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SECTION 3 General outcomes of coronary artery bypass graft surgery148
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from the ascending aorta. One important potential benet of
OPCAB is the ability to minimize or eliminate aortic manipulation. Unfortunately, the large majority of OPCAB cases in the three
largest RCTs to date (ROOBY, CORONARY, and GOPCABE),
were performed with multiple saphenous vein gras sutured to
the ascending aorta using a side- biting clamp, typically placed
on the pulsatile aorta without intraoperative epiaortic ultrasound
screening to detect and avoid aortic atherosclerosis. is extent of
aortic manipulation is similar to cannulation for bypass and crossclamping for cardioplegic arrest, and has been associated with risk
of perioperative stroke and death. In retrospect, it is perhaps not
surprising that none of these large RCTs have shown a statistically signicant reduction in perioperative stroke. Moreover, in the
largest RCT (CORONARY), 102 patients randomized to ONCAB
were converted to OPCAB during surgery when calcication of the
ascending aorta was identied intraoperatively; this likely blunted
the impact of OPCAB on neurological outcomes in the primary
intention- to- treat analysis of that important trial. In addition,
given that the overall incidence of perioperative stroke is quite
low, individual RCTs have been insuciently powered to show a
dierence. When Kowalewski and colleagues performed a metaanalysis of 100 RCTs including 19,192 patients, they found that
OPCAB was associated with a signicantly reduced incidence of
stroke (odds ratio 0.72, 95% condence interval (CI) 0.56– 0.92;
P =0.009). ese studies included OPCAB performed using a
side- biting clamp and other techniques including lesser degrees of
aortic manipulation. ere is strong evidence to suggest that further limiting aortic manipulation, such as with the use of clampless
facilitating anastomosis devices and ‘no- touch’ aortic techniques,
can reduce the risk of perioperative stroke even further. Zhao
and colleagues performed a network meta- analysis of 13 studies
including 37,720 patients and compared risk- adjusted incidence of
stroke with varying degrees of aortic manipulation during CABG.
Ano- aortic- touch OPCAB technique was associated with a 78%
reduction in risk of perioperative stroke compared to conventional
CABG on cardiopulmonary bypass.
It has been suggested that OPCAB utilizing a side- biting clamp
could be characterized as ‘OPCAB 1.0’. Use of a clampless facilitating device such as the Heartstring® to sew anastomoses to the
ascending aorta without clamping might be considered ‘OPCAB
2.0’. Ano- aortic- touch technique, in which bilateral internal thoracic arteries provide inow for multiple all- arterial coronary bypass gras may be described as ‘OPCAB 3.0’ and is perhaps the
present gold standard for surgical coronary revascularization.
A large single- centre series reported that comprehensive routine adoption of OPCAB 3.0 techniques led to a decrease in early
postoperative stroke from 0.83% to 0.09% among 4485 consecutive patients in a large cardiac surgical department. Similarly, a
meta- analysis of 13 studies and 37,720 patients reported a signicant reduction in the risk of perioperative stroke with anaortic
Completeness ofrevascularization and
graftpatency
Completeness of revascularization has been considered critical for
the success and durable benet of coronary artery bypass surgery
since its inception. Evidence from some smaller randomized trials
suggests equivalent revascularization can be achieved with OPCAB
compared to ONCAB techniques. However, some larger RCTs, as
well as meta- analyses of randomized trials, have shown a slightly
lower number of gras per patient in OPCAB versus ONCAB; this
mean dierence has typically been 0.1– 0.3 gras fewer per patient
in the OPCAB group., Incomplete revascularization has oen
been attributed to surgeon inexperience; however, even in trials
with more rigorous criteria for surgeon experience, patients who
underwent OPCAB tended to leave the operating room with slightly
fewer gras. Interestingly, this has not translated into a higher risk
of perioperative myocardial infarction, but has been associated with
poorer long- term outcomes in some RCTs, including the ROOBY
trial. e 5- year outcomes of the GOPCABE trial showed a strong
statistical signal that incomplete revascularization was associated
with diminished survival, irrespective of whether revascularization
was performed on- pump or o- pump.
Gra patency has been evaluated in several randomized trials. In
the rst RCT to assess gra patency by angiography prior to hospital
discharge and at 1- year follow- up, Puskas and colleagues in a singlecentre RCT demonstrated no dierence in patency rates at discharge
and at 1year. However, the multi- institutional Danish On- pump
versus O- pump Randomization Study (DOORS) and ROOBY
study suggested that OPCAB may be associated with slightly increased need for reintervention at 1year, while the CORONARY,
and GOPCABE trials, showed no dierence in revascularization
at 1year or 5years.
