients with stable angina is unclear The COURAGE trial has confirmed earlier studies in showing that even for patients with moderate anginal symptoms and positive stress tests, PCI provides no benefit over medical therapy with respect to death or with respect to death or myocardial infarction PCI was more effective at relieving angina, although most patients in the medical group had improvement in symptoms Thus, in patients with mild or moderate stable symptoms, aggressive lipid-lowering and antianginal therapy may be a preferable initial strategy, reserving PCI for patients with significant and refractory symptoms Several studies of PTCA versus CABG in patients with multivessel disease have been reported The consistent finding has been comparable mortality and infarction rates over follow-up periods of 1 3 years but a high rate (approximately 40%) of repeat procedures following PTCA As a result, the choice of revascularization procedure is often a matter of patient preference However, it should be noted that less than 20% of patients with multivessel disease met the entry criteria, so these results cannot be generalized to all multivessel disease patients Outcomes with percutaneous revascularization in diabetics have been inferior to those with CABG However, these trials preceded the widespread use of stenting
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cardiopulmonary bypass The surgical approach may involve a limited sternotomy, lateral thoracotomy (MIDCAB), or thoracoscopy (port-access) These approaches may be used in conjunction with standard cardiopulmonary bypass, with peripheral cardiopulmonary bypass, or with operating on the beating heart utilizing a mechanical coronary stabilizer Avoiding bypass may decrease the risk of cerebral complications These techniques allow earlier postoperative mobilization and discharge They are more technically demanding, usually not suitable for more than two grafts, and do not have established durability The operative mortality rate is increased in patients with poor LV function (LV EF < 35%) or those requiring additional procedures (valve replacement or ventricular aneurysmectomy) Patients over 70 years of age, patients undergoing repeat procedures, or those with important noncardiac disease (especially renal insufficiency and diabetes) or poor general health also have higher operative mortality and morbidity rates, and full recovery is slow Thus, CABG should be reserved for more severely symptomatic patients in this group Early (1 6 months) graft patency rates average 85 90% (higher for internal mammary grafts), and subsequent graft closure rates are about 4% annually Early graft failure is common in vessels with poor distal flow, while late closure is more frequent in patients who continue smoking and those with untreated hyperlipidemia Antiplatelet therapy with aspirin improves graft patency rates Smoking cessation and vigorous treatment of blood lipid abnormalities are necessary, with a goal for LDL cholesterol of 70 100 mg/dL and of HDL cholesterol 45 mg/dL Repeat revascularization (see below) is often necessitated by progressive native vessel disease and graft occlusions Reoperation is technically demanding and less often fully successful than the initial operation
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