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SECTION 8 Coronary artery bypass graft surgery inspecial situations408

1.0

Survival

120

Time in months

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Off-pump versus on-pump

Although there are some data showing improved or equivalent in-hospital mortality of women who undergo o-pump CABG compared to men and to women who undergo on-pump CABG, conclusive evidence has been limited by selection bias and omission of analysis of several important risk factors that are known to inuence mortality.– Review by the 2005 STS Workforce on Evidence-Based Surgery has led to a classIIa (level of evidence B) recommendation that the indications for o-pump CABG are the same for women as they are for men. However, a 2007 intentionto-treat analysis of 42,477 consecutive CABG cases from the STS National Cardiac Database found that adjusted odds ratios for death and most major complications in both men and women were signicantly lower with o-pump CABG than with on-pump CABG. Among on-pump CABG cases only, women had a signicantly greater adjusted risk of death, prolonged ventilation and prolonged length of stay than men. In contrast, among o-pump CABG cases, women had lower risk of re-exploration than men and similar risks for death, myocardial infarction and prolonged ventilation and hospital stay.

Outcomes

Shortterm

Comparisons of 30-day outcomes aer CABG between women and men are controversial. Both increased mortality in women compared to men,,,– as well as equivalent 30-day mortality in women versus men, have been demonstrated. Arecent analysis of all Medicare beneciaries undergoing CABG in the United States from 1999 to 2014 showed a higher mortality for women undergoing CABG compared to men while in-hospital, at 30days and at 1year. Some studies have suggested that the dierence in mortality may be more pronounced between younger women and men as women less than 50years of age were three times more likely to experience in-hospital mortality than men (3.4% vs 1.1%) and women 50–59years of age who were 2.4 times more likely to die than men (2.6% vs 1.1%). Although several theories have been proposed to contribute to mortality dierences between men and women including the inuence of sex hormones on coronary disease, generally smaller coronary arteries in women, and referral and ascertainment bias, these remain speculative. Multivariate analyses of risk factors found to be associated with increased risk of in-hospital mortality in women have included older age, heart failure, diabetes, chronic obstructive lung disease, and ascending aorta atherosclerosis.,  Despite the sex dierence in mortality aer CABG, overall mortality aer CABG has been declining in both sexes.,

Longterm

Long-term follow-up of hospital survivors following CABG indicates at least equivalent, if not increased, benet for women compared to men independent of conduit choice (Fig. 58.4). In a group of women receiving BITA bypass graing compared to a matched cohort of male patients receiving the same, there was no signicant dierence in long-term related mortality, late percutaneous coronary intervention, or reoperation for coronary disease. In fact,

(1) CABG in men (2) CABG in women

Women: hazard ratio 0.82, 95% conﬁdence interval 0.71–0.96, P = 0.014

01224364860728496 108

(2)

(1)

Fig.58.4 Ten-year mortality after CABG in women. Risk-adjusted

Kaplan–Meier survival plots of men and women undergoing CABG adjusted for all independent preoperative, intraoperative, and postoperative predictors for long-term mortality (age, race, emergency operation, ejection fraction, previous cardiac operation, peripheral vascular disease, myocardial infarction, intravenous nitroglycerine use, heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes mellitus, preoperative renal failure, preoperative renal failure on dialysis, thrombolysis, off-pump CABG, more than or equal to two arterial grafts, intraoperative stroke, postoperative myocardial infarction, deep sternal wound infection, sepsis, endocarditis, gastrointestinal complications, respiratory failure).

Source data from Angraal S, Khera R, Wang Y, Lu Y, Jean R, Dreyer RP, Geirsson A , Desai NR, Krumholz HM. Sex and race differences in the utilization and outcomes of coronary artery bypass grafting among Medicare beneﬁciaries, 1999–2014. J Am Heart Assoc 2018;7:e009014.

there were signicantly more cardiac-related deaths in men than women at 15years. In women receiving BITA gras, quality of life and freedom from angina were both signicantly improved compared to their age-adjusted norms. Long-term follow-up of over 10,000 patients from the Cleveland Clinic receiving either single ITA or BITA gras similarly demonstrated no dierences between the sexes in late mortality.

Cardiacrehabilitation

Cardiac rehabilitation is indicated aer acute coronary syndrome, a diagnosis of heart failure, percutaneous coronary intervention or open-heart surgery. is multidisciplinary outpatient programme has been shown to reduce overall and cardiovascular-related mortality and is recommended in both American and European Guidelines., Data show that women compared to men are less likely to be referred to and enrolled in cardiac rehabilitation programmes. ough the reasons for low enrolment are multifactorial, surgeon reinforcement of these recommendations can help improve participation.

