There was a small but statistically sig- ni cant increase in the rate of stroke in the aspiration thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n 20,960) found no signi cant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associated with a small but nonsigni cant increase in the risk of stroke (33). Several previous studies have found that higher thrombus burden in patients with STEMI is independently associated with higher risks of distal embolization, no- re ow phenomenon, transmural myocardial necrosis, major adverse cardiac events, stent thrombosis, and death (38 42). However, subgroup analyses from the TASTE and TOTAL trials did not suggest relative bene t from aspira- tion thrombectomy before primary PCI in patients with higher thrombus burden or in patients with initial Throm- bolysis in Myocardial Infarction (TIMI) ow grade 0 1 or left anterior descending artery/anterior infarction (34,35). On the basis of the results of these studies, the prior Class IIa recommendation for aspiration thrombectomy has been changed. Routine aspiration thrombectomy before primary PCI is now not recommended (Class III: No Bene t, LOE A). There are insuf cient data to assess the Recommendation 2015 Focused Update Recommendations Comments Class IIa Class IIb Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI (29 32). (Level of Evidence: B) The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established (33 37). (Level of Evidence: C-LD) Modi ed recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Bene t Routine aspiration thrombectomy before primary PCI is not useful (33 37).


Class III: No Bene t Routine aspiration thrombectomy before primary PCI is not useful (33 37). (Level of Evidence: A) New recommendation ( Class III: No Bene t added for routine aspiration thrombectomy before PCI). PCI indicates percutaneous coronary intervention; and LD, limited data. Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 potential bene t of a strategy of selective or bailout aspiration thrombectomy (Class IIb, LOE C-LD). Bailout aspiration thrombectomy is de ned as thrombectomy that was initially unplanned but was later used during the procedure because of unsatisfactory initial result or procedural complication, analogous to the de nition of bailout glycoprotein IIb/IIIa use. It should be noted that the preceding recommenda- tions and text apply only to aspiration thrombectomy; no clinical bene t for routine rheolytic thrombectomy has been demonstrated in patients with STEMI undergoing primary PCI (30,43,44). PRESIDENTS AND STAFF American College of Cardiology Kim A. Williams, Sr, MD, FACC, FAHA, President Shalom Jacobovitz, Chief Executive Of cer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications Amelia Scholtz, PhD, Publications Manager, Science, Education, and Quality American College of Cardiology/American Heart Association Lisa Brad eld, CAE, Director, Science and Clinical Policy Abdul R. Abdullah, MD, Associate Science and Medicine Advisor Allison Rabinowitz, Project Manager, Science and Clinical Policy American Heart Association Mark A. Creager, MD, FAHA, FACC, President Nancy Brown, Chief Executive Of cer Rose Marie Robertson, MD, FAHA, Chief Science Of cer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Of ce of Science Operations JodyHundley,ProductionManager,Scienti cPublications, Of ce of Science Operations R E F E R E N C E S 1. ACCF/AHA Task Force on Practice Guidelines.


PRESIDENTS AND STAFF American College of Cardiology Kim A. Williams, Sr, MD, FACC, FAHA, President Shalom Jacobovitz, Chief Executive Of cer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications Amelia Scholtz, PhD, Publications Manager, Science, Education, and Quality American College of Cardiology/American Heart Association Lisa Brad eld, CAE, Director, Science and Clinical Policy Abdul R. Abdullah, MD, Associate Science and Medicine Advisor Allison Rabinowitz, Project Manager, Science and Clinical Policy American Heart Association Mark A. Creager, MD, FAHA, FACC, President Nancy Brown, Chief Executive Of cer Rose Marie Robertson, MD, FAHA, Chief Science Of cer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Of ce of Science Operations JodyHundley,ProductionManager,Scienti cPublications, Of ce of Science Operations R E F E R E N C E S 1. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/ AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association. 2010. Available at: http://assets.cardiosource.com/ Methodology_Manual_for_ACC_AHA_Writing_Committees. pdf and http://my.americanheart.org/idc/groups/ ahamah-public/@wcm/@sop/documents/downloadable/ ucm_319826.pdf. Accessed January 23, 2015. 2. Committee on Standards for Developing Trust- worthy Clinical Practice Guidelines, Institute of Medi- cine (US). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press, 2011. 3. Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (US). Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: National Academies Press, 2011. 4. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/Amer- ican Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2304 22. 5. Arnett DK, Goodman RA, Halperin JL, et al.


2014;63:2304 22. 5. Arnett DK, Goodman RA, Halperin JL, et al. AHA/ ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services. J Am Coll Cardiol. 2014;64:1851 6. 6. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Founda- tion/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:213 65. 7. Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30- year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:1373 84. 8. Halperin JL, Levine GN, Al-Khatib SM, et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classi cation system: a report of the American College of Cardiology/American Heart Asso- ciation Task Force on Clinical Practice Guidelines [published online ahead of print September 23, 2015]. J Am Coll Cardiol. 2015, http://dx.doi.org/10.1016/ j.jacc.2015.09.001. 9. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Car- diology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Car- diovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44 122. 10. O Gara PT, Kushner FG, Ascheim DD, et al. 2013 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. J Am Coll Cardiol. 2013;61:e78 140. 11. Hannan EL, Samadashvili Z, Walford G, et al.


