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 Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R. Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka, Adolph M. Hutter, Jr, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas, Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, and Michael D. Winniford J. Am. Coll. Cardiol. 2011;58;e123-e210; originally published online Nov 7, 2011; doi:10.1016/j.jacc.2011.08.009 This information is current as of May 21, 2012 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://content.onlinejacc.org/cgi/content/full/58/24/e123 Downloaded from content.onlinejacc.org by on May 21, 2012 JournaloftheAmericanCollegeofCardiology Vol.58,No.24,2011 ©2011bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/$36.00 PublishedbyElsevierInc. doi:10.1016/j.jacc.2011.08.009 PRACTICE GUIDELINE 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 Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons Writing L. David Hillis, MD, FACC, Chair† Michael J. Mack, MD, FACC*¶ Committee Peter K. Smith, MD, FACC, Vice Chair*† Manesh R. Patel, MD, FACC† Members* John D. Puskas, MD, FACC*† Jeffrey L. Anderson, MD, FACC, FAHA*‡ Joseph F. Sabik, MD, FACC*# John A. Bittl, MD, FACC§ Ola Selnes, PHD† CharlesR.Bridges,MD,SCD,FACC,FAHA*† David M. Shahian, MD, FACC, FAHA** John G. Byrne, MD, FACC† Jeffrey C. Trost, MD, FACC*† Joaquin E. Cigarroa, MD, FACC† Michael D. Winniford, MD, FACC† Verdi J. DiSesa, MD, FACC† Loren F. Hiratzka, MD, FACC, FAHA† *Writingcommitteemembersarerequiredtorecusethemselvesfrom Adolph M. Hutter, JR, MD, MACC, FAHA† votingonsectionstowhichtheirspecificrelationshipswithindustryand other entities may apply; see Appendix 1 for recusal information. Michael E. Jessen, MD, FACC*† †ACCF/AHARepresentative.‡ACCF/AHATaskForceonPractice Ellen C. Keeley, MD, MS† GuidelinesLiaison.§JointRevascularizationSectionAuthor.(cid:1)Society Stephen J. Lahey, MD† ofCardiovascularAnesthesiologistsRepresentative.¶AmericanAsso- ciation for Thoracic Surgery Representative. #Society of Thoracic Richard A. Lange, MD, FACC, FAHA†§ SurgeonsRepresentative.**ACCF/AHATaskForceonPerformance Martin J. London, MD(cid:1) MeasuresLiaison. ACCF/AHA Alice K. Jacobs, MD, FACC, FAHA, Chair Robert A. Guyton, MD, FACC TaskForce Jeffrey L. Anderson, MD, FACC, FAHA, Jonathan L. Halperin, MD, FACC, FAHA Members Chair-Elect Judith S. Hochman, MD, FACC, FAHA Frederick G. Kushner, MD, FACC, FAHA Nancy Albert, PHD, CCNS, CCRN, FAHA E. Magnus Ohman, MD, FACC Mark A. Creager, MD, FACC, FAHA William Stevenson, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Clyde W. Yancy, MD, FACC, FAHA ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundation College of Cardiology Foundation/American Heart Association Task Force on Board of Trustees and the American Heart Association Science Advisory and PracticeGuidelines.JAmCollCardiol2011;58:e123–210. CoordinatingCommitteeinJuly2011,bytheSocietyofCardiovascularAnesthesi- ThisarticleiscopublishedinCirculation. ologistsandtheSocietyofThoracicSurgeonsinAugust2011,andbytheAmerican Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmerican AssociationforThoracicSurgeryinSeptember2011. CollegeofCardiology(www.cardiosource.org)andtheAmericanHeartAssociation TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocument (my.americanheart.org).Forcopiesofthisdocument,pleasecontacttheElsevierInc. becitedasfollows:HillisLD,SmithPK,AndersonJL,BittlJA,BridgesCR, ReprintDepartment,fax(212)633-3820,[email protected]. Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Permissions:Multiplecopies,modification,alteration,enhancement,and/ordis- KeeleyEC,LaheySJ,LangeRA,LondonMJ,MackMJ,PatelMR,PuskasJD, tributionofthisdocumentarenotpermittedwithouttheexpresspermissionofthe SabikJF,SelnesO,ShahianDM,TrostJC,WinnifordMD.2011ACCF/AHA American College of Cardiology Foundation. Please contact healthpermissions@ guideline for coronary artery bypass graft surgery: a report of the American elsevier.com. Downloaded from content.onlinejacc.org by on May 21, 2012 e124 Hillisetal. JACCVol.58,No.24,2011 2011ACCF/AHACABGGuideline December6,2011:e123–210 3.9.2. ChronicKidneyDisease.....................e146 TABLE OF CONTENTS 3.9.3. CompletenessofRevascularization..........e147 3.9.4. LVSystolicDysfunction....................e147 Preamble.....................................................e125 3.9.5. PreviousCABG.............................e147 3.9.6. UnstableAngina/Non(cid:1)ST-Elevation 1. Introduction .............................................e127 MyocardialInfarction.......................e147 3.9.7. DAPTComplianceandStentThrombosis: 1.1. MethodologyandEvidenceReview ............e127 Recommendation............................e147 1.2. OrganizationoftheWritingCommittee........e128 3.10. TMRasanAdjuncttoCABG.....................e148 3.11. HybridCoronaryRevascularization: 1.3. DocumentReviewandApproval................e128 Recommendations................................e148 2. ProceduralConsiderations............................e128 4. PerioperativeManagement...........................e148 2.1. IntraoperativeConsiderations..................e128 4.1. PreoperativeAntiplateletTherapy: 2.1.1. AnestheticConsiderations: Recommendations................................e148 Recommendations...........................e128 4.2. PostoperativeAntiplateletTherapy: 2.1.2. UseofCPB.................................e130 2.1.3. Off-PumpCABGVersus Recommendations................................e149 TraditionalOn-PumpCABG...............e131 4.3. ManagementofHyperlipidemia: 2.1.4. BypassGraftConduit:Recommendations.......e132 Recommendations................................e150 2.1.4.1. SAPHENOUSVEINGRAFTS..................e132 4.3.1. TimingofStatinUseandCABGOutcomes....e150 2.1.4.2. INTERNALMAMMARYARTERIES.............e132 4.3.1.1. POTENTIALADVERSEEFFECTSOF 