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Conclusion

Cardiovascular disease poses the greatest health threat to women in the developed world. Despite the fact that up until 2013 in the United States more women than men died annually of cardiovascular disease, women remain underdiagnosed and undertreated for cardiovascular disease.

Women gain the same benet of prolonged survival as men following surgical revascularization for multivessel coronary artery disease and the same prolonged survival from arterial graing. Based on available data, cardiac surgeons should be empowered to increase revascularization rates and utilization of ITA and radial arterial conduits in women. To further optimize prevention, diagnosis, and surgical management of women with cardiovascular disease, the specic impact of female sex must be studied in both basic science research and clinical trials on cardiovascular disease.

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44. Angraal S, Khera R, Wang Y, Lu Y, Jean R, Dreyer RP, etal. Sex and race dierences in the utilization and outcomes of coronary artery bypass graing among Medicare beneciaries, 1999–2014. J Am Heart Assoc. 2018;7(14):e009014.

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Coronary artery bypass graing in octogenarians

Derrick Y. Tam, Reena Karkhanis, and Stephen E. Fremes

Introduction

e prevalence of coronary artery disease in the elderly is high and has been shown to be greater than 80% in patients over the age of 80years. In a very early study of 84 consecutive symptomatic octogenarians undergoing angiography, 57% of patients had three-vessel disease while 13% of patients had le main disease, suggesting that 70% of patients had surgical disease. Coronary artery bypass graing (CABG) remains the treatment of choice in selected patients with advanced coronary disease in the absence of surgical contraindications. While much of the data presented in this chapter is not from the current decade, there are some recent studies that have examined trends and outcomes in the contemporary era. An analysis of four Canadian centres from 1996 to 2001 showed a signicant increase in the number of octogenarians undergoing isolated CABG from 3.8% to 6.2% with a simultaneous signicant decline in early mortality (25% to 10%). More recently, a single-centre retrospective analysis from 1999 to 2016 showed a doubling in the number of octogenarian and older patients undergoing cardiac surgery from 4.5% to 9.3%. In the same time period, predicted mortality by logistic EuroSCORE remained steady at 9–10% while observed mortality decreased signicantly from 9.4 to 4.7%.

Risk factors formortality

Octogenarians typically present with more surgical risk factors compared to younger patients. Several studies have shown that the incidence of chronic heart failure, preoperative renal insuciency, cerebrovascular disease, peripheral vascular disease, and previous myocardial infarction are higher in octogenarians compared to younger patients. Furthermore, octogenarians may be less likely to undergo invasive work-up for coronary artery disease until presenting with an urgent or emergent indication and hence may be more likely to undergo urgent or emergent surgery. e prevalence of aortic plaque and aortic atherosclerosis burden is likely higher in elderly individuals. Even in the general population of patients

of all ages undergoing CABG, epiaortic ultrasound scanning has shown that 50% of patients have some degree of atheroma in the ascending aorta.

Frailty, a syndrome of decreased physiological reserve that leads to vulnerability to stressors (such as cardiac surgery), has been well described in the cardiac surgery literature. e prevalence of frailty is highest in those aged over 65years; frailty can also aect up to 12% of younger patients, highlighting the important distinction between chronological age and biological age. Measures of frailty range from the traditional end of the bed ‘eyeball test’ (i.e. clinical gestalt, a measure that has been shown to have poor inter-rater reliability) to objective phenotypic assessment tools that examine physiological domains such as gait speed, handgrip strength, weight, and other measures of physical activity. Poor functional reserve can lead to increased morbidity and mortality aer CABG; reduced lung compliance and weak respiratory muscle strength may result in higher postoperative ventilatory failure while decreased kidney reserve may lead to acute kidney injury. Other age-related central nervous system changes may lead to higher incidences of delirium and delayed postoperative recovery. e use of multimodal frailty scores and scales may help predict outcomes aer CABG. Not surprisingly, frailty has been shown to be a strong predictor of in-hospital mortality. e use of the Clinical Frailty Scale shows a robust gradient response with mortality; those with the highest scores had an almost six times odds of in-hospital mortality and tripling in the hazard for mid-term mortality.