2013;61:e78 140. 11. Hannan EL, Samadashvili Z, Walford G, et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease. J Am Coll Cardiol Intv. 2010;3:22 31. 12. Toma M, Buller CE, Westerhout CM, et al. Non- culprit coronary artery percutaneous coronary inter- vention during acute ST-segment elevation myocardial infarction: insights from the APEX-AMI trial. Eur Heart J. 2010;31:1701 7. 13. Vlaar PJ, Mahmoud KD, Holmes DR Jr., et al. Culprit vessel only versus multivessel and staged percuta- neous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta- analysis. J Am Coll Cardiol. 2011;58:692 703. 14. Cavender MA, Milford-Beland S, Roe MT, et al. Prevalence, predictors, and in-hospital outcomes of non-infarct artery intervention during primary percuta- neous coronary intervention for ST-segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009;104:507 13. 15. Corpus RA, House JA, Marso SP, et al. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J. 2004;148:493 500. 16. Dziewierz A, Siudak Z, Rakowski T, et al. Impact of multivessel coronary artery disease and noninfarct- related artery revascularization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary inter- vention (from the EUROTRANSFER Registry). Am J Cardiol. 2010;106:342 7. 17. Engstr m T, Kelb k H, Helqvist S, et al. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI 3-PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386:665 71. 18. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel Disease: the CvLPRIT trial.


Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel Disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963 72. 19. Kornowski R, Mehran R, Dangas G, et al. Prognostic impact of staged versus one-time multivessel percutaneous intervention in acute myocardial infarc- tion: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol. 2011;58: 704 11. 20. Manari A, Varani E, Guastaroba P, et al. Long-term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit-only, immediate, or staged multivessel percutaneous revascularization strategies: insights J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. from the REAL registry. Catheter Cardiovasc Interv. 2014;84:912 22. 21. Politi L, Sgura F, Rossi R, et al. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Heart. 2010;96:662 7. 22. Roe MT, Cura FA, Joski PS, et al. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction. Am J Cardiol. 2001;88:170 3, A6. 23. Varani E, Balducelli M, Aquilina M, et al. Single or multivessel percutaneous coronary intervention in ST-elevation myocardial infarction patients. Catheter Cardiovasc Interv. 2008;72:927 33. 24. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115 23. 25. Sorajja P, Gersh BJ, Cox DA, et al. Impact of mul- tivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007;28:1709 16. 26. Park D-W, Clare RM, Schulte PJ, et al.


2007;28:1709 16. 26. Park D-W, Clare RM, Schulte PJ, et al. Extent, loca- tion, and clinical signi cance of non-infarct-related cor- onary artery disease among patients with ST-elevation myocardial infarction. JAMA. 2014;312:2019 27. 27. Hlinomaz O. Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revas- cularization versus conservative strategy. PRAGUE 13 trial. Available at: http://sbhci.org.br/wp-content/ September 10, 2015. 28. Vlaar PJ, Mahmoud KD, Holmes DR Jr., et al. Culprit vessel only versus multivessel and staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58:692 703. 29. Vlaar PJ, Svilaas T, van der Horst IC, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008;371:1915 20. 30. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehen- sive meta-analysis of randomized trials. Eur Heart J. 2008;29:2989 3001. 31. Sardella G, Mancone M, Bucciarelli-Ducci C, et al. Thrombus aspiration during primary percutaneous cor- onary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention) prospective, ran- domized trial. J Am Coll Cardiol. 2009;53:309 15. 32. Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspiration during primary percutaneous coronary inter- vention. N Engl J Med. 2008;358:557 67. 33. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy bene cial in patients undergoing pri- mary percutaneous coronary intervention? Meta- analysis of randomized trials. Circ Cardiovasc Interv. 2015;8:e002258. 34. Fr bert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med.


Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013;369: 1587 97. 35. Jolly SS, Cairns JA, Yusuf S, et al. Randomized trial of primary PCI with or without routine manual throm- bectomy. N Engl J Med. 2015;372:1389 98. 36. Lagerqvist B, Fr bert O, Olivecrona GK, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111 20. 37. Stone GW, Maehara A, Witzenbichler B, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307: 1817 26. 38. Napodano M, Dariol G, Al Mamary AH, et al. Thrombus burden and myocardial damage during primary percutaneous coronary intervention. Am J Cardiol. 2014;113:1449 56. 39. Sianos G, Papafaklis MI, Daemen J, et al. Angio- graphic stent thrombosis after routine use of drug- eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol. 2007;50:573 83. 40. Yip HK, Chen M-C, Chang H-W, et al. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow- ow and no-re ow phenomenon. Chest. 2002;122:1322 32. 41. Brener SJ, Dambrink J-H, Maehara A, et al. Bene ts of optimising coronary ow before stenting in primary percutaneous coronary intervention for ST-elevation myocardial infarction: insights from INFUSE-AMI. EuroIntervention. 2014;9:1195 201. 42. Costa RA, Abizaid A, Lotan C, et al. Impact of thrombus burden on outcomes after standard versus mesh-covered stents in acute myocardial infarction (from the MGuard for acute ST elevation reperfusion trial). Am J Cardiol. 2015;115:161 6. 43. Ali A, Cox D, Dib N, et al. Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study. J Am Coll Cardiol. 2006;48:244 52. 44.


Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study. J Am Coll Cardiol. 2006;48:244 52. 44. Migliorini A, Stabile A, Rodriguez AE, et al. Com- parison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol. 2010;56: 1298 306. KEY WORDS ACC/AHA Clinical Practice Guideline, culprit vessel, focused update, multivessel, myocardial infarction, primary PCI, thrombectomy Levine et al. J A C C V O L . 6 7 , N O .


J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Glenn N. Levine, Chair Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates, Vice Chair University of Michigan Professor of Medicine  Merck  Sano -aventis None None None None None 2 and 3 James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scienti c  Volcano None None 2 and 3 Steven R. Bailey University of Texas Medical Center Professor of Medicine and Radiology None None None None None None None John A. Bittl Munroe Heart Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation Section Head, Invasive and Interventional Cardiology  Abbott  Boston Scienti c  Medtronic None None None None None 2 and 3 Robert A. Guyton Emory Clinic, Inc.