2.1.4.3. RADIAL,GASTROEPIPLOIC,AND PERIOPERATIVESTATINTHERAPY............e150 2.1.5. IncisionINsFfEoRrIOCREaPrdIGiAaScTRAICccAeRsTsE.R.IE.S...........................ee113323 4.4. HormonalManipulation:Recommendations...e151 2.1.6. AnastomoticTechniques....................e133 4.4.1. GlucoseControl.............................e151 2.1.7. IntraoperativeTEE:Recommendations.....e133 4.4.2. PostmenopausalHormoneTherapy.........e152 2.1.8. Preconditioning/Managementof 4.4.3. CABGinPatientsWithHypothyroidism.....e152 MyocardialIschemia:Recommendations......e135 4.5. PerioperativeBetaBlockers: 2.2. ClinicalSubsets..................................e136 Recommendations................................e152 2.2.1. CABGinPatientsWithAcuteMI: 4.6. ACEInhibitors/ARBs:Recommendations......e153 Recommendations...........................e136 4.7. SmokingCessation:Recommendations........e154 2.2.2. Life-ThreateningVentricularArrhythmias: 4.8. EmotionalDysfunctionand Recommendations...........................e137 PsychosocialConsiderations:Recommendation..e155 2.2.3. EmergencyCABGAfterFailedPCI: 4.8.1. EffectsofMoodDisturbanceandAnxietyon Recommendations...........................e138 CABGOutcomes...........................e155 2.2.4. CABGinAssociationWithOther 4.8.2. InterventionstoTreatDepressionin CardiacProcedures:Recommendations......e138 CABGPatients.............................e155 3. CADRevascularization ................................e139 4.9. CardiacRehabilitation:Recommendation.......e155 4.10. PerioperativeMonitoring........................e156 3.1. HeartTeamApproachtoRevascularization 4.10.1. ElectrocardiographicMonitoring: Decisions:Recommendations...................e139 Recommendations...........................e156 3.2. RevascularizationtoImproveSurvival: 4.10.2. PulmonaryArteryCatheterization: Recommendations................................e141 Recommendations...........................e156 3.3. RevascularizationtoImproveSymptoms: 4.10.3. CentralNervousSystemMonitoring: Recommendations................................e142 Recommendations...........................e156 3.4. CABGVersusContemporaneousMedical 5. CABG-AssociatedMorbidityandMortality: Therapy............................................e142 OccurrenceandPrevention...........................e157 3.5. PCIVersusMedicalTherapy.....................e143 3.6. CABGVersusPCI.................................e143 5.1. PublicReportingofCardiacSurgeryOutcomes: 3.6.1. CABGVersusBalloonAngioplastyorBMS....e143 Recommendation.................................e157 3.6.2. CABGVersusDES.........................e144 5.1.1. UseofOutcomesorVolumeasCABG 3.7. LeftMainCAD ....................................e144 QualityMeasures:Recommendations.......e158 3.7.1. CABGorPCIVersusMedicalTherapyfor 5.2. AdverseEvents...................................e159 LeftMainCAD............................e144 5.2.1. AdverseCerebralOutcomes.................e159 3.7.2. StudiesComparingPCIVersusCABGfor 5.2.1.1. STROKE................................e159 5.2.1.1.1. USEOFEPIAORTICULTRASOUND LeftMainCAD............................e145 IMAGINGTOREDUCESTROKERATES: 3.7.3. RevascularizationConsiderationsfor LeftMainCAD............................e145 RECOMMENDATION..............e159 5.2.1.1.2. THEROLEOFPREOPERATIVECAROTID 3.8. ProximalLADArteryDisease ...................e146 ARTERYNONINVASIVESCREENINGIN 3.9. ClinicalFactorsThatMayInfluencetheChoice CABGPATIENTS:RECOMMENDATIONS..e160 ofRevascularization.............................e146 5.2.1.2. DELIRIUM...............................e161 3.9.1. DiabetesMellitus ...........................e146 5.2.1.3. POSTOPERATIVECOGNITIVEIMPAIRMENT......e161 Downloaded from content.onlinejacc.org by on May 21, 2012 JACCVol.58,No.24,2011 Hillisetal. e125 December6,2011:e123–210 2011ACCF/AHACABGGuideline 5.2.2. Mediastinitis/PerioperativeInfection: When properly applied, expert analysis of available data on Recommendations...........................e161 thebenefitsandrisksofthesetherapiesandprocedurescan 5.2.3. RenalDysfunction:Recommendations........e163 improvethequalityofcare,optimizepatientoutcomes,and 5.2.4. PerioperativeMyocardialDysfunction: favorably affect costs by focusing resources on the most Recommendations...........................e164 5.2.4.1. TRANSFUSION:RECOMMENDATION...........e165 effectivestrategies.Anorganizedanddirectedapproachtoa 5.2.5. PerioperativeDysrhythmias: thorough review of evidence has resulted in the production Recommendations...........................e165 ofclinicalpracticeguidelinesthatassistphysiciansinselect- 5.2.6. PerioperativeBleeding/Transfusion: ingthebestmanagementstrategyforanindividualpatient. Recommendations...........................e165 Moreover, clinical practice guidelines can provide a foun- 6. SpecificPatientSubsets..............................e166 dationforotherapplications,suchasperformancemeasures, appropriate use criteria, and both quality improvement and 6.1. Elderly.............................................e166 clinical decision support tools. 6.2. Women.............................................e167 The American College of Cardiology Foundation 6.3. PatientsWithDiabetesMellitus................e167 (ACCF)andtheAmericanHeartAssociation(AHA)have 6.4. AnomalousCoronaryArteries: jointly produced guidelines in the area of cardiovascular Recommendations................................e168 disease since 1980. The ACCF/AHA Task Force on 6.5. PatientsWithChronicObstructivePulmonary PracticeGuidelines(TaskForce),chargedwithdeveloping, Disease/RespiratoryInsufficiency: Recommendations................................e169 updating,andrevisingpracticeguidelinesforcardiovascular diseases and procedures, directs and oversees this effort. 