Routine use of intraoperative transit time Doppler ow measurements to assess gra patency is recommended by the updated 2018
European Society of Cardiology/ European Association for Cardiooracic Surgery Guidelines for myocardial revascularization.
is is a classIIa, level of evidence B recommendation for both
OPCAB and ONCAB cases and is likely to be a useful adjunct to
improve gra patency, since it identies approximately 2– 4% of
gras that need revision., Moreover, dual antiplatelet medical
therapy (DAPT) aer CABG has been shown to improve gra patency, especially among vein gras, reducing early mortality aer
CABG, especially among OPCAB patients. In OPCAB, the administration of DAPT may mimic the benecial eects of cardiopulmonary bypass- induced coagulopathy on gra patency and
should be routine early aer OPCAB when bleeding risk is acceptable. Regrettably, DAPT was not commonly used in the three largest RCTs of OPCAB, each of which has now passed 5years of
follow- up.
OPCAB compared to either ONCAB or OPCAB with aortic
clamping. In fact, the 2018 European Guidelines on myocardial
revascularization include a classIrecommendation for anaortic
High- risk patients benefit most fromOPCAB
OPCAB. However, OPCAB 3.0 (anaortic, all- arterial OPCAB)
is a technically demanding procedure that is only slowly being
embraced as a routine practice by genuine coronary surgical
specialists.
e perioperative risk prole of patients referred for bypass surgery
has changed signicantly over the last two decades. Patients are
older, with more comorbidities and more extensive atherosclerotic
Observed mortality rate
0.20
0.20
OPCAB
Predicted mortality or major morbidity rate
https://t.me/medicina_free
17 Evidence base foroff-pump coronary artery bypassgrafting 149
0.5
0.15
0.10
0.05
0.00
0.00
Fig.17.1 OPCAB disproportionately benefits high- risk patients.
Among 14,766 patients at a single centre (7083 OPCAB; 48%) and 7683
ONCAB (52%), patients with low STS predicted risk of mortality had
similar observed mortality risk after OPCAB or ONCAB. For patients
with predicted risk of mortality in excess of 2.5%, OPCAB was associated
with reduced observed 30- day mortality compared to ONCAB. This
benefit of OPCAB increased with increasing STS predicted risk. CPB,
cardiopulmonary bypass.
Reproduced from Puskas, JD, Thourani, VH, Kilgo, P, Cooper, W, Vassiliades, T, Vega, JD,
Morris, C, Chen, E, Schmotzer, BJ, Guyton, RA & Lattouf, OM 2009. Off- pump coronary
artery bypass disproportionately benefits high- risk patients. Ann Thorac Surg, 88, 1142–
1147 with permission from Elsevier.
disease. e rationale for OPCAB is that avoiding cardiopulmonary
bypass may reduce the risk of perioperative complications, especially in frail patients with multiple comorbidities. Among 14,766
patients at a single centre (7083 OPCAB and 7683 ONCAB), patients with low STS predicted risk of mortality had similar observed
mortality between operative groups. But for patients with predicted
risk of mortality in excess of 2.5%, OPCAB was associated with
signicantly reduced 30- day mortality compared to ONCAB. is
benet of OPCAB increased with increasing STS predicted risk
(Fig. 17.1). e relationship between STS predicted risk of mortality and the relative mortality benet of OPCAB over ONCAB was
conrmed among 876,081 patients in the STS National Database
(Fig. 17.2). ese ndings were again reconrmed by a recent
meta- analysis of 100 randomized controlled studies including
19,192 patients; these authors found signicantly reduced all- cause
mortality and cerebrovascular events aer OPCAB among higherrisk patients.
Randomizing high- risk patients had been dicult. e Best Bypass
Surgery trial randomized 341 patients with a mean EuroSCORE of
6.9 (predicted risk of 30- day mortality 3%) to have o- pump versus
on- pump surgery and reported mortality of 3.4% for OPCAB versus
6.7% for ONCAB, myocardial infarction 5.1% for OPCAB versus
9.2% for ONCAB, and incidence of the primary composite outcome
15% for OPCAB versus 17% for ONCAB (P=not signicant for all
comparisons).
0.05
STS predicted risk of mortality
0.10 0.15
CABG on CPB
0.4
0.3
0.2
0.1
0.0
0.00
0.06
0.03 0.10 0.15 0.20
STS predicted risk of mortality
CABG on CPB
OPCAB
Fig.17.2 Outcomes of OPCAB versus ONCAB:impact of preoperative
risk. The relationship between STS predicted risk of mortality and the
relative mortality benefit of OPCAB over ONCAB was confirmed among
876,081 patients in the STS national database.