1 0 , 2 0 1 6 Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Glenn N. Levine, Chair Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates, Vice Chair University of Michigan Professor of Medicine  Merck  Sano -aventis None None None None None 2 and 3 James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scienti c  Volcano None None 2 and 3 Steven R. Bailey University of Texas Medical Center Professor of Medicine and Radiology None None None None None None None John A. Bittl Munroe Heart Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation Section Head, Invasive and Interventional Cardiology  Abbott  Boston Scienti c  Medtronic None None None None None 2 and 3 Robert A. Guyton Emory Clinic, Inc. Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None 2 and 3 Steven M. Hollenberg Cooper Medical School of Rowan University Professor of Medicine None None None None None None None Umesh N. Khot Cleveland Clinic Vice Chairman, Department of Cardiovascular Medicine  AstraZeneca None None None None None None Richard A. Lange Texas Tech University Health Sciences Center El Paso President None None None None None None None Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scienti c  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sano -aventis Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scienti c  Janssen (John- son & Johnson)  Merck  Sano -aventis None None  BMS/Sano - aventis  Regado  STENTYS None None 2 and 3 Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Of cer None None None None None None None Continued on the next page APPENDIX 1.


Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None 2 and 3 Steven M. Hollenberg Cooper Medical School of Rowan University Professor of Medicine None None None None None None None Umesh N. Khot Cleveland Clinic Vice Chairman, Department of Cardiovascular Medicine  AstraZeneca None None None None None None Richard A. Lange Texas Tech University Health Sciences Center El Paso President None None None None None None None Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scienti c  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sano -aventis Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scienti c  Janssen (John- son & Johnson)  Merck  Sano -aventis None None  BMS/Sano - aventis  Regado  STENTYS None None 2 and 3 Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Of cer None None None None None None None Continued on the next page APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (PERCUTANEOUS CORONARY INTERVENTION WRITING COMMITTEE) (NOVEMBER J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. APPENDIX 1.


1 0 , 2 0 1 6 Levine et al. APPENDIX 1. CONTINUED Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Debabrata Mukherjee Texas Tech University Chief, Cardiovascular Medicine None None None None None None None Henry H. Ting New York Presbyterian Hospital, The University Hospital of Columbia and Cornell Senior Vice President and Chief Quality Of cer None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.


Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their speci c relationships with industry and other entities may apply. No nancial bene t. Signi cant relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interventions. Levine et al. J A C C V O L . 6 7 , N O .


J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Patrick T. O Gara, Chair Harvard Medical School Professor of Medicine None None None None None None None Frederick G. Kushner, Vice Chair Tulane University School of Medicine Clinical Professor of Medicine; Heart Clinic of Louisiana Medical Director None None None None None None None Deborah D. Ascheim Mount Sinai School of Medicine Associate Professor; InCHOIR Clinical Director of Research None None None None None None None Ralph G. Brindis UCSF Philip R. Lee Institute for Health Policy Studies Clinical Professor of Medicine None None None None None None None Donald E. Casey, Jr. Thomas Jefferson College of Population Health Adjunct Faculty; Alvarez & Marsal and Founder None None None None None None None Mina K. Chung Cleveland Clinic Foundation Professor of Medicine  Boston Scienti c  Medtronic  St. Jude Medical None None  Biosense Webster  Boston Scienti c  Medtronic  St. Jude Medical None None 2 and 3 James A. de Lemos UT Southwestern Medical Center Professor of Medicine  Abbott Diagnostics  Novo Nordisc  St. Jude Medical None None  Abbott Diagnostics None None 2 and 3 Deborah B. Diercks UT Southwestern Medical Center Audre and Bernard Rapoport Distinguished Chair in Clinical Care and Research; Department of Emergency Medicine Professor and Chair None None None None None None None James C. Fang University of Utah Cardiovascular Division  Boston Scienti c None None None None None 2 and 3 Barry A. Franklin William Beaumont Hospital Director, Cardiac Rehabilitation and Exercise Laboratories None None None None None None None Christopher B. Granger Duke Clinical Research Institute Director, Cardiac Care Unit; Professor of Medicine None None None  Medtronic Foundation  Merck None None 2 and 3 Harlan M. Krumholz Yale University School of Medicine Professor of Epidemiology and Public Health None None None  Johnson & Johnson  Medtronic None None 2 and 3 Jane A. Linderbaum Mayo Clinic Assistant Professor of Medicine None None None None None None None David A. Morrow Harvard Medical School Professor of Medicine  Abbott  Merck None None  Abbott  GlaxoSmithKline  Johnson & Johnson  Merck None None 2 and 3 L. Kristin Newby Duke University Medical Center, Division of Cardiology Professor of Medicine  Philips None None  Merck None None 2 and 3 Continued on the next page APPENDIX 2.


AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (ST-ELEVATION MYOCARDIAL INFARCTION WRITING COMMITTEE) (FEBRUARY 2014) J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. APPENDIX 2. CONTINUED Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Joseph P. Ornato Department of Emergency Medicine Virginia Commonwealth University Professor and Chairman None None None None None None None Narith Ou Mayo Clinic Pharmacotherapy Coordinator, Cardiology None None None None None None None Martha J. Radford NYU Langone Medical Center Chief Quality Of cer; NYU School of Medicine Professor of Medicine (Cardiology) None None None None None None None Jacqueline E. Tamis- Holland Mount Sinai Saint Luke s Hospital and The Icahn School of Medicine Program Director, Interventional Cardiology Fellowship Program None None None None None None None Carl L. Tommaso Skokie Hospital Director of Catheterization Laboratory; NorthShore University HealthSystems Partner None None None None None None None Cynthia M. Tracy George Washington University Medical Center Associate Director, Division of Cardiology None None None None None None None Y. Joseph Woo Stanford University Professor and Chair, Cardiothoracic Surgery None None None None None None None David X. Zhao Wake Forest Baptist Health Professor of Medicine, Heart and Vascular Center of Excellence Director None None None  St. Jude Medical  Medtronic None None 2 and 3 This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.