6.6. PatientsWithEnd-StageRenalDiseaseon Dialysis:Recommendations.....................e169 Writing committees are charged with regularly reviewing 6.7. PatientsWithConcomitantValvularDisease: and evaluating all available evidence to develop balanced, Recommendations................................e170 patient-centric recommendations for clinical practice. 6.8. PatientsWithPreviousCardiacSurgery: Expertsinthesubjectunderconsiderationareselectedby Recommendation.................................e170 the ACCF and AHA to examine subject-specific data and 6.8.1. IndicationsforRepeatCABG ..............e170 write guidelines in partnership with representatives from 6.8.2. OperativeRisk..............................e170 other medical organizations and specialty groups. Writing 6.8.3. Long-TermOutcomes......................e170 committeesareaskedtoperformaformalliteraturereview; 6.9. PatientsWithPreviousStroke..................e171 weighthestrengthofevidencefororagainstparticulartests, 6.10. PatientsWithPAD................................e171 treatments,orprocedures;andincludeestimatesofexpected 7. EconomicIssues........................................e171 outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may 7.1. Cost-EffectivenessofCABGandPCI...........e172 influence the choice of tests or therapies are considered. 7.1.1. Cost-EffectivenessofCABGVersusPCI.......e172 When available, information from studies on cost is con- 7.1.2. CABGVersusPCIWithDES.............e172 sidered, but data on efficacy and outcomes constitute the 8. FutureResearchDirections...........................e172 primary basis for the recommendations contained herein. In analyzing the data and developing recommendations 8.1. HybridCABG/PCI.................................e173 and supporting text, the writing committee uses evidence- 8.2. ProteinandGeneTherapy.......................e173 basedmethodologiesdevelopedbytheTaskForce(1).The 8.3. TeachingCABGtotheNextGeneration: ClassofRecommendation(COR)isanestimateofthesize UseofSurgicalSimulators......................e173 of the treatment effect considering risks versus benefits in References..................................................e174 addition to evidence and/or agreement that a given treat- ment or procedure is or is not useful/effective or in some Appendix1.AuthorRelationshipsWithIndustry situationsmaycauseharm.TheLevelofEvidence(LOE)is andOtherEntities(Relevant)............................e204 an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence Appendix2.ReviewerRelationshipsWithIndustry supporting each recommendation with the weight of evi- andOtherEntitites(Relevant)...........................e207 dence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identi- Appendix3.AbbreviationList............................e210 fiedasobservational,retrospective,prospective,orrandom- ized where appropriate. For certain conditions for which inadequate data are available, recommendations are based Preamble on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are sup- The medical profession should play a central role in evalu- ported by historical clinical data, appropriate references atingtheevidencerelatedtodrugs,devices,andprocedures (including clinical reviews) are cited if available. For issues for the detection, management, and prevention of disease. for which sparse data are available, a survey of current Downloaded from content.onlinejacc.org by on May 21, 2012 e126 Hillisetal. JACCVol.58,No.24,2011 2011ACCF/AHACABGGuideline December6,2011:e123–210 Table1. ApplyingClassificationofRecommendationsandLevelofEvidence ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials. Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective. *Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheart failure,andprioraspirinuse.†Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirect comparisonsofthetreatmentsorstrategiesbeingevaluated. practice among the clinicians on the writing committee is In view of the advances in medical therapy across the the basis for LOE C recommendations, and no references spectrum of cardiovascular diseases, the Task Force has arecited.TheschemaforCORandLOEissummarizedin designated the term guideline(cid:1)directed medical therapy Table 1, which also provides suggested phrases for writing (GDMT)torepresentoptimalmedicaltherapyasdefinedby recommendationswithineachCOR.Anewadditiontothis ACCF/AHA guideline–recommended therapies (primarily methodology is separation of the Class III recommenda- Class I). This new term, GDMT, will be used herein and tionstodelineateiftherecommendationisdeterminedtobe throughout all future guidelines. of“nobenefit”orisassociatedwith“harm”tothepatient.In Because the ACCF/AHA practice guidelines address addition, in view of the increasing number of comparative patient populations (and healthcare providers) residing in effectiveness studies, comparator verbs and suggested North America, drugs that are not currently available in phrases for writing recommendations for the comparative North America are discussed in the text without a specific effectiveness of one treatment or strategy versus another COR. For studies performed in large numbers of subjects have been added for COR I and IIa, LOE A or B only. outsideNorthAmerica,eachwritingcommitteereviewsthe Downloaded from content.onlinejacc.org by on May 21, 2012 JACCVol.58,No.24,2011 Hillisetal. e127 December6,2011:e123–210 2011ACCF/AHACABGGuideline potentialinfluenceofdifferentpracticepatternsandpatient Additionally, to ensure complete transparency, writing com- populations on the treatment effect and relevance to the mittee members’ comprehensive disclosure information— ACCF/AHA target population to determine whether the includingRWInotpertinenttothisdocument—isavailableas findings should inform a specific recommendation. an online supplement. Comprehensive disclosure information TheACCF/AHApracticeguidelinesareintendedtoassist for the Task Force is also available online at