Reproduced from Polomsky, M, He, X, O’Brien, SM & Puskas, JD 2013. Outcomes of
off- pump versus on- pump coronary artery bypass grafting:Impact of preoperative risk.
J Thorac Cardiovasc Surg, 145, 1193– 1198 with permission from Elsevier.
Transfusion rate, respiratory complications,
acute kidney injury, and perioperative low
cardiac outputsyndrome
Bloodtransfusion
e need for perioperative transfusion of blood products has been
linked to increased rates of various complications, particularly infection. Results with OPCAB have consistently shown a decrease in the
rate of perioperative transfusion compared to ONCAB, in both randomized trials and retrospective registry studies. e CORONARY
trial, for example, found a transfusion rate of 50.7% versus 63.3%
in favour of OPCAB (relative risk (RR) 0.61, 95% CI 0.40– 0.93; P
<0.001). Deppe and colleagues’ meta- analysis of 51 RCTs conrmed
this on a larger scale, with a transfusion rate of 40.4% with OPCAB
and 50.8% with ONCAB (P <0.0001).
Renaldysfunction
Like perioperative transfusion, postoperative renal dysfunction is
associated with poorer outcomes. Deppe etal.’s meta- analysis found
a signicantly decreased incidence of perioperative acute kidney
injury in patients who were operated using an o- pump approach
(11.0% vs 13.1%; P <0.0003). However, there was no dierence in
the need for renal replacement therapy, which was quite low across
both groups (1.3% vs 1.7%; P=0.0945).
Low cardiac outputsyndrome
e literature suggests that patients who have CABG surgery performed without cardiopulmonary bypass and cardioplegic arrest
SECTION 3 General outcomes of coronary artery bypass graft surgery150
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have a lower incidence of perioperative low cardiac output syndrome, with an incidence of 4.9% versus 8.8% in a meta- analysis of
published RCTs (P=0.0003).
e CORONARY tria l, the largest RCT of OPCAB versus ONCAB,
showed a relative risk reduction for OPCAB versus ONCAB with respect to reoperation for bleeding (1.4% vs 2.4%; RR 0.61, 95% CI
0.40– 0.93; P=0.02), acute kidney injury (28.0% vs 32.1%; RR 0.87,
95% CI 0.80– 0.96; P=0.01) and respiratory complications (5.9% vs
7.5%; RR 0.79, 95% CI 0.63– 0.98; P=0.03). ese benets were also
conrmed in multiple large- scale retrospective analyses of the STS
Adult Cardiac Database.,,
OPCAB forredoCABG
Small single- surgeon series, and a meta- analysis of 3471 patients have reported superior outcomes with OPCAB in the setting
of repeat surgical coronary revascularization, including reduced
risk of myocardial infarction, stroke, renal dysfunction, low cardiac output syndrome, and respiratory failure. Of course, many redo
CABG cases are very dicult to perform without cardiopulmonary
bypass and it may be dicult to adjust for selection bias in these
comparisons.
follow- up, there remained no dierence in mortality (HR 1.08, 95%
CI 0.93– 1.26; P=0.3), myocardial infarction (HR 0.92, 95% CI 0.75–
1.13; P=0.41), stroke (HR 0.83, 95% CI 0.58– 1.19; P=0.32), new dia-
lysis (HR 0.89, 95% CI 0.58– 1.37; P=0.60), repeat revascularization
(HR 1.21, 95% CI 0.85– 1.73; P =0.29) or the composite primary
endpoint of death, stroke, myocardial infarction, renal failure, or
repeat revascularization (HR 0.98, 95% CI 0.87– 1.10; P= 0.72).
Similarly, the GOPCABE trial enrolled 2539 patients at 12 centres in
Germany, most of whom were over 75years of age and randomized
them to OPCAB versus ONCAB by surgeons who had an average
experience of more than 500 OPCAB and more than 1300 ONCAB
cases. GOPCABE reported a 1- year OPCAB mortality HR of 0.93
(95% CI 0.76– 1.16) compared to ONCAB. At 5years of followup, all- cause mortality aer OPCAB versus ONCAB was virtually
identical (HR 1.03, 95% CI 0.89– 1.19; P = 0.71), as was the incidence of the composite primary endpoint of death, myocardial infarction, and repeat revascularization (HR 1.03, 95% CI 0.89– 1.18;
P = 0.70). Importantly, incomplete revascularization occurred in
34% of OPCAB patients and 29% of ONCAB patients (P <0.001).
