Coronary artery bypass surgery post-operative care and complications
Coronary Artery Bypass Surgery Microchapters
Coronary artery bypass surgery post-operative care and complications On the Web
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. 
- 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:
- 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
- Infection at incision sites or sepsis. Women, obese patients, and diabetic patients are at greater risk of this complication.
- Deep vein thrombosis (DVT)
- Anesthetic complications such as malignant hyperthermia.
- Keloid scarring
- Chronic pain at incision sites
- Chronic stress related illnesses
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)
|"1. Cognitive behavior therapy or collaborative care for patients with clinical depression after CABG can be beneficial to reduce objective measures of depression. (Level of Evidence: B)"|
Cardiac Rehabilitation (DO NOT EDIT)
|"1. Cardiac rehabilitation is recommended for all eligible patients after CABG. (Level of Evidence: A)"|
Recommendations for duration of DAPT in patients undergoing CABG
|"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)"|
|"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)
|"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. (Level of Evidence: A)"|
|"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)"|
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