www. healthcareprovidersinclinicaldecisionmakingbydescribinga cardiosource.org/ACC/About-ACC/Leadership/Guidelines- range of generally acceptable approaches to the diagnosis, and-Documents-Task-Forces.aspx. The work of the writing management,andpreventionofspecificdiseasesorconditions. committeewassupportedexclusivelybytheACCFandAHA Theguidelinesattempttodefinepracticesthatmeettheneeds without commercial support. Writing committee members of most patients in most circumstances. The ultimate judg- volunteeredtheirtimeforthisactivity. mentregardingthecareofaparticularpatientmustbemadeby Inanefforttomaintainrelevanceatthepointofcarefor thehealthcareproviderandpatientinlightofallthecircum- practicing physicians, the Task Force continues to oversee stances presented by that patient. As a result, situations may an ongoing process improvement initiative. As a result, in arise for which deviations from these guidelines may be response to pilot projects, evidence tables (with references appropriate. Clinical decision making should involve consid- linked to abstracts in PubMed) have been added. eration of the quality and availability of expertise in the area In April 2011, the Institute of Medicine released 2 wherecareisprovided.Whentheseguidelinesareusedasthe reports: Finding What Works in Health Care: Standards for basis for regulatory or payer decisions, the goal should be Systematic Reviews and Clinical Practice Guidelines We Can improvementinqualityofcare.TheTaskForcerecognizesthat Trust (2,3). It is noteworthy that the ACCF/AHA guide- situations arise in which additional data are needed to inform linesarecitedasbeingcompliantwithmanyoftheproposed patientcaremoreeffectively;theseareaswillbeidentifiedwithin standards. A thorough review of these reports and of our eachrespectiveguidelinewhenappropriate. current methodology is under way, with further enhance- Prescribed courses of treatment in accordance with these ments anticipated. recommendationsareeffectiveonlyiffollowed.Becauselackof The recommendations in this guideline are considered patient understanding and adherence may adversely affect currentuntiltheyaresupersededbyafocusedupdateorthe outcomes, physicians and other healthcare providers should full-textguidelineisrevised.Guidelinesareofficialpolicyof makeeveryefforttoengagethepatient’sactiveparticipationin both the ACCF and AHA. prescribedmedicalregimensandlifestyles.Inaddition,patients Alice K. Jacobs, MD, FACC, FAHA Chair shouldbeinformedoftherisks,benefits,andalternativestoa ACCF/AHA Task Force on Practice Guidelines particulartreatmentandbeinvolvedinshareddecisionmaking wheneverfeasible,particularlyforCORIIaandIIb,wherethe 1. Introduction benefit-to-riskratiomaybelower. The Task Force makes every effort to avoid actual, potential,orperceivedconflictsofinterestthatmayariseas 1.1. Methodology and Evidence Review aresultofindustryrelationshipsorpersonalinterestsamong the members of the writing committee. All writing com- Wheneverpossible,therecommendationslistedinthisdocu- mittee members and peer reviewers of the guideline are ment are evidence based. Articles reviewed in this guideline requiredtodiscloseallsuchcurrentrelationships,aswellas revision covered evidence from the past 10 years through thoseexisting12monthspreviously.InDecember2009,the January2011,aswellasselectedotherreferencesthroughApril ACCF and AHA implemented a new policy for relation- 2011. Searches were limited to studies, reviews, and other ships with industry and other entities (RWI) that requires evidenceconductedinhumansubjectsthatwerepublishedin thewritingcommitteechairplusaminimumof50%ofthe English.Keysearchwordsincludedbutwerenotlimitedtothe writing committee to have no relevant RWI (Appendix 1 following: analgesia, anastomotic techniques, antiplatelet agents, for the ACCF/AHA definition of relevance). These state- automated proximal clampless anastomosis device, asymptomatic ments are reviewed by the Task Force and all members ischemia,Cardica C-port,cost effectiveness,depressed left ventric- during each conference call and meeting of the writing ular(LV)function,distalanastomotictechniques,directproximal committee and are updated as changes occur. All guideline anastomosis on aorta, distal anastomotic devices, emergency coro- recommendationsrequireaconfidentialvotebythewriting nary artery bypass graft (CABG) and ST-elevation myocardial committee and must be approved by a consensus of the infarction(STEMI),heartfailure,interruptedsutures,LVsystolic voting members. Members are not permitted to write, and dysfunction, magnetic connectors, PAS-Port automated proximal must recuse themselves from voting on, any recommenda- clampless anastomotic device, patency, proximal connectors, renal tion or section to which their RWI apply. Members who disease, sequential anastomosis, sternotomy, symmetry connector, recused themselves from voting are indicated in the list of symptomaticischemia,proximalconnectors,sequentialanastomosis, writingcommitteemembers,andsectionrecusalsarenotedin T grafts, thoracotomy, U-clips, Ventrica Magnetic Vascular Port Appendix 1. Authors’ and peer reviewers’ RWI pertinent to system, Y grafts. Additionally, the committee reviewed docu- thisguidelinearedisclosedinAppendixes1and2,respectively. mentsrelatedtothesubjectmatterpreviouslypublishedbythe Downloaded from content.onlinejacc.org by on May 21, 2012 e128 Hillisetal. JACCVol.58,No.24,2011 2011ACCF/AHACABGGuideline December6,2011:e123–210 ACCF and AHA. References selected and published in this superviseanestheticcareofpatientswhoareconsideredtobeat documentarerepresentativebutnotall-inclusive. highrisk(16–18).