While various scores such as the Society of oracic Surgeons score or the EuroSCORE have been traditionally used to predict mortality in patients undergoing CABG (Fig. 59.1), these tools may not be as accurate in octogenarians. Risk factors that are pertinent to an elderly population such as frailty, marked skeletal abnormalities, and neurocognitive impairment are not captured in traditional risk models and hence the accuracy of these scores in octogenarians may be limited. Afundamental aw of these risk scores is that they were determined in patients who were accepted (not rejected) for surgery. Acomprehensive frailty assessment by a gerontologist may uncover additional details that can be used to predict an individual patient’s course in hospital.

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Predicted mortality risk (%)

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60 62 64 66 68 70 72

Low risk Intermediate risk High risk

Fig.59.1 Change in the Society of Thoracic Surgeons predicted risk of mortality score by age for a low-risk (elective), intermediate-risk (urgent), and

high-risk (emergent) male with hypertension, peripheral vascular disease, diabetes, and signiﬁcant three-vessel disease, undergoing isolated CABG.

74 76 78 80 82 84 86 88

Age (years)

CABG versus percutaneous coronary intervention versus medicaltherapy

An analysis of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical and administrative database, suggests that the absolute risk reduction for late mortality with CABG compared to medical therapy or percutaneous coronary intervention (PCI) was highest in octogenarians compared to younger patients. CABG and PCI were associated with an absolute risk dierence of 17% and 11%, respectively, compared to medical therapy. Four-year adjusted survival rates for CABG, PCI, and medical therapy were 77.4%, 71.6%, and 60.3%, respectively. ese ndings suggest that octogenarians still derive benet from aggressive revascularization strategies.

In an observational comparison of PCI versus CABG for octogenarians with two- or three-vessel disease in the Northern New England Cardiovascular Disease Study Group (NNECDSG) registry, CABG was associated with a higher in-hospital mortality (5.9% vs

3.0%) although patients in the CABG group had higher predicted risk with more comorbidities. In this same study, the adjusted risk of death was higher for CABG in the rst 6months (hazard ratio (HR) for mortality 1.32; P=0.135) but was signicantly lower from 6months to 8years (HR 0.72; P= 0.005). In another unadjusted comparison of 120 PCI and 181 CABG octogenarians, early mortality was signicantly higher with CABG (9.9% vs 2.5%; P=0.01) but the CABG group had higher predicted risk (more le main disease, peripheral vascular disease, previous myocardial infarctions, and emergent surgery). However, freedom from recurring angina and need for repeat revascularization at 4years was lower with CABG compared to PCI. In a meta-analysis that included only studies with octogenarians that directly compared CABG to PCI, short-term mortality was higher with CABG (HR 1.47, 95% CI 1.05–

2.06; P= 0.02) while CABG patients had better late survival (HR

0.81, 95% CI 0.73–0.89). ere was no dierence in early stroke or myocardial infarction. Overall, these studies suggest that there is a higher upfront mortality risk with CABG compared to PCI while

late survival and freedom from major adverse cardiac events may be better with CABG. However, given that most of these studies were observational in nature, the assignment of treatment at the surgeon’s discretion may have confounded both early and late outcomes. It is important to acknowledge that there is a paucity of randomized controlled trial evidence comparing PCI to CABG for multivessel disease and le main disease in octogenarians. While age has not been an exclusion criterion, the range of mean age of patients enrolled in contemporary randomized controlled trial was 63–66years.

Outcomes

An analysis of the National Inpatient Sample (NIS) from 797 hospitals and 134,117 patients aged 80years or older in the United States showed a mortality rate of 4–6% in those undergoing isolated CABG from 2003 to 2011. A retrospective review of 15,070 patients undergoing CABG of whom 725 were octogenarians demonstrated that the risk for in-hospital death (odds ratio (OR) 2.64, 95% CI

1.95–3.57) and stroke (OR 3.25, 95% CI 2.15–4.93) was signicantly higher in octogenarians. Aretrospective analysis of 414 octogenarians show that 5-year survival aer isolated CABG was 66.5%. Risk factors for death included age, dyslipidaemia, poor le ventricular function, and high creatinine. Similarly, in a retrospective analysis of 241 octogenarians, the early mortality rate was 5.8% and survival at 1 and 5years was 91.9% and 83.5%, respectively. Multivariable regression showed that peripheral vascular disease and previous PCI were risk factors for late death. Ameta-analysis of 66 observational studies indirectly compared PCI to CABG in octogenarians for early and late survival. ere was selection bias—those that underwent CABG had more multivessel disease and were more likely to be male. However, pooled unadjusted estimates for 30-day mortality were similar between CABG (7.3%, 95% CI 6.3–8.2%) and PCI (5.4%, 95% CI 4.4–6.4%) with similar rates of 1-year survival. Overall, there has been substantial improvement in in-hospital mortality for octogenarians over time and acceptable late

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survival, although the evidence base is entirely derived from observational studies.