CONTINUED Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Joseph P. Ornato Department of Emergency Medicine Virginia Commonwealth University Professor and Chairman None None None None None None None Narith Ou Mayo Clinic Pharmacotherapy Coordinator, Cardiology None None None None None None None Martha J. Radford NYU Langone Medical Center Chief Quality Of cer; NYU School of Medicine Professor of Medicine (Cardiology) None None None None None None None Jacqueline E. Tamis- Holland Mount Sinai Saint Luke s Hospital and The Icahn School of Medicine Program Director, Interventional Cardiology Fellowship Program None None None None None None None Carl L. Tommaso Skokie Hospital Director of Catheterization Laboratory; NorthShore University HealthSystems Partner None None None None None None None Cynthia M. Tracy George Washington University Medical Center Associate Director, Division of Cardiology None None None None None None None Y. Joseph Woo Stanford University Professor and Chair, Cardiothoracic Surgery None None None None None None None David X. Zhao Wake Forest Baptist Health Professor of Medicine, Heart and Vascular Center of Excellence Director None None None  St. Jude Medical  Medtronic None None 2 and 3 This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily re ect relationships with industry at the time of publication.


The table does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their speci c relationships with industry and other entities may apply. Dr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was completed. According to policy, she recused herself from the nal voting process. Signi cant relationship. No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; NYU, New York University; UCSF, University of California San Francisco; and UT, University of Texas. Levine et al.


No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; NYU, New York University; UCSF, University of California San Francisco; and UT, University of Texas. Levine et al. J A C C V O L . 6 7 , N O .


J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Elliott M. Antman Of cial Reviewer AHA Harvard Medical School Professor of Medicine, Associate Dean for Clinical and Translational Research None None None None None None Deepak L. Bhatt Of cial Reviewer AHA Harvard Medical School Professor; Interventional Cardiovascular Programs Executive Director None None None  Bristol-Myers Squibb*  Ischemix*  Medtronic*  St. Jude Medical  Regado Biosciences None Christopher P. Cannon Of cial Reviewer AHA Harvard Medical School Professor of Medicine; Brigham and Women s Hospital Senior Investigator, TIMI Study Group, Cardiovascular Division  Bristol-Myers Squibb  Merck  Regeneron/ Sano -aventis* None None  Merck* None None Joaquin E. Cigarroa Of cial Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Oregon Health & Science University Clinical Professor of Medicine None None None None None None George Dangas Of cial Reviewer ACC Board of Trustees Icahn School of Medicine Professor of Cardiology and Vascular Surgery; Mount Sinai Medical Center Director, Cardiovascular Innovation  Abbott  Biosensors  Boston Scienti c  Johnson & Johnson*  Merck  Osprey Medical*  Regado Biosciences None None None  Abbott  Medtronic  Osprey None Charles J. Davidson Of cial Reviewer SCAI Northwestern University Feinberg School of Medicine Professor of Medicine, Director of Cardiac Catheterization Lab None None None  Baxter International None None Kirk N. Garratt Of cial Reviewer SCAI Hofstra University Medical School Associate Chair of Quality and Research; Professor of Medicine  Abbott  Boston Scienti c  The Medicines Company  Daiichi-Sankyo/ Eli Lilly  AstraZeneca None  LifeCuff Technologies  Global Delivery Systems None  Boston Scienti c None Steven L. Goldberg Of cial Reviewer SCAI University of Washington Medical Center Cath Lab Director  Terumo None None None None None Continued on the next page APPENDIX 3.


REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (COMBINED PEER REVIEWERS FROM 2011 PCI AND 2013 STEMI GUIDELINES) J A C C V O L . , N O . , Levine et al. M A R C H , : ACC/AHA/SCAI Focused Update on Primary PCI Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness G.B. John Mancini Of cial Reviewer ACC Board of Governors Vancouver Hospital Research Pavilion Professor of Medicine  Merck  Sano -aventis/ Regeneron None None None None None Jonathan M. Tobis Of cial Reviewer SCAI University of California Los Angeles Professor of Medicine and Cardiology  St. Jude Medical None None None None None Jeffrey L. Anderson Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Intermountain Medical Center Associate Chief of Cardiology None None None None None None Thomas M. Bashore Content Reviewer Duke University Professor of Medicine None None None None None None James A. Burke Content Reviewer ACC Interventional Scienti c Council Lehigh Valley Heart Specialists Associate Chief, Division of Cardiology None None None None None None Jeffrey J. Cavendish Content Reviewer ACC Prevention of Cardiovascular Disease Committee Kaiser Permanente Cardiology Interventional Cardiologist None None None None  Abbott None Gregory J. Dehmer Content Reviewer ACC Appropriate Use Criteria Texas A&M College of Medicine Professor of Medicine; Scott & White Healthcare None None None None None None John S. Douglas, Jr.