(LevelofEvidence:C) To provide clinicians with a comprehensive set of data, CLASSIIa wheneverdeemedappropriateorwhenpublished,theabsolute 1. Volatile anesthetic-based regimens can be useful in facilitating risk difference and number needed to treat or harm are early extubation and reducing patient recall (5,19–21). (Level of providedintheguideline,alongwithconfidenceinterval(CI) Evidence:A) and data related to the relative treatment effects such as odds ratio(OR),relativerisk(RR),hazardratio(HR),orincidence CLASSIIb 1. Theeffectivenessofhighthoracicepiduralanesthesia/analgesiafor rateratio. routineanalgesicuseisuncertain(22–25).(LevelofEvidence:B) Thefocusoftheseguidelinesisthesafe,appropriate,and efficacious performance of CABG. CLASSIII:HARM 1. Cyclooxygenase-2inhibitorsarenotrecommendedforpainreliefin 1.2. Organization of the Writing Committee thepostoperativeperiodafterCABG(26,27).(LevelofEvidence:B) The committee was composed of acknowledged experts in 2. Routineuseofearlyextubationstrategiesinfacilitieswithlimited CABG, interventional cardiology, general cardiology, and backupforairwayemergenciesoradvancedrespiratorysupportis potentiallyharmful.(LevelofEvidence:C) cardiovascularanesthesiology.Thecommitteeincludedrep- resentatives from the ACCF, AHA, American Association SeeOnlineDataSupplement1foradditionaldataonanesthetic for Thoracic Surgery, Society of Cardiovascular Anesthesi- considerations. ologists, and Society of Thoracic Surgeons (STS). Anesthetic management of the CABG patient mandates 1.3. Document Review and Approval a favorable balance of myocardial oxygen supply and de- This document was reviewed by 2 official reviewers, each mand to prevent or minimize myocardial injury (Section nominated by both the ACCF and the AHA, as well as 1 2.1.8). Historically, the popularity of several anesthetic reviewer each from the American Association for Thoracic techniques for CABG has varied on the basis of their Surgery, Society of Cardiovascular Anesthesiologists, and known or potential adverse cardiovascular effects (e.g., STS,aswellasmembersfromtheACCF/AHATaskForce cardiovascular depression with high doses of volatile anes- on Data Standards, ACCF/AHA Task Force on Perfor- thesia, lack of such depression with high-dose opioids, or mance Measures, ACCF Surgeons’ Scientific Council, coronaryvasodilationandconcernfora“steal”phenomenon ACCF Interventional Scientific Council, and Southern with isoflurane) as well as concerns about interactions with Thoracic Surgical Association. All information on review- preoperative medications (e.g., cardiovascular depression ers’ RWI was distributed to the writing committee and is with beta blockers or hypotension with angiotensin- published in this document (Appendix 2). converting enzyme [ACE] inhibitors and angiotensin- This document was approved for publication by the receptorblockers[ARBs][28–30])(Sections2.1.8and4.5). governingbodiesoftheACCFandtheAHAandendorsed Independentoftheseconcerns,effortstoimproveoutcomes by the American Association for Thoracic Surgery, Society and to reduce costs have led to shorter periods of postop- of Cardiovascular Anesthesiologists, and STS. erativemechanicalventilationandeven,insomepatients,to prompt extubation in the operating room (“accelerated 2. Procedural Considerations recovery protocols” or “fast-track management”) (5,31). High-dose opioid anesthesia with benzodiazepine sup- 2.1. Intraoperative Considerations plementationwasusedcommonlyinCABGpatientsinthe United States in the 1970s and 1980s. Subsequently, it 2.1.1. Anesthetic Considerations: Recommendations became clear that volatile anesthetics are protective in the CLASSI settingofmyocardialischemiaandreperfusion,andthis,in 1. Anestheticmanagementdirectedtowardearlypostoperativeextu- combination with a shift to accelerated recovery or “fast- bation and accelerated recovery of low- to medium-risk patients track” strategies, led to their ubiquitous use. As a result, undergoinguncomplicatedCABGisrecommended(4–6).(Levelof opioids have been relegated to an adjuvant role (32,33). Evidence:B) Despite their widespread use, volatile anesthetics have not 2. Multidisciplinaryeffortsareindicatedtoensureanoptimallevelof been shown to provide a mortality rate advantage when analgesiaandpatientcomfortthroughouttheperioperativeperiod compared with other intravenous regimens (Section 2.1.8). (7–11).(LevelofEvidence:B) Optimal anesthesia care in CABG patients should in- 3. Effortsarerecommendedtoimproveinterdisciplinarycommunication clude 1) a careful preoperative evaluation and treatment of andpatientsafetyintheperioperativeenvironment(e.g.,formalized modifiableriskfactors;2)properhandlingofallmedications checklist-guidedmultidisciplinarycommunication)(12–15).(Levelof Evidence:B) given preoperatively (Sections 4.1, 4.3, and 4.5); 3) estab- 4. Afellowship-trainedcardiacanesthesiologist(orexperiencedboard- lishmentofcentralvenousaccessandcarefulcardiovascular certifiedpractitioner)credentialedintheuseofperioperativetrans- monitoring; 4) induction of a state of unconsciousness, esophagealechocardiography(TEE)isrecommendedtoprovideor analgesia,andimmobility;and5)asmoothtransitiontothe Downloaded from content.onlinejacc.org by on May 21, 2012 JACCVol.58,No.24,2011 Hillisetal. e129 December6,2011:e123–210 2011ACCF/AHACABGGuideline early postoperative period, with a goal of early extubation, occurrence of epidural hematoma or abscess, these entities patient mobilization, and hospital discharge. Attention occur on occasion (38). Finally, the use of other regional should be directed at preventing or minimizing adverse anesthetic approaches for postoperative analgesia, such as hemodynamic and hormonal alterations that may induce parasternal block, has been reported (39). myocardialischemiaorexertadeleteriouseffectonmyocar- Over the past decade, early extubation strategies (“fast- dial metabolism (as may occur during cardiopulmonary track”anesthesia)oftenhavebeenusedinlow-tomedium- bypass [CPB]) (Section 2.1.8). This requires close