Coronary artery bypass surgery post-operative care and complications

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Overview

Pathophysiology

Saphenous Vein Graft Disease
Other Non-Atherosclerotic Saphenous Vein Graft Diseases

Indications for CABG

Prognosis

Diagnosis

Imaging in the Patient Undergoing CABG

Chest X Ray

Angiography

CT Angiography
MRI Angiography

Trans-Esophageal Echocardiography

Treatment

Goals of Treatment

Perioperative Management

Perioperative Monitoring

Electrocardiographic Monitoring
Pulmonary Artery Catheterization
Central Nervous System Monitoring

Surgical Procedure

Anesthetic Considerations
Intervention in left main coronary artery disease
The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)
Minimally Invasive CABG
Hybrid coronary revascularization
Conduits Used for Bypass
Videos on Spahenous Vein Graft Harvesting
Videos on Coronary Artery Bypass Surgery

Post-Operative Care and Complications

Recommendation for Duration of DAPT in Patients With ACS Treated With CABG

Special Scenarios

Anomalous Coronary Arteries
COPD/Respiratory Insufficiency
Existing Renal Disease
Concomitant Valvular Disease
Previous Cardiac Surgery
Menopause
Carotid Disease evaluation before surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Mohammed A. Sbeih, M.D. [3]

Post-Operative Complications

Patients undergoing coronary artery bypass grafting are at risk for the same complications as any surgery. There are also additional risks associated specifically with CABG.

CABG Associated Complications

  • Postperfusion syndrome (also known as "pumphead"), is a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research demonstrates that the incidence is initially decreased by Off-pump coronary artery bypass, but no difference in neurocognitive function was observed beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). The neurocognitive decline has also been attributed to the administration of general anesthesia as part of the procedure.
  • Nonunion of the sternum; internal thoracic artery (LIMA) harvesting devascularizes the sternum and may increase the risk.
  • Myocardial infarction due to hypoperfusion, reperfusion injury, early graft occlusion due to thrombosis or technical failures at the anastomotic site, or graft failure. In the PREVENT IV study, perioperative MI was defined as a creatinine kinase-MB increase > or = 10 X the upper limit of normal or a > or = 5 X the upper limit of normal with the development of new 30-ms Q waves within 24 hours of surgery. Perioperative MI was observed in 9.8% of patients. Perioperative MI was associated with 1) longer surgery (250 vs 230 minutes; p <0.001), higher rates of on-pump surgery as compared with minimally invasive surgery (83% vs 78%; p = 0.048), and worse quality of target vessels (p <0.001). Perioperative MI was associated with more frequent angiography within 30 days of the procedure (1.7% vs 0.6%; p = 0.021) as well as higher rates of SVG failure at one year (62.4% vs 43.8%, p <0.001). Perioperative MI was associated with an increased risk of death, MI, or revascularization at two years(19.4% vs 15.2%; p = 0.039, multivariate hazard ratio 1.33, 95% confidence interval 1.00 to 1.76, p = 0.046) adjusting for differences in significant predictors. [1]
  • Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis and excessive intimal hyperplasia causing recurrent angina or myocardial infarction.
  • Acute renal failure due to hypoperfusion, embolization of debris from the aorta, and reperfusion injury. The incidence is approximately 3.6%. The mortality is approximately 20%. The length of hospitalization is prolonged from 4 days to 20 days in patients with post-operative renal failure.
  • Stroke, secondary to aortic manipulation or hypoperfusion and reperfusion injury.
  • Delirium may occur the postoperative period in 46% of patients:[2]
    • Patients without postoperative delirium: cognition may take one yeaer to return to normal. At 6 months, 40% returned to their original cognition
    • Patients with postoperative delirium: cognition returns to normal after one month. At 6 months, 24% returned to their original cognition
  • Shunting due to SVG anastomosis into the great cardiac vein

General Surgical Complications

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[3]

Emotional Dysfunction and Psychosocial Considerations (DO NOT EDIT)[3]

Class IIa
"1. Cognitive behavior therapy or collaborative care for patients with clinical depression after CABG can be beneficial to reduce objective measures of depression.[4][5][6][7][8] (Level of Evidence: B)"

Cardiac Rehabilitation (DO NOT EDIT)[3]

Class I
"1. Cardiac rehabilitation is recommended for all eligible patients after CABG.[9][10][11][12][13][14][15] (Level of Evidence: A)"

Recommendations for duration of DAPT in patients undergoing CABG

Class I
"1. In patients treated with DAPT after coronary stent implantation who subsequently undergo CABG, P2Y12 inhibitor therapy should be resumed postoperatively so that DAPT continues until the recommended duration of therapy is completed.(Level of Evidence: C-EO)"
"2. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS(Level of Evidence: C-LD)"
"3. In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)"
Class IIb
"1. In patients with SIHD, DAPT (with clopidogrel initiated early postoperatively) for 12 months after CABG may be reasonable to improve vein graft patency (Level of Evidence: B-NR)"

Postoperative Antiplatelet Therapy (DO NOT EDIT)[3]

Class I
"1. If aspirin (100 mg to 325 mg daily) was not initiated preoperatively, it should be initiated within 6 hours postoperatively and then continued indefinitely to reduce the occurrence of saphenous vein graft closure and adverse cardiovascular events.[16][17][18] (Level of Evidence: A)"
Class IIa
"1. For patients undergoing CABG, clopidogrel 75 mg daily is a reasonable alternative in patients who are intolerant of or allergic to aspirin. (Level of Evidence: C)"