In addition to survival, health-related quality of life is also an important outcome, particularly in elderly patients. Areview of the cardiac surgical literature demonstrates that octogenarians undergoing CABG report signicant improvements in symptoms and quality of life, both early and late aer surgery. At 2-year follow-up, over 80% of patients live independently at home. Measures of quality of life on scales such as the Short Form-36 show similar quality of life aer surgery comparable to that of age-matched controls.

a survival advantage for the use of the radial artery over the saphenous vein gra by age groups, the authors found that a mortality benet was no longer present in patients aged over 70years. ere is limited evidence to support the use of bilateral ITA graing strategies in octogenarians. In a propensity-matched study of 804 pairs of patients aged at least 70years (mean age 75–76years aer matching), in-hospital mortality was numerically higher with bilateral ITA (2.7% vs 1.6%; P=0.11) although not statistically signicant while the rate of any sternal wound infection (7.7% vs 5.1%; P=0.031) and deep sternal wound infection (4.0% vs 2.2%; P=0.048) was signicantly higher in the bilateral ITA group.

Off-pump versus on-pump

Guidelines

e randomized clinical trial German O-Pump Coronary Artery Bypass Graing in Elderly Patients (GOPCABE) attempted to compare o versus on-pump CABG in patients aged at least 75years. While the mean age of enrolled patients was 78years, the authors found no dierence in mortality (2.8 vs 2.6%; P=0.75), or stroke (2.7% vs 2.2%; P=0.47) although the study has been criticized for being unpowered to detect dierences in these outcomes given that the study randomized only 2539 patients. An analysis of over 134,000 octogenarians in the NIS from 2003 to 2011 showed that while o-pump CABG did not confer any survival benet aer covariate adjustment for baseline dierences, the rate of stroke was signicantly lower with o-pump CABG (2.4% vs 1.8%; P=0.004). ese ndings are supported by a meta-analysis of 16 observational studies in octogenarians that showed comparable mortality in 9744 on-pump and 8566 o-pump patients yet a reduced stroke rate with o-pump CABG (1.3% vs 2.4%; P <0.001). Finally, a completely anaortic technique has been shown to reduce the odds of stroke by two- to fourfold, indicated that it may be an important technique in octogenarians given the high prevalence of aortic atherosclerosis in older patients in whom aortic manipulation (cannulation, cross-clamping, etc. for cardiopulmonary bypass) can lead to a higher risk of perioperative stroke. Nonetheless, regardless of technique chosen, complete revascularization is key in octogenarians. Aretrospective analysis compared complete to incomplete revascularization in 580 patients and found that mean late survival was signicantly lower in those with incomplete revascularization (6.7 vs 4.2years; P=0.007).

Imagingconsiderations

Given the higher prevalence of peripheral vascular disease and cerebrovascular disease in octogenarians, there are important preoperative imaging considerations that may not be necessary in younger patients. e 2018 European revascularization guidelines recommend the routine use of non-contrast computed tomography in patients at high risk for postoperative stroke (>70years, previous transient ischaemic attack or stroke) as preoperative computed tomography scanning may alter cannulation strategies in up to 20% of these high-risk patients., Furthermore, guidelines recommend routine carotid duplex studies only in patients with a recent history of stroke or transient ischaemic attack (classI, level of evidence B) and in those at higher risk (classIIb, level of evidence B). Intraoperatively, there is a recommendation to use epiaortic ultrasound scanning to identify atheromatous plaque (class IIa, level of evidence C) which may be particularly prudent in elderly patients with a higher burden of aortic atheroma. Indeed, the use of epiaortic scanning has been shown to reduce the number of neurological events in a retrospective propensity-matched cohort study and a cumulative summation analysis showed that the number of preventable adverse events is highest in patients aged over 70years.