John Mancini Of cial Reviewer ACC Board of Governors Vancouver Hospital Research Pavilion Professor of Medicine  Merck  Sano -aventis/ Regeneron None None None None None Jonathan M. Tobis Of cial Reviewer SCAI University of California Los Angeles Professor of Medicine and Cardiology  St. Jude Medical None None None None None Jeffrey L. Anderson Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Intermountain Medical Center Associate Chief of Cardiology None None None None None None Thomas M. Bashore Content Reviewer Duke University Professor of Medicine None None None None None None James A. Burke Content Reviewer ACC Interventional Scienti c Council Lehigh Valley Heart Specialists Associate Chief, Division of Cardiology None None None None None None Jeffrey J. Cavendish Content Reviewer ACC Prevention of Cardiovascular Disease Committee Kaiser Permanente Cardiology Interventional Cardiologist None None None None  Abbott None Gregory J. Dehmer Content Reviewer ACC Appropriate Use Criteria Texas A&M College of Medicine Professor of Medicine; Scott & White Healthcare None None None None None None John S. Douglas, Jr. Content Reviewer Emory University Hospital Professor of Medicine None None None  Abbott  Medtronic None None John P. Erwin III Content Reviewer ACC/AHA Task Force on Performance Measures Texas A&M College of Medicine Associate Professor; Scott & White Healthcare Vice Chair of the Department of Medicine None None None None None None T. Bruce Ferguson Content Reviewer ACC Surgeons Scienti c Council East Carolina Institute Brody School of Medicine Professor of Surgery and Physiology None None None None None None Anthony Gershlick Content Reviewer University Hospitals of Leicester, Department of Cardiology  Abbott  Boston Scienti c  Cordis  Medtronic  Abbott None None None None Jonathan L. Halperin Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Mt.


Content Reviewer Emory University Hospital Professor of Medicine None None None  Abbott  Medtronic None None John P. Erwin III Content Reviewer ACC/AHA Task Force on Performance Measures Texas A&M College of Medicine Associate Professor; Scott & White Healthcare Vice Chair of the Department of Medicine None None None None None None T. Bruce Ferguson Content Reviewer ACC Surgeons Scienti c Council East Carolina Institute Brody School of Medicine Professor of Surgery and Physiology None None None None None None Anthony Gershlick Content Reviewer University Hospitals of Leicester, Department of Cardiology  Abbott  Boston Scienti c  Cordis  Medtronic  Abbott None None None None Jonathan L. Halperin Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Mt. Sinai Medical Professor of Medicine  Bayer Healthcare  Boston Scienti c  Johnson & Johnson  Medtronic None None None None None Continued on the next page APPENDIX 3. CONTINUED Levine et al. J A C C V O L . , N O .


J A C C V O L . , N O . , ACC/AHA/SCAI Focused Update on Primary PCI M A R C H , : Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Howard C. Herrmann Content Reviewer University of Pennsylvania Perelman School of Medicine Professor of Medicine, Director of Interventional Cardiology Program  Seimens Medical  St. Jude Medical None None  Abbott*  Medtronic  Siemens Medical*  St. Jude Medical None None Morton J. Kern Content Reviewer University of California Irvine Professor of Medicine, Associate Chief of the Division of Cardiology  Acist Medical  Merit Medical*  St. Jude Medical* None None None None Fred M. Kosumoto Content Reviewer Mayo Clinic Director, Pacing and Electrophysiology Service None None None None None None David J. Maron Content Reviewer Stanford University School of Medicine Professor of Medicine and Emergency Medicine None None None None None None Douglass A. Morrison Content Reviewer University of Arizona Professor of Medicine; Southern Arizona VA Health Care System Cardiac Catheterization Laboratories, Director None None None None None None Manesh R. Patel Content Reviewer ACC Appropriate Use Criteria Duke University Medical Center Associate Professor of Medicine  Bayer Healthcare*  Janssen Pharmaceuticals* None None  Johnson & Johnson* None None M. Eugene Sherman Content Reviewer ACC Board of Governors Aurora Denver Cardiology None None None None  Bristol-Myers Squibb*  Hospira* None Daniel I. Simon Content Reviewer University Hospitals Case Medical Center Professor of Cardiovascular Research  Cordis/Johnson & Johnson*  Janssen Pharmaceuticals/ Johnson & Johnson  Medtronic Vascular  Merck  Abbott None None None None Richard W. Snyder Content Reviewer ACC Board of Governors HeartPlace None None None None None None William A. Tansey III Content Reviewer Summit Medical Group Cardiologist None None None None None None David D. Waters Content Reviewer San Francisco General Hospital Chief, Division of Cardiology None None None None  Merck None Continued on the next page APPENDIX 3.


CONTINUED J A C C V O L . , N O . , Levine et al. M A R C H , : ACC/AHA/SCAI Focused Update on Primary PCI Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Patrick L. Whitlow Content Reviewer Cleveland Clinic Foundation Director, Interventional Cardiology None None None  Abbott  Medtronic* David O. Williams Content Reviewer Harvard Medical School Professor of Medicine; Brigham and Women s Hospital None None None None None None Clyde W. Yancy Content Reviewer ACC/AHA Task Force on Practice Guidelines Northwestern University Feinberg School of Medicine Vice Dean for Diversity and Inclusion, Chief of Medicine- Cardiology, Professor None None None None None None Yerem Yeghiazarians Content Reviewer University of California San Francisco Associate Professor None None None None None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than signi cant under the preceding de nition. Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.


Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Signi cant relationship. No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; SCAI, Society for Cardiovascular Angiography and Interventions; STEMI, ST-elevation myocardial infarction; PCI, percutaneous coronary interventions; TIMI, Thrombolysis In Myocardial Infarction; and VA, Veterans Affairs. APPENDIX 3. CONTINUED Levine et al. J A C C V O L . , N O . , ACC/AHA/SCAI Focused Update on Primary PCI M A R C H , :