Incomplete revascularization was associated with a lower 5- year
survival, irrespective of the type of surgery (HR 1.19, 95% CI 1.01–
1.39; P=0.04).
Longer- term outcomes ofOPCAB versusONCAB
In addition, a post- hoc analysis of the Arterial Revascularisation
Trial (ART) compared risk- adjusted 5- year outcomes with OPCAB
versus ONCAB and found no dierence in death or major adverse
e ROOBY trial, which randomly assigned 2203 patients to either
OPCAB or ONCAB in the Veteran’s Administration hospital system
in the United States, published 5- year mortality data in favour of
ONCAB. Mortality at 5years was 15.2% in the OPCAB group,
compared to 11.9% in patients who underwent on- pump surgery
(P=0.02). e investigators also found an increase in major adverse
cardiovascular events (31.0% vs 27.1%; P=0.046) and repeat CABG
at 5years (1.4% vs 0.5%; P= 0.02) in the OPCAB group. ese results
have been heavily criticized because of strikingly asymmetric surgeon experience with OPCAB and ONCAB (only 20 prior OPCAB
cases were required of surgeons to participate in ROOBY) and the
fact that 60% of operations were performed by trainees supervised
by these surgeons who were themselves relatively inexperienced in
cardiac and cerebrovascular events; at 10years of follow- up these
results were unchanged.
e importance of surgeon and institutional experience in performing optimal OPCAB surgery was emphasized by a recent comparison of outcomes for OPCAB versus ONCAB in low- volume
and high- volume centres and by low- volume and high- volume surgeons. is study of the United States National Inpatient Sample
analysed more than 2million CABG cases and found that among
surgeons performing more than 48 OPCAB case annually and in
centres performing more than 164 OPCAB cases annually, there was
a striking mortality benet for OPCAB. is benet was not found
for patients operated by less experienced surgeons or in less experienced centres.
OPCAB. As a result, there was a 12% rate of intraoperative conversion from OPCAB to ONCAB in ROOBY, more than three times the
conversion rate reported in the contemporary STS database. ese
Summary andconclusions
conversions are felt by critics to have signicantly diminished outcomes for OPCAB patients in the intention- to- treat analysis, since
intraoperative conversion is known to result in higher rates of adverse events, including mortality, than either an OPCAB or ONCAB
approach without the need for conversion. e ROOBY trial fuelled
debate over the safety of OPCAB, particularly in the low- risk patient population in which it was conducted, and focused attention
on the technical challenge of accomplishing precise and complete
surgical coronary revascularization o- pump. ROOBY raised the
question of which surgeons should perform OPCAB and which patients should have o- pump CABG.
In contrast to the ROOBY trial, outcomes of the larger
CORONARY trial, which enrolled 4752 patients from 19 countries operated by surgeons who had each performed more than 100
OPCAB cases, showed no dierence in any primary or secondary
outcomes; the 1- year OPCAB mortality had a hazard ratio (HR) of
0.91 (95% CI 0.077– 1.07) compared to ONCAB. Aer 5years of
OPCAB is a technically demanding procedure and the expertise
of the surgical and anaesthetic team is vital to optimize outcomes.
Large propensity- matched observational registries have consistently reported that OPCAB is associated with reduced 30- day
mortality, stroke, and overall major morbidity, especially when
patient comorbidities render preoperative predicted risk of mortality greater than 2.5%. However, among low- or very low- risk patients, there is likely no demonstrable mortality benet of OPCAB
over ONCAB.