Operativeconsiderations

ere are no age-specic recommendations in the latest European revascularization guidelines pertaining to age thresholds for arterial

Conduitchoice

graing. e use of additional arterial gras should be considered in in the context of the patient’s life expectancy along with the risk factors for sternal wound complications (in the case of bilateral ITA

ere is some evidence to suggest to that the use of arterial gras confers late survival benet without compromising early outcomes in octogenarians. A retrospective analysis of 2605 elderly patients showed that both unadjusted and adjusted late mortality to 10years was improved in those that underwent internal thoracic artery (ITA)/radial artery graing compared to ITA/saphenous vein graing in both septuagenarian and octogenarian subgroups. In contrast, a meta-analysis using individual patient-level data from randomized controlled trials showed a signicant age–treatment effect interaction for patients aged at least 75years such that the use of a radial artery as the second conduit no longer conferred late benet for major adverse cardiac events (HR 1.00, 95% CI 0.48–2.08), although the number of patients aged 75 years or older was small (n=172). In a spline analysis to determine an age threshold for

harvesting) and conduit availability. O-pump and no-touch aortic techniques received a classI(level of evidence B) recommendation in patients with signicant atherosclerotic aortic disease in the latest European guidelines and in high-risk patients when performed by experienced o-pump teams.

A Heart Teamapproach

Overall, there has been a decline in in-hospital mortality in patients undergoing CABG and acceptable late survival has been demonstrated in several observational studies. Studies have shown that advanced age is not a contraindication to CABG—the choice of revascularization strategy should be individualized. ose at high predicted risk of mortality may be better served with PCI while those at low or intermediate risk may improve late event-free survival

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with CABG. e Heart Team should be central in deciding the relevant treatment modality aer consideration of all relevant factors. Undoubtedly, octogenarians may present with additional comorbidities or more advanced disease that necessitates important perioperative and operative considerations. e Heart Team approach may also be instrumental in devising the operative strategy, determining the most appropriate conduits, and selecting the optimal surgical technique (o- vs on-pump, complete no-touch aortic technique, hybrid strategies). Finally, chronological age and biological age are dierent entities and may impact surgical risk independently; the inclusion of geriatric specialists to help assess patient frailty and provide prognostication may be useful in treatment decision-making.

REFERENCES

1. Yazdanyar A, Newman AB. e burden of cardiovascular disease in the elderly:morbidity, mortality, and costs. Clin Geriatr Med. 2009;25(4):563–77.

2. Kowalchuk GJ, Siu SC, Lewis SM. Coronary artery disease in the octogenarian:angiographic spectrum and suitability for revascularization. Am J Cardiol. 1990;66(19):1319–23.

3. Baskett R, Buth K, Ghali W, Norris C, Maas T, Maitland A, etal. Outcomes in octogenarians undergoing coronary artery bypass graing. CMAJ 2005;172(9):1183–6.

4. Habib AM, Hussain A, Jarvis M, Cowen ME, Chaudhry MA, Loubani M, etal. Changing clinical proles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18years:a single-centre experience. Interact Cardiovasc orac Surg. 2019;28(4):602–6.

5. Yanagawa B, Graham MM, Alalo J, Hassan A, Arora RC. Frailty as a risk predictor in cardiac surgery:beyond the eyeball test. J orac Cardiovasc Surg. 2018;156(1):172–6.

6. Seco M, Edelman JJ, Forrest P, Ng M, Wilson MK, Fraser J, etal. Geriatric cardiac surgery:chronology vs. biology. Heart Lung Circ. 2014;23(9):794–801.

7. Reichart D, Rosato S, Nammas W, Onorati F, Dalén M, Castro L, etal. Clinical frailty scale and outcome aer coronary artery bypass graing. Eur J Cardiothorac Surg. 2018;54(6):1102–9.

8. Luc JGY, Graham MM, Norris CM, Al Shouli S, Nijjar YS, Meyer SR. Predicting operative mortality in octogenarians for isolated coronary artery bypass graing surgery:a retrospective study. BMC Cardiovasc Disord. 2017;17(1):275.

9. Graham MM, Ghali WA, Faris PD, Galbraith PD, Norris CM,

the elderly. Circulation. 2002;105(20):2378–84.

10. Dacey LJ, Likosky DS, Ryan TJ, Robb JF, Quinn RD, DeVries

JT, etal. Long-term survival aer surgery versus percutaneous intervention in octogenarians with multivessel coronary disease. Ann orac Surg. 2007;84(6):1904–11.

11. Ben-Gal Y, Finkelstein A, Banai S, Medalion B, Weisz G,

Genereux P, etal. Surgical myocardial revascularization versus percutaneous coronary intervention with drug-eluting stents in octogenarian patients. Heart Surg Forum. 2012;15(4):E204–9.

12. Zhang Q, Zhao XH, Gu HF, Xu ZR, Yang YM. Clinical outcomes

of coronary artery bypass graing vs percutaneous coronary intervention in octogenarians with coronary artery disease. Can J Cardiol. 2016;32(9):1166.e21–8.