References

  1. Yau JM, Alexander JH, Hafley G, Mahaffey KW, Mack MJ, Kouchoukos N, Goyal A, Peterson ED, Gibson CM, Califf RM, Harrington RA, Ferguson TB (2008). "Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV)". The American Journal of Cardiology. 102 (5): 546–51. doi:10.1016/j.amjcard.2008.04.069. PMID 18721510. Retrieved 2010-07-14. Unknown parameter |month= ignored (help)
  2. Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK; et al. (2012). "Cognitive trajectories after postoperative delirium". N Engl J Med. 367 (1): 30–9. doi:10.1056/NEJMoa1112923. PMID 22762316.
  3. 3.0 3.1 3.2 3.3 Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "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". Circulation. 124 (23): e652–735. doi:10.1161/CIR.0b013e31823c074e. PMID 22064599.
  4. Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB; et al. (2003). "Depression as a risk factor for mortality after coronary artery bypass surgery". Lancet. 362 (9384): 604–9. doi:10.1016/S0140-6736(03)14190-6. PMID 12944059.
  5. Connerney I, Shapiro PA, McLaughlin JS, Bagiella E, Sloan RP (2001). "Relation between depression after coronary artery bypass surgery and 12-month outcome: a prospective study". Lancet. 358 (9295): 1766–71. doi:10.1016/S0140-6736(01)06803-9. PMID 11734233.
  6. Freedland KE, Skala JA, Carney RM, Rubin EH, Lustman PJ, Dávila-Román VG; et al. (2009). "Treatment of depression after coronary artery bypass surgery: a randomized controlled trial". Arch Gen Psychiatry. 66 (4): 387–96. doi:10.1001/archgenpsychiatry.2009.7. PMID 19349308.
  7. Rollman BL, Belnap BH, LeMenager MS, Mazumdar S, Houck PR, Counihan PJ; et al. (2009). "Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial". JAMA. 302 (19): 2095–103. doi:10.1001/jama.2009.1670. PMC 3010227. PMID 19918088. Review in: Evid Based Nurs. 2010 Apr;13(2):37 Review in: Evid Based Med. 2010 Apr;15(2):57-8
  8. Rollman BL, Belnap BH, LeMenager MS, Mazumdar S, Schulberg HC, Reynolds CF (2009). "The Bypassing the Blues treatment protocol: stepped collaborative care for treating post-CABG depression". Psychosom Med. 71 (2): 217–30. doi:10.1097/PSY.0b013e3181970c1c. PMID 19188529.
  9. Engblom E, Korpilahti K, Hämäläinen H, Rönnemaa T, Puukka P (1997). "Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation". J Cardiopulm Rehabil. 17 (1): 29–36. PMID 9041068.
  10. Hansen D, Dendale P, Leenders M, Berger J, Raskin A, Vaes J; et al. (2009). "Reduction of cardiovascular event rate: different effects of cardiac rehabilitation in CABG and PCI patients". Acta Cardiol. 64 (5): 639–44. PMID 20058510.
  11. Milani RV, Lavie CJ (1998). "The effects of body composition changes to observed improvements in cardiopulmonary parameters after exercise training with cardiac rehabilitation". Chest. 113 (3): 599–601. PMID 9515831.
  12. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K; et al. (2004). "Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials". Am J Med. 116 (10): 682–92. doi:10.1016/j.amjmed.2004.01.009. PMID 15121495. Review in: ACP J Club. 2004 Nov-Dec;141(3):62
  13. Clark AM, Hartling L, Vandermeer B, McAlister FA (2005). "Meta-analysis: secondary prevention programs for patients with coronary artery disease". Ann Intern Med. 143 (9): 659–72. PMID 16263889. Review in: Evid Based Med. 2006 Jun;11(3):87 Review in: Evid Based Nurs. 2006 Jul;9(3):77
  14. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J; et al. (2007). "AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services". Circulation. 116 (14): 1611–42. doi:10.1161/CIRCULATIONAHA.107.185734. PMID 17885210.
  15. Walther C, Möbius-Winkler S, Linke A, Bruegel M, Thiery J, Schuler G; et al. (2008). "Regular exercise training compared with percutaneous intervention leads to a reduction of inflammatory markers and cardiovascular events in patients with coronary artery disease". Eur J Cardiovasc Prev Rehabil. 15 (1): 107–12. doi:10.1097/HJR.0b013e3282f29aa6. PMID 18277195.
  16. Mangano DT (2002). "Aspirin and mortality from coronary bypass surgery". The New England Journal of Medicine. 347 (17): 1309–17. doi:10.1056/NEJMoa020798. PMID 12397188. Retrieved 2011-12-14. Unknown parameter |month= ignored (help)
  17. Sethi GK, Copeland JG, Goldman S, Moritz T, Zadina K, Henderson WG (1990). "Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. Department of Veterans Affairs Cooperative Study on Antiplatelet Therapy". Journal of the American College of Cardiology. 15 (1): 15–20. PMID 2404046. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  18. "Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients". BMJ (Clinical Research Ed.). 324 (7329): 71–86. 2002. PMC 64503. PMID 11786451. Retrieved 2011-12-14. Unknown parameter |month= ignored (help)



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