Among the three largest RCTs, one (ROOBY) reported inferior
1- year and 5- year outcomes with OPCAB, while CORONARY and
GOPCABE reported similar outcomes with OPCAB and ONCAB at
30days, 1year, and 5years. ere is strong evidence from network
meta- analyses that OPCAB performed with a no- aortic- touch technique reduces incidence of mortality, stroke, myocardial infarction,
renal failure, bleeding, and atrial brillation (Fig. 17.3). However,
17 Evidence base foroff-pump coronary artery bypassgrafting 151
(a) Stroke
(c) Myocardial infarction
(b) Mortality
(e) Bleeding
https://t.me/medicina_free
anOPCABG
0.48
(0.27–0.86)
0.34
(0.22–0.52)
0.22
(0.14–0.33)
OPCABG-HS
0.97
(0.50–1.91)
0.82
(0.45–1.50)
0.71
(0.40–1.27)
anOPCABG
0.78
(0.52–1.13)
0.64
(0.45–0.95)
0.52
(0.31–0.87)
OPCABG-HS
0.71
(0.44–1.11)
0.45
(0.28–0.69)
anOPCABG
0.84
(0.51–1.37)
0.73
(0.44–1.18)
OPCABG-PC
0.82
(0.60–1.10)
0.67
(0.44–1.04)
OPCABG-PC
0.64
(0.48–0.83)
OPCABG-PC
0.86
(0.57–1.32)
CABG
0.82
(0.52–1.30)
CABG
CABG
OPCABG-HS
anOPCABG
0.80
(0.55–1.13)
0.60
(0.38–0.94)
0.50
(0.35–0.70)
(d) Renal failure
anOPCABG
0.79
(0.53–1.13)
0.64
(0.39–1.05)
0.47
(0.31–0.68)
(f) Atrial fibrillation
anOPCABG
0.80
(0.68–0.97)
0.71
(0.55–0.87)
0.66
(0.49–0.89)
OPCABG-PC
0.75
(0.50–1.12)
0.63
(0.48–0.81)
OPCABG-PC
0.75
(0.52–1.28)
0.59
(0.41–0.84)
OPCABG-PC
0.88
(0.69–1.06)
0.82
(0.60–1.09)
OPCABG-HS
0.84
(0.57–1.22)
OPCABG-HS
0.73
(0.45–1.14)
CABG
0.94
(0.70–1.29)
CABG
CABG
OPCABG-HS
Fig.17.3 League tables for CABG with and without manipulation of the ascending aorta. This figure shows results of a network meta- analysis of 13
studies, including 37,720 patients operated with four techniques:on- pump CABG, OPCABG- PC (off- pump CABG with partial aortic clamping for
proximal anastomoses), OPCABG- HS (off- pump CABG with clampless proximal anastomoses on the ascending aorta with Heartstring® facilitating
device), and anOPCABG (off- pump CABG with no- aortic- touch technique). Odds ratios for each adverse event may be compared between any pair of
alternative surgical techniques by reading the box at the intersection of the vertical column and horizontal row corresponding to the two techniques
being compared. No- aortic- touch off- pump CABG showed highly significant advantages over other techniques for mortality, stroke, renal failure,
bleeding, and atrial fibrillation.
Zhao, DF, Edelman, JJ, Seco, M, Bannon, PG, Wilson, MK, Byrom, MJ, Thourani, V, Lamy, A, Taggart, DP, Puskas, JD & Vallely, MP 2017. Coronary Artery Bypass Grafting With and
Without Manipulation of the Ascending Aorta:A Network Meta- Analysis. J Am Coll Cardiol, 69, 924– 936.
it is also clear that gra patency can be poorer with OPCAB, especially with vein gra conduits among less expert surgeons. Formal
training, mentoring, and expert team building should be routine to
develop the technical and mental skill set necessary to accomplish
reproducibly precise OPCAB surgery. DAPT should also be used
routine early aer OPCAB in the absence of contraindications.
Aer 30 years and more than 100 RCTs, what can be condently said about the OPCAB controversy? First, both OPCAB
and ONCAB procedures have excellent short- term outcomes with
low mortality when performed by experienced surgeons. Second,
in experienced hands both techniques assure similar mid- term
survival. Retrospective studies have shown that avoidance of cardiopulmonary bypass and aortic manipulation reduces the risk of
stroke and operative mortality in high- risk patients. As the population of the developed world ages and the prevalence of diabetes
and coronary artery disease continues to increase, surgical coronary
revascularization will remain a vital and common therapy. It is critically important that we continuously rene our techniques for surgical coronary revascularization, both on- pump and o- pump, to
better serve these patients with complex comorbidities.
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24. Polomsky M, He X, O’brien SM, Puskas JD. Outcomes
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25. Møller CH, Perko MJ, Lund JT, Andersen LW, Kelbaek H,
Madsen JK, etal. No major dierences in 30- day outcomes
in high- risk patients randomized to o- pump versus onpump coronary bypass surgery:the best bypass surgery trial.