interac- riskCABGpatients.Thesestrategiesallowashortertimeto tion between the anesthesiologist and surgeon, particularly extubation, a decreased length of intensive care unit (ICU) when manipulation of the heart or great vessels is likely to stay, and variable effects on length of hospital stay (4–6). induce hemodynamic instability. During on-pump CABG, Immediate extubation in the operating room, with or particular care is required during vascular cannulation and without markedly accelerated postoperative recovery path- weaning from CPB; with off-pump CABG, the hemody- ways (e.g., “ultra-fast-tracking,” “rapid recovery protocol,” namic alterations often caused by displacement or vertical- “short-stay intensive care”) have been used safely, with low ization of the heart and application of stabilizer devices on rates of reintubation and no influence on quality of life theepicardium,withresultantchangesinheartrate,cardiac (40–44). Observational data suggest that physician judg- output, and systemic vascular resistance, should be moni- ment in triaging lower-risk patients to early or immediate tored carefully and managed appropriately. extubationworkswell,withratesofreintubation(cid:2)1%(45). In the United States, nearly all patients undergoing Certainfactorsappeartopredictfast-track“failure,”includ- CABG receive general anesthesia with endotracheal intu- ing previous cardiac surgery, use of intra-aortic balloon bation utilizing volatile halogenated general anesthetics counterpulsation, and possibly advanced patient age. with opioid supplementation. Intravenous benzodiazepines Provisionofadequateperioperativeanalgesiaisimportant often are given as premedication or for induction of anes- in enhancing patient mobilization, preventing pulmonary thesia, along with other agents such as propofol or etomi- complications, and improving the patient’s psychological date.Nondepolarizingneuromuscular-blockingagents,par- well-being (9,11). The intraoperative use of high-dose ticularly nonvagolytic agents with intermediate duration of morphine (40 mg) may offer superior postoperative pain action, are preferred to the longer-acting agent, pancuro- reliefandenhancepatientwell-beingcomparedwithfenta- nium. Use of the latter is associated with higher intraoper- nyl (despite similar times to extubation) (46). ative heart rates and a higher incidence of residual neuro- The safety of nonsteroidal anti-inflammatory agents for muscular depression in the early postoperative period, with analgesia is controversial, with greater evidence for adverse a resultant delay in extubation (23,34). In addition, low cardiovascular events with the selective cyclooxygenase-2 concentrations of volatile anesthetic usually are adminis- inhibitors than the nonselective agents. A 2007 AHA tered via the venous oxygenator during CPB, facilitating scientific statement presented a stepped-care approach to amnesia and reducing systemic vascular resistance. themanagementofmusculoskeletalpaininpatientswithor Outside the United States, alternative anesthetic tech- at risk for coronary artery disease (CAD), with the goal of niques,particularlytotalintravenousanesthesiaviapropofol limiting the use of these agents to patients in whom safer and opioid infusions with benzodiazepine supplementation therapies fail (47). In patients hospitalized with unstable with or without high thoracic epidural anesthesia, are angina (UA) and non–ST-elevation myocardial infarction commonlyused.Theuseofhighthoracicepiduralanesthe- (NSTEMI), these agents should be discontinued promptly siaexertssalutaryeffectsonthecoronarycirculationaswell and reinstituted later according to the stepped-care ap- asmyocardialandpulmonaryfunction,attenuatesthestress proach (48). response, and provides prolonged postoperative analgesia In the setting of cardiac surgery, nonsteroidal anti- (24,25,35). In the United States, however, concerns about inflammatory agents previously were used for perioperative the potential for neuraxial bleeding (particularly in the analgesia. A meta-analysis of 20 trials of patients undergo- setting of heparinization, platelet inhibitors, and CPB- ing thoracic or cardiac surgery, which evaluated studies induced thrombocytopenia), local anesthetic toxicity, and published before 2005, reported significant reductions in logistical issues related to the timing of epidural catheter pain scores, with no increase in adverse outcomes (49). Sub- insertion and management have resulted in limited use of sequently, 2 RCTs, both studying the oral cyclooxygenase-2 these techniques (22). Their selective use in patients with inhibitorvaldecoxibanditsintravenousprodrug,parecoxib, severepulmonarydysfunction(Section6.5)or chronicpain reported a higher incidence of sternal infections in 1 trial syndromes may be considered. Although meta-analyses of andasignificantincreaseinadversecardiovasculareventsin randomized controlled trials (RCTs) of high thoracic epi- the other (26,27). On the basis of the results of these 2 dural anesthesia/analgesia in CABG patients (particularly studies(aswellasothernonsurgicalreportsofincreasedrisk on-pump) have yielded inconsistent results on morbidity withcyclooxygenase-2–selectiveagents),theU.S.Foodand and mortality rates, it does appear to reduce time to Drug Administration in 2005 issued a “black box” warning extubation,pain,andpulmonarycomplications(36–38).Of forallnonsteroidalanti-inflammatoryagents(exceptaspirin) interest, although none of the RCTs have reported the immediatelyafterCABG(50).Theconcurrentadministration Downloaded from content.onlinejacc.org by on May 21, 2012 e130 Hillisetal. JACCVol.58,No.24,2011 2011ACCF/AHACABGGuideline December6,2011:e123–210 of ibuprofen with aspirin has been shown to attenuate the retrieved from the operative field during on-pump CABG latter’s inhibition of platelet aggregation, likely because of