ACCF/AHA 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 COMMITTEE MEMBERS* L. David Hillis, MD, FACC, Chair ; Peter K. Smith, MD, FACC, Vice Chair* ; Jeffrey L. Anderson, MD, FACC, FAHA* ; John A. Bittl, MD, FACC ; Charles R. Bridges, MD, SCD, FACC, FAHA* ; John G. Byrne, MD, FACC ; Joaquin E. Cigarroa, MD, FACC ; Verdi J. DiSesa, MD, FACC ; Loren F. Hiratzka, MD, FACC, FAHA ; Adolph M. Hutter, Jr, MD, MACC, FAHA ; Michael E. Jessen, MD, FACC* ; Ellen C. Keeley, MD, MS ; Stephen J. Lahey, MD ; Richard A. Lange, MD, FACC, FAHA ; Martin J. London, MD ; Michael J. Mack, MD, FACC* ; Manesh R. Patel, MD, FACC ; John D. Puskas, MD, FACC* ; Joseph F. Sabik, MD, FACC*#; Ola Selnes, PhD ; David M. Shahian, MD, FACC, FAHA**; Jeffrey C. Trost, MD, FACC* ; Michael D. Winniford, MD, FACC ACCF/AHA TASK FORCE MEMBERS Alice K. Jacobs, MD, FACC, FAHA, Chair; Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect; Nancy Albert, PhD, CCNS, CCRN, FAHA; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC; Jonathan L. Halperin, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; E. Magnus Ohman, MD, FACC; William Stevenson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship with industry and other entities may apply; see Appendix 1 for recusal information. ACCF/AHA Representative.


ACCF/AHA Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. Joint Revascularization Section Author. Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery Representative. #Society of Thoracic Surgeons Representative. **ACCF/AHA Task Force on Performance Measures Liaison. This document was approved by the American Heart Association Science Advisory and Coordinating Committee in July 2011, and by the American College of Cardiology Foundation Board of Trustees in July 2011. The American Heart Association requests that this document be cited as follows: Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 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. Circulation. 2011;124:e652 e735. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the By Topic link or the By Publication Date link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the Policies and Development link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp.


Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page. 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31823c074e Table of Contents Preamble e654 1. Introduction e656 1.1. Methodology and Evidence Review e656 1.2. Organization of the Writing Committee e657 1.3. Document Review and Approval e657 2. Procedural Considerations e657 2.1. Intraoperative Considerations e657 2.1.1. Anesthetic Considerations: Recommendations e657 2.1.2. Use of CPB e659 2.1.3. Off-Pump CABG Versus Traditional On-Pump CABG e659 2.1.4. Bypass Graft Conduit: Recommendations e660 2.1.4.1. Saphenous Vein Grafts e661 2.1.4.2. Internal Mammary Arteries e661 2.1.4.3. Radial, Gastroepiploic, and Inferior Epigastric Arteries e661 2.1.5. Incisions for Cardiac Access e661 2.1.6. Anastomotic Techniques e662 2.1.7. Intraoperative TEE: Recommendations e662 2.1.8. Preconditioning/Management of Myocardial Ischemia: Recommendations e663 2.2. Clinical Subsets e664 2.2.1. CABG in Patients With Acute MI: Recommendations e664 2.2.2. Life-Threatening Ventricular Arrhythmias: Recommendations e666 2.2.3. Emergency CABG After Failed PCI: Recommendations e666 2.2.4. CABG in Association With Other Cardiac Procedures: Recommendations e667 3. CAD Revascularization e667 3.1. Heart Team Approach to Revascularization Decisions: Recommendations e668 3.2. Revascularization to Improve Survival: Recommendations e668 3.3. Revascularization to Improve Symptoms: Recommendations e671 3.4. CABG Versus Contemporaneous Medical Therapy e671 3.5. PCI Versus Medical Therapy e671 3.6. CABG Versus PCI e672 3.6.1. CABG Versus Balloon Angioplasty or BMS e672 3.6.2. CABG Versus DES e672 3.7. Left Main CAD e673 3.7.1. CABG or PCI Versus Medical Therapy for Left Main CAD e673 3.7.2. Studies Comparing PCI Versus CABG for Left Main CAD e673 3.7.3. Revascularization Considerations for Left Main CAD e674 3.8.


Studies Comparing PCI Versus CABG for Left Main CAD e673 3.7.3. Revascularization Considerations for Left Main CAD e674 3.8. Proximal LAD Artery Disease e674 3.9. Clinical Factors That May Influence the Choice of Revascularization e674 3.9.1. Diabetes Mellitus e674 3.9.2. Chronic Kidney Disease e675 3.9.3. Completeness of Revascularization e675 3.9.4. LV Systolic Dysfunction e675 3.9.5. Previous CABG e675 3.9.6. Unstable Angina/Non ST-Elevation Myocardial Infarction e676 3.9.7. DAPT Compliance and Stent Thrombosis: Recommendation e676 3.10. TMR as an Adjunct to CABG e676 3.11. Hybrid Coronary Revascularization: Recommendations e676 4. Perioperative Management e677 4.1. Preoperative Antiplatelet Therapy: Recommendations e677 4.2. Postoperative Antiplatelet Therapy: Recommendations e677 4.3. Management of Hyperlipidemia: Recommendations e678 4.3.1. Timing of Statin Use and CABG Outcomes e679 4.3.1.1. Potential Adverse Effects of Perioperative Statin Therapy e679 4.4. Hormonal Manipulation: Recommendations e679 4.4.1. Glucose Control e679 4.4.2. Postmenopausal Hormone Therapy e680 4.4.3. CABG in Patients With Hypothyroidism e680 4.5. Perioperative Beta Blockers: Recommendations e680 4.6. ACE Inhibitors/ARBs: Recommendations e681 4.7. Smoking Cessation: Recommendations e682 4.8. Emotional Dysfunction and Psychosocial Considerations: Recommendation e683 4.8.1. Effects of Mood Disturbance and Anxiety on CABG Outcomes e683 4.8.2. Interventions to Treat Depression in CABG Patients e683 4.9. Cardiac Rehabilitation: Recommendation e683 4.10. Perioperative Monitoring e684 Hillis et al 2011 ACCF/AHA CABG Guideline e653 4.10.1. Electrocardiographic Monitoring: Recommendations e684 4.10.2. Pulmonary Artery Catheterization: Recommendations e684 4.10.3. Central Nervous System Monitoring: Recommendations e684 5. CABG-Associated Morbidity and Mortality: Occurrence and Prevention e685 5.1. Public Reporting of Cardiac Surgery Outcomes: Recommendation e685 5.1.1. Use of Outcomes or Volume as CABG Quality Measures: Recommendations e686 5.2. Adverse Events e687 5.2.1. Adverse Cerebral Outcomes e687 5.2.1.1. Stroke e687 5.2.1.1.1. Use of Epiaortic Ultra- sound Imaging to Reduce Stroke Rates: Recom- mendation e687 5.2.1.1.2. The Role of Preoperative Carotid Artery Noninva- sive Screening in CABG Patients: Recommenda- tions e687 5.2.1.2.