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Vassiliades TA, etal. Outcomes aer o- pump reoperative
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27. Bruno VD, Zakkar M, Rapetto F, Rathore A, Marsico R,
Chivasso P, etal. Early health outcome and 10- year survival
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SECTION 4
Pre- , intra- , and postoperative
management ofthe coronary
artery bypass gra patient
Section editors:John M.Murkin and Gregory Fischer
18. Preoperative assessment in coronary bypass
surgery 155
Daniel Sellers and George Djaiani
19. Anaesthetic management of on- and off- pump
coronary artery bypass grafting 161
Elvera L.Baron, Menachem M.Weiner, and David L.Reich
20. Postoperative management after coronary artery
bypass graft surgery 167
Jason Chui and John M.Murkin
21. Fast- track cardiac anaesthesia and early
extubation 175
Janet Martin and Davy Cheng
22. Management of coagulopathy 181
Zev Noah Kornfield and George Despotis
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https://t.me/medicina_free
Preoperative assessment in
coronary bypasssurgery
Daniel Sellers and George Djaiani
‘e man who planned badly, if fortune is on his side, may have a stroke of luck; but his plan
was a bad one nonetheless.’
Herodotus
Introduction
Surgical revascularization of the heart has been an integral part of
the management of coronary artery disease for more than half a century. Over this time period, mortality rates have dropped from 10%
in 1971 to 1.9% in 2009. However, patient levels of comorbidity continues to increase. According to the Society of oracic Surgeons
(STS) National Database, even between 2000 and 2009, rates of dia-
congestive cardiac failure from 7.9% to 11.9%, and le main stem
disease from 14% to 21%. More urgent procedures were performed
(38% to 54%), internal thoracic artery use slightly increased (88%
vs 95%), and o- pump coronary artery bypass graing (CABG)
increased in popularity (14% vs 21%), but otherwise there was no
major change in surgical technique. Unfortunately, the decrease
in major morbidity has not been as universal, with small absolute
drops in mortality (2.4% to 1.9%) and stroke (1.6% to 1.2%) over the
same time period, but rates of renal failure, reoperation for bleeding,
deep sternal wound infection and atrial brillation remaining unchanged. More recent data show that the prevalence of most of
these comorbidities is not reduced (diabetes 43%, le main disease
32%, urgent CABG 56%).
Some of the improvements that have been made in surgical outcomes thus far can be attributed to more preventative medicine.
In the same database study, beta- blocker, angiotensin- converting
enzyme inhibitor, and aspirin use all increased. However, use of
these medications for optimizing the medical therapy of these
patients is nearing maximum penetration in the United States
and Western Europe. In addition, since the late 1990s, delirium,
postoperative cognitive dysfunction, mild respiratory disease,
subclinical renal impairment, glucose intolerance, frailty, and anaemia have been identied as risk factors for perioperative morbidity and mortality.
In order to continue to drive improvements in outcomes in these
patients, it will be imperative to identify non- cardiac factors which
contribute to morbidity and mortality and develop perioperative
medical therapies to mitigate them.
Carotid stenosis, perioperative stroke
risk, and carotidendarterectomy
Coronary artery disease shares many of the same risk factors and
pathophysiology as cerebral and peripheral vascular disease, so it is not
surprising that half of CABG candidates have subclinical ischaemic infarcts on magnetic resonance imaging scan preoperatively, with magnetic resonance angiography demonstrating 25% with internal carotid
disease, and 41% external carotid disease, and that the relative risk of
perioperative stroke in these patients is ve times higher. However, this
does not imply a causal association, since 76% of perioperative strokes
are thought to be embolic, with only 5.3% of perioperative strokes anatomically correlated to carotid stenosis. It is likely that carotid stenosis
is a marker for other causes of perioperative stroke, for example, atherosclerotic plaque in the ascending aorta and aortic arch.
e question remains whether carotid endarterectomy pre- or
intraoperatively decreases stroke rate, and if so, what severity of
stenosis mandates carotid endarterectomy. Guidelines from the
American Heart Association (AHA), and the European Association
for Cardio- oracic Surgery are shown in Table 18.1.
Postoperative cognitive dysfunction and
delirium
Early postoperative cognitive dysfunction is most likely related to
cerebral microembolization, relative hypotension, and the overall
SECTION 4 Pre-, intra-, and postoperative management ofthe coronary artery bypass graft patient156
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Table18.1 Guidelines forcarotid screening and performance ofcarotid endarterectomy
European Association for Cardio- Thoracic Surgery (2018) American Heart Association (2011)
Consider screening patients with
Value of routine duplex Doppler screening is uncertain. Investigation should
be driven by clinical suspicion in high- risk patients
Perform endarterectomy if
Patients with recent (<6months) CVA or TIA
50– 99% carotid stenosis If >50% stenosis, reasonable to perform joint CEA- CABG
Do not consider if stenosis <50%
Not recommended in <50% stenosis in men, or <70% stenosis in women
In asymptomatic patients
Men with bilateral >70% stenosis, or >70% stenosis with contralateral
occlusion, or >70% stenosis with specific radiological finding
a
Contralateral TIA/ stroke, ipsilateral silent infarction on cerebral imaging, intraplaque haemorrhage or lipid- rich necrotic core on magnetic resonance angiography,
or any of the following ultrasound imaging findings:stenosis progression (>20%), spontaneous embolization on transcranial Doppler, impaired cerebral vascular
reserve, large plaques, echolucent plaques, or increased juxtaluminal hypoechogenic area.