contains lipid material and particulate matter, which have competitive inhibition of cyclooxygenase at the platelet- been implicated as possible causes of postoperative neuro- receptorbindingsite(51). cognitive dysfunction. Although a study (59) reported that Observationalanalysesinpatientsundergoingnoncardiac CPB-associated neurocognitive dysfunction can be miti- surgery have shown a significant reduction in perioperative gated by the routine processing of shed blood with a cell death with the use of checklists, multidisciplinary surgical saverbeforeitsreinfusion,anotherstudy(60)failedtoshow care, intraoperative time-outs, postsurgical debriefings, and such an improvement. othercommunicationstrategies(14,15).Suchmethodology It has been suggested that CPB leads to an increased is being used increasingly in CABG patients (12–14). incidence of postoperative renal failure requiring dialysis, In contrast to extensive literature on the role of the butalargeRCTcomparingon-pumpandoff-pumpCABG surgeonindeterminingoutcomeswithCABG,limiteddata showednodifferenceinitsoccurrence(61).Ofinterest,this on the influence of the anesthesiologist are available. Of 2 study failed to show a decreased incidence of postoperative such reports from single centers in the 1980s, 1 suggested adverseneurologicalevents(stroke,coma,orneurocognitive that the failure to control heart rate to (cid:1)110 beats per deficit) in those undergoing off-pump CABG. minutewasassociatedwithahighermortalityrate,andthe TheoccurrenceofSIRSinpatientsundergoingCPBhas other suggested that increasing duration of CPB adversely led to the development of strategies designed to prevent or influencedoutcome(52,53).Anotherobservationalanalysis to minimize its occurrence. Many reports have focused on of data from vascular surgery patients suggested that anes- the increased serum concentrations of cytokines (e.g., IL-2R, thetic specialization was independently associated with a IL-6, IL-8, tumor necrosis factor alpha) and other modu- reduction in mortality rate (54). lators of inflammation (e.g., P-selectin, sE-selectin, soluble Tomeetthechallengesofprovidingcarefortheincreas- intercellular adhesion molecule-1, plasma endothelial cell ingly higher-risk patients undergoing CABG, efforts have adhesion molecule-1, and plasma malondialdehyde), which been directed at enhancing the experience of trainees, reflect leukocyte and platelet activation, in triggering the particularly in the use of newer technologies such as TEE. onset of SIRS. A study showed a greater upregulation of Cardiac anesthesiologists, in collaboration with cardiolo- neutrophil CD11b expression (a marker of leukocyte acti- gistsandsurgeons,haveimplementednationaltrainingand vation) in patients who sustained a (cid:2)50% increase in the certificationprocessesforpractitionersintheuseofperiop- serum creatinine concentration after CPB, thereby impli- erative TEE (Section 2.1.7) (164,165). Accreditation of catingactivatedneutrophilsinthepathophysiologyofSIRS cardiothoracic anesthesia fellowship programs from the and the occurrence of post-CPB renal dysfunction (62). AccreditationCouncilforGraduateMedicalEducationwas Modulating neutrophil activation to reduce the occurrence initiated in 2004, and efforts are ongoing to obtain formal of SIRS has been investigated; however, the results have subspecialty certification (18). been inconsistent. Preoperative intravenous methylpred- nisolone (10 mg/kg) caused a reduction in the serum 2.1.2. Use of CPB concentrations of many of these cytokines after CPB, but Several adverse outcomes have been attributed to CPB, this reduction was not associated with improved hemody- including 1) neurological deficits (e.g., stroke, coma, post- namicvariables,diminishedbloodloss,lessuseofinotropic operativeneurocognitivedysfunction);2)renaldysfunction; agents, shorter duration of ventilation, or shorter ICU and 3) the Systemic Inflammatory Response Syndrome lengthofstay(63).Similarly,theuseofintravenousimmu- (SIRS). The SIRS is manifested as generalized systemic noglobulinGinpatientswithpost-CPBSIRShasnotbeen inflammationoccurringafteramajormorbidevent,suchas associated with decreased rates of short-term morbidity or trauma, infection, or major surgery. It is often particularly 28-day mortality (64). apparent after on-pump cardiac surgery, during which OtherstrategiestomitigatetheoccurrenceofSIRSafter surgical trauma, contact of blood with nonphysiological CPB have been evaluated, including the use of 1) CPB surfaces (e.g., pump tubing, oxygenator surfaces), myocar- circuits (including oxygenators) coated with materials dialischemiaandreperfusion,andhypothermiacombineto known to reduce complement and leukocyte activation; cause a dramatic release of cytokines (e.g., interleukin [IL] 2) CPB tubing that is covalently bonded to heparin; and 6andIL8)andothermediatorsofinflammation(55).Some 3) CPB tubing coated with polyethylene oxide polymer or investigators have used serum concentrations of S100 beta Poly(2-methoxyethylacrylate).Leukocytedepletionviaspe- as a marker of brain injury (56) and have correlated cializedfiltersintheCPBcircuitshasbeenshowntoreduce increased serum levels with the number of microemboli the plasma concentrations of P-selectin, intercellular adhe- exiting the CPB circuit during CABG. In contrast, others sion molecule-1, IL-8, plasma endothelial cell adhesion have noted the increased incidence of microemboli with molecule-1, and plasma malondialdehyde after CPB (65). on-pump CABG (relative to off-pump CABG) but have Finally, closed mini-circuits for CPB have been devel- failedtoshowacorrespondingworseningofneurocognitive opedinanattempttominimizetheblood–airinterfaceand function1weekto6monthspostoperatively(57,58).Blood blood contact with nonbiological surfaces, both of which Downloaded from content.onlinejacc.org by on