13. Benedetto U, Angelini GD, Caputo M, Feldman DN, Kim LK,

Lau C, etal. O- vs. on-pump coronary artery bypass gra surgery on hospital outcomes in 134,117 octogenarians. J orac Dis. 2017;9(12):5085–92.

14. Rohde SL, Baker RA, Tully PJ, Graham S, Cullen H, Knight JL. Preoperative and intraoperative factors associated with long-term survival in octogenarian cardiac surgery patients. Ann orac Surg. 2010;89(1):105–11.

15. Nicolini F, Molardi A, Verdichizzo D, Gallazzi MC, Spaggiari I, Cocconcelli F, etal. Coronary artery surgery in octogenarians:evolving strategies for the improvement in early and late results. Heart Vessels. 2012;27(6):559–67.

16. McKellar SH, Brown ML, Frye RL, Scha HV, Sundt TM. Comparison of coronary revascularization procedures in octogenarians:a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med. 2008;5(11):738–46.

17. Shan L, Saxena A, McMahon R, Newcomb A. Coronary artery bypass gra surgery in the elderly:a review of postoperative quality of life. Circulation. 2013;128(21):2333–43.

18. Sen B, Niemann B, Roth P, Aser R, Schonburg M, Boning A. Shortand long-term outcomes in octogenarians aer coronary artery bypass surgery. Eur J Cardiothorac Surg. 2012;42(5):e102–7.

19. Diegeler A, Börgermann J, Kappert U, Breuer M, Böning A, Ursulescu A, etal. O-pump versus on-pump coronaryartery bypass graing in elderly patients. N Engl J Med. 2013;368(13):1189–98.

20. Altarabsheh SE, Deo SV, Rababa’h AM, Lim JY, Cho YH, Sharma V, etal. O-pump coronary artery bypass reduces early stroke in octogenarians:a meta-analysis of 18,000 patients. Ann orac Surg. 2015;99(5):1568–75.

21. Moss E, Puskas JD, ourani VH, Kilgo P, Chen EP, Leshnower BG, etal. Avoiding aortic clamping during coronary artery bypass graing reduces postoperative stroke. J orac Cardiovasc Surg. 2015;149(1):175–80.

22. Aziz A, Lee AM, Pasque MK, Lawton JS, Moazami N, Damiano RJ, etal. Evaluation of revascularization subtypes in octogenarians undergoing coronary artery bypass graing. Circulation. 2009;120(11, Suppl):S65–9.

23. Habib RH, Abou-Arraj NE, Schwann TA. Radial artery as a second arterial gra in the elderly and both sexes. Ann Cardiothorac Surg. 2013;2(4):453–7.

24. Gaudino M, Benedetto U, Fremes S, Biondi-Zoccai G, Sedrakyan A, Puskas JD, etal. Radial-artery or saphenous-vein gras in coronary-artery bypass surgery. N Engl J Med. 2018;378(22): 2069–77.

25. Benedetto U, Codispoti M. Age cuto for the loss of survival benet from use of radial artery in coronary artery bypass graing. J orac Cardiovasc Surg. 2013;146(5):1078–84.

26. Rubino AS, Gatti G, Reichart D, Tauriainen T, De Feo M, Onorati F, etal. Early outcome of bilateral versus single internal mammary artery graing in the elderly. Ann orac Surg. 2018;105(6):1717–23.

27. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.

28. Lee R, Matsutani N, Polimenakos AC, Levers LC, Lee M, Johnson RG. Preoperative noncontrast chest computed tomography identies potential aortic emboli. Ann orac Surg. 2007;84(1):38–41.

29. Evered LA, Silbert BS, Scott DA. Postoperative cognitive dysfunction and aortic atheroma. Ann orac Surg. 2010;89(4):1091–7.

30. Luthra S, Leiva Juarez MM, Tahir Z, Yiu P. Intraoperative epiaortic scans reduce adverse neurological sequelae in elderly, high risk patients undergoing coronary artery bypass surgery—a propensity matched, cumulative sum control analysis. Heart Lung Circ. 2017;26(7):709–16.

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Coronary artery bypass gra surgery inthe setting ofacute myocardial infarction

Babatunde A. Yerokun and Peter K. Smith

Introduction

Myocardial infarction is a part of the spectrum of ischaemic heart disease that ranges from chronic heart failure to stable or unstable angina to myocardial infarction. As a whole, ischaemic heart disease remains the leading cause of mortality worldwide. Coronary revascularization remains the definitive therapy for selective patients with ischaemic heart disease. This recommendation holds true for patients with myocardial infarction. While the use of coronary artery bypass grafting (CABG) for patients presenting with an acute myocardial infarction (AMI) has continued to decrease (Fig. 60.1 and Fig. 60.2) this remains a very important therapeutic option. The 2018 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization are the classes of recommendations (CORs) and the levels of evidence (LOEs) cited for this chapter.

