Coronary Artery Bypass Grafting

Question 1

2014 ACC/AHA/AATS/SCAI/STS guidelines for CABG indications for asymptomatic patients?

Answer 1

Left main stenosis, left main equivalent (proximal LAD and circumflex), 3v dz, 2v dz including prox LAD + LV dysfx.

Question 2

2014 ACC/AHA/AATS/SCAI/STS guidelines for CABG indications for symptomatic patients with non-STEMI?

Answer 2

2-vessel disease not involving LAD if large area of myocardium involved.
Single-vessel disease if LAD if associated with extensive ischemia and LV dysfunction.

Should be done before DC.

Question 3

2014 ACC/AHA/AATS/SCAI/STS guidelines for CABG indications for STEMI?

Answer 3

• Failed angioplasty w/ persistent pain or hemodynamic instability.
• Persistent uncontrollable angina w/ acceptable vessels and large amount of myocardium at risk.
• Mechanical complications of STEMI (LV rupture, VSD, and/or acute valve insufficiency).
• Cardiogenic shock w/ myocardium at risk.
• Recurrent or life-threatening arrhythmias w/ left main or triple vessel disease.

Question 4

In general, patients with coronary artery disease, good ventricular function, minimal symptoms, and limited myocardium at risk should be initially be treated with what?

Answer 4

Best medical management.

Question 5

In general, patients with CAD who have symptoms that compromise quality of life should be treated with what?

Answer 5

Revascularization (should be considered). CABG appears to be lower risk of mortality compared to PCI in most patients w/ DM and complex multi-vessel disease.

Question 6

What is fibrillatory arrest with CPB?

Answer 6

Similar to on-pump beating heart surgery, but induced V fib provides non-beating operative field. Induced w/ T <30C or metal clips attached to AC current. LV sump/vent required to prevent LV distention. Distal anastomosis before proximal if heart beating. Distal anastomosis can be done under fibrillatory, but cooling is required to protect the heart, especially w/ LV hypertrophy.

Question 7

What are advantages of cardiac arrest w/ CPB?

Answer 7

Bloodless field, flaccid heart, diastolic arrest, well protected. Myocardial protection is the key component - del Nido solution.

Question 8

How long is del Nido effective for aortic cross-clamping?

Answer 8

90 minutes.

Question 9

What is the typical pattern of multi-vessel anastomosis in CABG w/ cardiac arrest?

Answer 9

Less important, but typically distal to back of the heart (RC system), lateral wall (circ), LAD, then proximal anastomoses.