May 21, 2012 JACCVol.58,No.24,2011 Hillisetal. e131 December6,2011:e123–210 2011ACCF/AHACABGGuideline promote cytokine elaboration, but it is uncertain if these off-pump CABG; p(cid:3)0.19). The primary long-term end- maneuvers and techniques have a discernible effect on out- point, a composite of death from any cause, a repeat comesafterCABG. revascularizationprocedure,oranonfatalmyocardialinfarc- tion (MI) within 1 year of surgery, occurred more often in 2.1.3. Off-Pump CABG Versus those undergoing off-pump CABG (9.9%) than in those Traditional On-Pump CABG havingon-pumpCABG(7.4%;p(cid:3)0.04).Neuropsycholog- SincethefirstCABGwasperformedinthelate1960s,the icaloutcomesandresourceutilizationweresimilarbetween standard surgical approach has included the use of cardiac the 2 groups. One year after surgery, graft patency was arrest coupled with CPB (so-called on-pump CABG), higher in the on-pump group (87.8% versus 82.6%; thereby optimizing the conditions for construction of vas- p(cid:2)0.01).Inshort,theROOBYinvestigatorsfailedtoshow cular anastomoses to all diseased coronary arteries without anadvantageofoff-pumpCABGcomparedwithon-pump cardiac motion or hemodynamic compromise. Such on- CABGinapatientpopulationconsideredtobeatlowrisk. pump CABG has become the gold standard and is per- Instead, use of the on-pump technique was associated with formed in about 80% of subjects undergoing the procedure better 1-year composite outcomes and 1-year graft patency intheUnitedStates.Despitetheexcellentresultsthathave rates,withnodifferenceinneuropsychologicaloutcomesor been achieved, the use of CPB and the associated manipu- resource utilization. lation of the ascending aorta are linked with certain peri- Althoughnumerousinvestigatorshaveusedsingle-center operative complications, including myonecrosis during aor- registries, the STS database, and meta-analyses in an tic occlusion, cerebrovascular accidents, generalized attempt to identify patient subgroups in whom off-pump neurocognitivedysfunction,renaldysfunction,andSIRS.In CABGisthepreferredprocedure,eventheseanalyseshave anefforttoavoidthesecomplications,off-pumpCABGwas reached inconsistent conclusions about off-pump CABG’s developed (58,66). Off-pump CABG is performed on the ability to reduce morbidity and mortality rates (69,72–83). beating heart with the use of stabilizing devices (which A retrospective cohort study of 14,766 consecutive patients minimizecardiacmotion);inaddition,itincorporatestech- undergoing isolated CABG identified a mortality benefit niques to minimize myocardial ischemia and systemic he- (OR:0.45)foroff-pumpCABGinpatientswithapredicted modynamic compromise. As a result, the need for CPB is riskofmortality(cid:4)2.5%(82),butasubsequentrandomized obviated. This technique does not necessarily decrease the comparison of off-pump CABG to traditional on-pump need for manipulation of the ascending aorta during con- CABGin341high-riskpatients(aEuroscore(cid:4)5)showed struction of the proximal anastomoses. no difference in the composite endpoint of all-cause death, Todate,theresultsofseveralRCTscomparingon-pump acute MI, stroke, or a required reintervention procedure and off-pump CABG in various patient populations have (78).AnanalysisofdatafromtheNewYorkStateCardiac beenpublished(61,67,68).Inaddition,registrydataandthe Surgery Reporting system did not demonstrate a reduction resultsofmeta-analyseshavebeenusedtoassesstherelative in mortality rate with off-pump CABG in any patient efficacies of the 2 techniques (69,70). In 2005, an AHA subgroup, including the elderly (age (cid:4)80 years) or those scientific statement comparing the 2 techniques concluded with cerebrovascular disease, azotemia, or an extensively that both procedures usually result in excellent outcomes calcified ascending aorta (69). andthatneithertechniqueshouldbeconsideredsuperiorto Despite these results, off-pump CABG is the preferred the other (71). At the same time, several differences were approach by some surgeons who have extensive experience noted.Off-pumpCABGwasassociatedwithlessbleeding, with it and therefore are comfortable with its technical lessrenaldysfunction,ashorterlengthofhospitalstay,and nuances.Recently,publisheddatasuggestedthattheavoid- lessneurocognitivedysfunction.Theincidenceofperioper- ative stroke was similar with the 2 techniques. On-pump ance of aortic manipulation is the most important factor in CABG was noted to be less technically complex and reducing the risk of neurological complications (84,85). allowedbetteraccesstodiseasedcoronaryarteriesincertain Patientswithextensivediseaseoftheascendingaortaposea anatomic locations (e.g., those on the lateral LV wall) as special challenge for on-pump CABG; for these patients, well as better long-term graft patency. cannulation or cross-clamping of the aorta may create an In2009,theresultsofthelargestRCTtodatecomparing unacceptably high risk of stroke. In such individuals, off- on-pump CABG to off-pump CABG, the ROOBY (Ran- pump CABG in conjunction with avoidance of manipula- domized On/Off Bypass) trial, were published, reporting tion of the ascending aorta (including placement of proxi- the outcomes for 2,203 patients (99% men) at 18 Veterans mal anastomoses) may be beneficial. Surgeons typically Affairs Medical Centers (61). The primary short-term end- prefer an on-pump strategy in patients with hemodynamic point, a composite of death or complications (reoperation, compromise because CPB offers support for the systemic new mechanical support, cardiac arrest, coma, stroke, or circulation. In the end, most surgeons consider either renal failure) within 30 days of surgery, occurred with approach to be reasonable for the majority of subjects similar frequency (5.6% for on-pump CABG; 7.0% for undergoing CABG. Downloaded from content.onlinejacc.org by on May 21, 2012