Non-ST-segment elevation myocardialinfarction

Only about 12% of patients who present with a non-ST-segment myocardial infraction (NSTEMI) are denitively managed with CABG. When excluding patients who do not undergo angiography, this increases to approximately 18%. While the superiority of revascularization is well established compared to conservative management alone for NSTEMI, the decision between CABG and percutaneous coronary intervention should be customized to the individual patient and clinical scenario.,,

ere are some anatomical considerations that favour CABG for patients who present with NSTEMI which include le main stem disease, three-vessel disease, or two-vessel disease with proximal le anterior descending artery stenosis., While most of the randomized controlled trials on anatomical considerations were conducted on stable coronary disease, there is no evidence to suggest that outcomes would be dierent for stabilized patients with NSTEMI.

In addition, age appears to be a signicant factor in patients treated with CABG. Outcomes in older patients who present with NSTEMI tend to be better in those treated with CABG. Finally, patients with diabetes and chronic kidney disease are more likely to benet from CABG as opposed to percutaneous coronary intervention given the advanced atherosclerosis that is associated with these conditions.,

ST-segment elevation myocardialinfarction

Given the degree of myocardial ischaemia associated with ST-segment elevation myocardial infarction (STEMI) and the need for timely revascularization, CABG is less oen utilized as the primary revascularization procedure. Despite the infrequency, there is still an indication for CABG in patients who present with STEMI, especially when coronary disease is not amenable to revascularization with percutaneous coronary intervention for patients in cardiogenic shock (COR IIa; LOE C).,, Mechanical circulatory support may be required in the latter group of patients; however, the only trial comparing the use of mechanical circulatory support plus CABG in AMI patients with cardiogenic shock demonstrated no benet compared to CABG alone. In a randomized study of 600 patients receiving intra-aortic balloon counterpulsation aer revascularization versus no intra-aortic balloon counterpulsation, no dierences were seen in 30-day mortality between the two treatment arms. However, it must be noted that the trial is not completely generalizable since 95.8% of patients underwent percutaneous coronary intervention as opposed to CABG.

Operativeconsiderations

The timing of surgical revascularization is a challenging decision in patients with AMI. The timing of coronary angiography from the initial presentation has been investigated. Several studies have shown that early coronary angiography is associated with

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(a)

Patients (%)

(a)

Patients (%)

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100

1990 1992 1994 1996 1998 2000 2002 2004 2006

(b)

100

1990 1992 1994 1996 1998 2000 2002 2004 2006

Cardiac catheterization PCI

CABG Medical therapy

100

1994 1996 1998 2000 2002 2004 2006

(b)

100

1994 1996 1998 2000 2002 2004 2006

Aspirin Beta blocker ACE-I/ARB Lipid-lowering agent Other oral antiplatelet

Fig.60.1 Temporal trends in therapies administered within 24 hours of

admission in patients in the National Registry of Myocardial Infarction. (a)Patients presenting with STEMI. (b)Patients presenting with NSTEMI.

Reproduced from Peterson, E.D., Shah, B.R., Parsons, L., Pollack, C.V., Jr., French, W.J., Canto, J.G., Gibson, C.M. & Rogers, W.J. 2008. Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J, 156, 1045–55 with permission for Elsevier.

better outcomes as opposed to delayed angiography. In terms of the timing of CABG, the literature is inconclusive, though most data suggest delaying CABG until after 3days may be advantageous.– Despite the inconclusiveness, certain conditions would favour earlier urgent revascularization with the goal of decreasing end-organ damage. These conditions include, but are not limited to, cardiogenic shock, recurrent angina despite medical therapy, sustained ventricular arrhythmias, new ST-segment changes, or mechanical AMI complications (ventricular septal defect, ventricular free wall rupture, papillary muscle rupture). For these groups of patients, mechanical circulatory support plays a critical role in maintaining cardiac output in the perioperative period.