CABG, coronary artery bypass grafting; CEA, carotid endarterectomy; CVA, cerebrovascular accident; TIA , transient ischaemic attack.
Reproduced from Abah, U.& Large, S., 2012. Stroke prevention in cardiac surgery. Interactive Cardiovascular and Thoracic Surgery, 15(1), pp.155– 157 with
permission from Oxford University Press.
a
Age >65years
Left mainstem disease
Severe peripheral vascular disease
TIA or CVA
Carotid bruit
History of smoking, diabetes, hypertension
If bilateral stenosis >70%, or unilateral stenosis >70% with
contralateral occlusion
inammatory response associated with cardiopulmonary bypass
and surgery.
Postoperative cognitive dysfunction occurs in a considerable
number of patients and may result in reduced quality of life following otherwise successful surgery. However, perioperative assessment of patients’ cognitive function requires a lengthy battery
of neuropsychological tests evaluating learning, memory, attention,
concentration, and psychomotor speed, as well as language and
promising results for ketamine have not been sustained in large
trials. However, meta- analyses found that dexmedetomidine was
eective for prevention of delirium in intensive care units (ICUs)
and reported that this medication reduced delirium, 30- day mortality, intubation time, ICU stay, and hospital stay in cardiac surgical
patients., In addition, a multicomponent non- pharmacological
approach including preoperative counselling is an eective measure
in reducing the incidence of delirium.
higher intellectual functioning. Furthermore, late postoperative
cognitive dysfunction is more likely related to the presence of baseline cognitive decits rather than perioperative perturbations. Our
current understanding is that late postoperative cognitive dysfunc-
Respiratory disease and risk factors
forprolongedintubation
tion is primarily associated with natural progression of cardio- and
cerebrovascular disease risk factors.
Predictors of delirium aer cardiac surgery include advanced
age, preoperative cognitive impairment, major depression, anaemia, and atrial brillation, some of which are potentially amenable to optimization in the preassessment clinic. e perioperative
causes of delirium are multifactorial including blood pressure uctuations, regional cerebral hypoxia, microembolization, handling
the aorta, drug eects, and inammatory response from surgery, as
well as drug side eects, pain, disorientation, and sleep deprivation.
e consequences of delirium are devastating. ey include a
10– 20% higher all- cause mortality for every 48 hours of delirium,
a twofold increased risk of post- discharge institutionalization
and death, up to a tenfold increased risk of longer- term dementia, accelerated functional decline, and extremely high costs to healthcare.
Patients at high risk for delirium may be candidates for targeted
pharmacological therapy in order to reduce the risk of delirium.
Dexmedetomidine and ketamine have surfaced as two potential
contenders to mitigate the risk of delirium. Unfortunately, initial
Chronic respiratory disease is a risk factor in the established risk
prediction systems, in terms of both mortality and prolonged ventilation. Prolonged ventilation is a more powerful risk factor for
ventilator- associated pneumonia, and oen also results in tracheostomy. e timing of this intervention should be planned in advance,
as performing a tracheostomy within 48 hours may be associated
with deep sternal wound infection, but mortality rates increase
steadily from postoperative day ve if tracheostomy is withheld.
e strongest interventions for preventing postoperative respiratory failure are lung- protective ventilation, avoiding unnecessary
blood product administration, and fast- track extubation protocols,
but these are already a standard of care in most institutions.
Minimally invasive surgical approaches and/ or thoracic epidural
analgesia could potentially reduce the incidence further but they
are technically challenging, and introduce their own complications;
these should be considered on a case- by- case basis.
Preoperative interventions to reduce risk of respiratory failure
are an area of potential gain. Screening for mild chronic obstructive
18 Preoperative assessment in coronary bypasssurgery 157
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pulmonary disease, which is both common in patients with coronary
artery disease and underdiagnosed in primary care, oers the opportunity to optimize medical therapy in the months preceding CABG.
Pulmonary function tests therefore remain a mainstay of assessment. Preoperative physiotherapy interventions (‘prehabilitation’)
are strongly advised before cardiac surgery, particularly in patients
normal ageing and comorbidities on physiological reserve) have
increasingly been used for risk stratication in geriatric and acute
medicine, critical care, and cardiac surgery. ese use a combination of objective clinical tests with simple performance measures (such as grip strength), which are easily reproducible in the
preassessment clinic.
at high risk of respiratory failure.