The Role of Preoperative Carotid Artery Noninva- sive Screening in CABG Patients: Recommenda- tions e687 5.2.1.2. Delirium e689 5.2.1.3. Postoperative Cognitive Impairment e689 5.2.2. Mediastinitis/Perioperative Infection: Recommendations e689 5.2.3. Renal Dysfunction: Recommendations e691 5.2.4. Perioperative Myocardial Dysfunction: Recommendations e692 Recommendation e692 5.2.5. Perioperative Dysrhythmias: Recommendations e692 5.2.6. Perioperative Bleeding/Transfusion: Recommendations e693 6. Specific Patient Subsets e694 6.1. Elderly e694 6.2. Women e694 6.3. Patients With Diabetes Mellitus e695 6.4. Anomalous Coronary Arteries: Recommendations e696 6.5. Patients With Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency: Recommendations e696 6.6. Patients With End-Stage Renal Disease on Dialysis: Recommendations e697 6.7. Patients With Concomitant Valvular Disease: Recommendations e697 6.8. Patients With Previous Cardiac Surgery: Recommendation e697 6.8.1. Indications for Repeat CABG e697 6.8.2. Operative Risk e698 6.8.3. Long-Term Outcomes e698 6.9. Patients With Previous Stroke e698 6.10. Patients With PAD e698 7. Economic Issues e698 7.1. Cost-Effectiveness of CABG and PCI e698 7.1.1. Cost-Effectiveness of CABG Versus PCI e699 7.1.2. CABG Versus PCI With DES e699 8. Future Research Directions e699 8.1. Hybrid CABG/PCI e700 8.2. Protein and Gene Therapy e700 8.3. Teaching CABG to the Next Generation: Use of Surgical Simulators e700 References e701 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e731 Appendix 2. Reviewer Relationships With Industry and Other Entitites (Relevant) e733 Appendix 3. Abbreviation List e735 Preamble The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When prop- erly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies.


When prop- erly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guide- lines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing commit- tees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patientcentric recom- mendations for clinical practice. Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is consid- ered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.


When available, information from studies on cost is consid- ered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein. In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are avail- able, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommen- dations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing commit- tee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table Table 1. Applying Classification of Recommendations and Level of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials.


Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of prior myocardial infarction, history of heart failure, and prior aspirin use. For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct omparisons of the treatments or strategies being evaluated. Hillis et al 2011 ACCF/AHA CABG Guideline e655 1, which also provides suggested phrases for writing recommen- dations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of no benefit or is associated with harm to the patient. In addition, in view of the increasing number of comparative effectiveness studies, com- parator verbs and suggested phrases for writing recommenda- tions for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only. In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines. Because the ACCF/AHA practice guidelines address pa- tient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR.


Because the ACCF/AHA practice guidelines address pa- tient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influ- ence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation. The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding the care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate. Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient s active participation in prescribed medical regimens and lifestyles.


Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benefit-to-risk ratio may be lower. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must recuse themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors and peer reviewers RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively.


Authors and peer reviewers RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members comprehen- sive disclosure information including RWI not pertinent to this document is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines- and-Documents-Task-Forces.aspx. The work of the writing com- mittee was supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity. In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, evidence tables (with references linked to abstracts in PubMed) have been added. In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the ACCF/AHA guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated. The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA. Alice K. Jacobs, MD, FACC, FAHA Chair ACCF/AHA Task Force on Practice Guidelines 1.1. Methodology and Evidence Review Whenever possible, the recommendations listed in this docu- ment are evidence based. Articles reviewed in this guideline revision covered evidence from the past 10 years through January 2011, as well as selected other references through April 2011. Searches were limited to studies, reviews, and other evidence conducted in human subjects that were published in English.


Searches were limited to studies, reviews, and other evidence conducted in human subjects that were published in English. Key search words included but were not limited to the following: analgesia, anastomotic techniques, antiplatelet agents, automated proximal clampless anastomosis device, asymptomatic ischemia, Cardica C-port, cost effectiveness, de- pressed left ventricular (LV) function, distal anastomotic tech- niques, direct proximal anastomosis on aorta, distal anastomotic devices, emergency coronary artery bypass graft (CABG) and ST-elevation myocardial infarction (STEMI), heart failure, in- terrupted sutures, LV systolic dysfunction, magnetic connectors, PAS-Port automated proximal clampless anastomotic device, patency, proximal connectors, renal disease, sequential anasto- mosis, sternotomy, symmetry connector, symptomatic ischemia, proximal connectors, sequential anastomosis, T grafts, thoracot- omy, U-clips, Ventrica Magnetic Vascular Port system, Y grafts. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are repre- sentative but not all-inclusive. To provide clinicians with a comprehensive set of data, whenever deemed appropriate or when published, the absolute risk difference and number needed to treat or harm are provided in the guideline, along with confidence interval (CI) and data related to the relative treatment effects such as odds ratio (OR), relative risk (RR), hazard ratio (HR), or incidence rate ratio. The focus of these guidelines is the safe, appropriate, and efficacious performance of CABG. 1.2. Organization of the Writing Committee The committee was composed of acknowledged experts in CABG, interventional cardiology, general cardiology, and cardiovascular anesthesiology. The committee included rep- resentatives from the ACCF, AHA, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiolo- gists, and Society of Thoracic Surgeons (STS). 1.3.