In addition to the timing of surgery, the management of preoperative medications is important. Given that most AMI patients receive intravenous anticoagulation and antiplatelet therapy during

Fig.60.2 Procedural interventions in patients in the National Registry

of Myocardial Infarction. (a)Patients presenting with STEMI. (b)Patients presenting with NSTEMI. ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.

diagnostic angiography, appropriate management of these medications for patients undergoing surgical revascularization becomes critical as this can also inuence timing of surgery. For the surgeon, these decisions balance the risk of re-thrombosis while also attempting to decrease the risk of bleeding during/aer cardiac surgery. With regard to antiplatelet therapy, major society guidelines recommend both aspirin and a P2Y inhibitor for patients presenting with AMI (COR I, LOE A).,,, Despite the recommendation, only 57% of patients who present with a NSTEMI receive dual antiplatelet therapy at the time of the event compared with 90% of STEMI patients. Additionally, anticoagulation is recommended for this cohort of patients at the time of diagnosis. e anticoagulation regimen oen varies by institution but can range from unfractionated heparin to low-molecular-weight heparin to a direct thrombin inhibitor or a factor Xa inhibitor.

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Once CABG has been established as the optimal method of revascularization, the surgeon will be responsible for coordinating the continuation or discontinuation of all these medications. Aspirin should be continued perioperatively and through discharge unless there is a contraindication (COR I, LOE C). e most commonly used P2Y inhibitors are clopidogrel, prasugrel, and ticagrelor. Given the longer half-lives of these medications along with the associated increased risk of bleeding, they are usually discontinued before surgery. Of the three drugs, prasugrel has the highest risk for major bleeding, while clopidogrel and ticagrelor have similar lower rates. Despite the bleeding risk, patients treated with prasugrel have been found to have an associated increased survival aer CABG compared to clopidogrel. Current guidelines recommend that prasugrel should be discontinued for 7days before elective CABG to decreased CABG-associated haemorrhage, compared to 5 and 3days of discontinuation for clopidogrel and ticagrelor respectively (COR IIa, LOE B). Despite these recommendations, earlier CABG should be considered if the benets outweigh the risks, especially in the case of a STEMI patient in cardiogenic shock., Anticoagulation should be continued aer deciding on CABG and can be safely discontinued from 6 to 24 hours preoperatively depending on the medication used (COR I, LOE A). e selection of the anticoagulant should be based on risk and benet to the patient given the dierent ecacy–safety proles of each agent (COR I, LOR C). In addition to antiplatelets and anticoagulation, initiation and continuation of a beta blocker and a statin are recommended perioperatively. Dual antiplatelet therapy, a beta blocker, and a statin should be resumed immediately aer CABG and continued through discharge up to 12months aer surgery if not contraindicated (COR I, LOE C).

REFERENCES

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2. Peterson ED, Shah BR, Parsons L, Pollack CV Jr, French WJ, Canto JG, etal. Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008;156(6):1045–55.

3. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.

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8. Weintraub WS, Grau-Sepulveda MV, Weiss JM, O’Brien SM, Peterson ED, Kolm P, etal. Comparative eectiveness of revascularization strategies. N Engl J Med. 2012;366(16):1467–76.

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10. Farkouh ME, Domanski M, Dangas GD, Godoy LC, Mack MJ, Siami FS, etal. Long-term survival following multivesselrevascularization in patientswith diabetes:the FREEDOM follow-on study. J Am Coll Cardiol. 2019;73(6):629–38.

11. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, etal. ACCF/AHA guideline for the management of ST-elevation myocardial infarction. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362–425.

12. Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, etal. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. e Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J. 2012;33(20):2569–619.

13. iele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, etal. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287–96.

14. Lee DC, Oz MC, Weinberg AD, Ting W. Appropriate timing of surgical intervention aer transmural acute myocardial infarction. J orac Cardiovasc Surg. 2003;125(1):115–9.

15. Weiss ES, Chang DD, Joyce DL, Nwakanma LU, Yuh DD. Optimal timing of coronary artery bypass aer acute myocardial infarction:a review of California discharge data. J orac Cardiovasc Surg. 2008;135(3):503–11.

16. Davierwala PM, Verevkin A, Leontyev S, Misfeld M, Borger MA, Mohr FW. Does timing of coronary artery bypass surgery aect early and long-term outcomes in patients with non-ST-segmentelevation myocardial infarction? Circulation. 2015;132(8): 731–40.

17. Sherwood MW, Wiviott SD, Peng SA, Roe MT, Delemos J, Peterson ED, etal. Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US:insights from the National Cardiovascular Data Registry. J Am Heart Assoc. 2014;3(2):e000849.

18. Smith PK, Goodnough LT, Levy JH, Poston RS, Short MA, Weerakkody GJ, etal. Mortality benet with prasugrel in the Triton-TIMI 38 coronary artery bypass graing cohort:riskadjusted retrospective data analysis. J Am Coll Cardiol. 2012;60(5):388–96.

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