Renaldisease
Anaemia
Exposure to allogenic blood transfusion is well known to worsen
Patients presenting for CABG share risk factors for renal impairment, particularly hypertension and diabetes. Acute kidney injury
occurs frequently (5– 8%) aer cardiac surgery, and the association
between postoperative acute kidney injury and increased mortality
is well known. However, preoperative decreased glomerular ltration rate (GFR) is present in one- quarter of patients, and, once
the GFR is less than 50– 60 mL/ min, mortality rates are increased
threefold. ese patients could potentially benet from treatment
adaptions made in the preassessment clinic. Minimization of drugs
which exacerbate renal dysfunction, such as non- steroidal antiinammatories, loop diuretics, synthetic colloids, and iodinated
contrast agents is advisable. One study showed the potential benets
of perioperative administration of dexmedetomidine in mitigating
renal injury aer cardiac surgery.
outcomes after cardiac surgery, leading to increased rates of
deep sternal wound infection, renal failure, ventilator- associated
pneumonia, and even late graft failure. This has led to scrupu-
lous efforts to avoid transfusion with intraoperative cell salvage,
point- of- care coagulation testing, and restrictive transfusion
triggers, which are all now standards of care in many institutions.
However, patients with low baseline haemoglobin concentrations
are still likely to receive red cell transfusion as a result of car-
diopulmonary bypass- related haemodilution and perioperative
bleeding.
e most common cause of preoperative anaemia in patients
undergoing cardiac surgery is functional iron deciency. e
same study identied that elevated plasma hepcidin, a key protein
responsible for iron regulation, was associated with worse outcome. Intravenous iron infusions are simple, require a single dose,
Diabetes andobesity
are now free from anaphylaxis risk, and have been used in the context of chronic anaemia, chronic kidney disease, and heart failure
where they demonstrate an increase in red cell mass and func-
Severe obesity (body mass index >35 kg/ m) is a risk factor for
acute kidney injury, deep sternal wound infection, prolonged ventilation, new- onset atrial arrhythmias, and mortality. Achieving
clinically signicant and sustained weight loss in this patient group
is dicult and time- consuming; however, the benecial eects in
reducing the adverse events is striking. Possible referral for bariatric surgery should be weighed against the urgency of the required
revascularization.
Diabetes is a risk factor for deep sternal wound infection, mor-
tality, major adverse cardiac and cerebrovascular events, and stroke,
tional status. However, most studies in cardiac surgery have utilized intravenous iron in lieu of blood transfusion postoperatively,
where it is ineective in reducing red cell transfusion, due to insufcient dosing and time required for erythropoiesis.
Erythropoietin infusion between 1 and 3 weeks preoperatively
has a potent eect on reducing rates of red cell transfusion, but it is
expensive and requires several treatments over a period of weeks.
ere are several scoring systems which can predict the need for
red cell transfusion, one example of which is the Transfusion Risk
Understanding Scoring Tool (TRUST) (Table 18.2).
particularly in those who are insulin dependent, with haemoglobin A1c (HbA1c) scores greater than 7%, or newly diagnosed.
Importantly, HbA1c is also a potent preoperative biomarker for
adverse events, even in patients who are not known to be diabetic.
Given that the impact of tight perioperative glucose control is uncertain at best, this is an area where gains can best be made in the
months preceding surgery, and detection and optimization of diabetes and impaired glucose tolerance should take place in parallel
with rst surgical referral.
Frailty
Predictive risk scoring systems in cardiac surgery generally rely on
discreet clinical factors to calculate an aggregated risk of death or
morbidity based on regression analysis of large datasets. However,
this approach does not allow for an assessment of physiological
performance and reserve. As the population ages, the use of
scoring systems to assess frailty (the synergistic negative eect of
Table18.2 TRUST score forpredicting red cell transfusion
Risk factors (each adds 1
to score total score)
Hb <135 g/ L 0 <20%
Weight <77kg 1 20– 40%
Female sex 2 40– 60%
Age >65 3 60– 80%
Emergency surgery 4– 8 >80%
Creatinine >120 µmol/ L
Redo surgery
Multiple procedures
Hb, haemoglobin.
Reproduced from Alghamdi, A.A.etal., 2006. Development and validation of
Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients
according to their blood transfusion needs. Transfusion, 46(7), pp.1120– 1129 with
permission John Wiley and Sons.
Total score Transfusion risk
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