The committee included rep- resentatives from the ACCF, AHA, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiolo- gists, and Society of Thoracic Surgeons (STS). 1.3. Document Review and Approval This document was reviewed by 2 official reviewers, each nominated by both the ACCF and the AHA, as well as 1 reviewer each from the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS, as well as members from the ACCF/AHA Task Force on Data Standards, ACCF/AHA Task Force on Performance Measures, ACCF Surgeons Scientific Council, ACCF Inter- ventional Scientific Council, and Southern Thoracic Surgical Association. All information on reviewers RWI was distrib- uted to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the gov- erning bodies of the ACCF and the AHA and endorsed by the American Association for Thoracic Surgery, Society of Car- diovascular Anesthesiologists, and STS. 2. Procedural Considerations 2.1. Intraoperative Considerations 2.1.1. Anesthetic Considerations: Recommendations Class I 1. Anesthetic management directed toward early postop- erative extubation and accelerated recovery of low- to medium-risk patients undergoing uncomplicated CABG is recommended.4 6 (Level of Evidence: B) 2. Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.7 11 (Level of Evidence: B) 3. Efforts are recommended to improve interdisciplin- ary communication and patient safety in the periop- erative environment (eg, formalized checklist-guided multidisciplinary communication).12 15 (Level of Ev- idence: B) 4. A fellowship-trained cardiac anesthesiologist (or ex- perienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocar- diography (TEE) is recommended to provide or supervise anesthetic care of patients who are consid- ered to be at high risk.16 18 (Level of Evidence: C) Class IIa 1.


A fellowship-trained cardiac anesthesiologist (or ex- perienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocar- diography (TEE) is recommended to provide or supervise anesthetic care of patients who are consid- ered to be at high risk.16 18 (Level of Evidence: C) Class IIa 1. Volatile anesthetic-based regimens can be useful in facilitating early extubation and reducing patient recall.5,19 21 (Level of Evidence: A) Class IIb 1. The effectiveness of high thoracic epidural anesthe- sia/analgesia for routine analgesic use is uncer- tain.22 25 (Level of Evidence: B) Class III: HARM 1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.26,27 (Level of Evidence: B) 2. Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C) See Online Data Supplement 1 for additional data on anes- thetic considerations. Anesthetic management of the CABG patient mandates a favorable balance of myocardial oxygen supply and demand to prevent or minimize myocardial injury (Section 2.1.8). Histori- cally, the popularity of several anesthetic techniques for CABG has varied on the basis of their known or potential adverse cardiovascular effects (eg, cardiovascular depression with high doses of volatile anesthesia, lack of such depression with high-dose opioids, or coronary vasodilation and concern for a steal phenomenon with isoflurane) as well as concerns about interactions with preoperative medications (eg, cardiovascular depression with beta blockers or hypotension with angiotensin- converting enzyme [ACE] inhibitors and angiotensin-receptor blockers [ARBs]28 30) (Sections 2.1.8 and 4.5).


Histori- cally, the popularity of several anesthetic techniques for CABG has varied on the basis of their known or potential adverse cardiovascular effects (eg, cardiovascular depression with high doses of volatile anesthesia, lack of such depression with high-dose opioids, or coronary vasodilation and concern for a steal phenomenon with isoflurane) as well as concerns about interactions with preoperative medications (eg, cardiovascular depression with beta blockers or hypotension with angiotensin- converting enzyme [ACE] inhibitors and angiotensin-receptor blockers [ARBs]28 30) (Sections 2.1.8 and 4.5). Independent of these concerns, efforts to improve outcomes and to reduce costs have led to shorter periods of postoperative mechanical ventila- tion and even, in some patients, to prompt extubation in the operating room ( accelerated recovery protocols or fast-track High-dose opioid anesthesia with benzodiazepine supple- mentation was used commonly in CABG patients in the United States in the 1970s and 1980s. Subsequently, it became clear that volatile anesthetics are protective in the setting of myocardial ischemia and reperfusion, and this, in Hillis et al 2011 ACCF/AHA CABG Guideline e657 combination with a shift to accelerated recovery or fast- track strategies, led to their ubiquitous use. As a result, opioids have been relegated to an adjuvant role.32,33 Despite their widespread use, volatile anesthetics have not been shown to provide a mortality rate advantage when compared with other intravenous regimens (Section 2.1.8). Optimal anesthesia care in CABG patients should include 1) a careful preoperative evaluation and treatment of modifi- able risk factors; 2) proper handling of all medications given of central venous access and careful cardiovascular monitor- ing; 4) induction of a state of unconsciousness, analgesia, and immobility; and 5) a smooth transition to the early postoper- ative period, with a goal of early extubation, patient mobili- zation, and hospital discharge.


Optimal anesthesia care in CABG patients should include 1) a careful preoperative evaluation and treatment of modifi- able risk factors; 2) proper handling of all medications given of central venous access and careful cardiovascular monitor- ing; 4) induction of a state of unconsciousness, analgesia, and immobility; and 5) a smooth transition to the early postoper- ative period, with a goal of early extubation, patient mobili- zation, and hospital discharge. Attention should be directed at preventing or minimizing adverse hemodynamic and hor- monal alterations that may induce myocardial ischemia or exert a deleterious effect on myocardial metabolism (as may occur during cardiopulmonary bypass [CPB]) (Section 2.1.8). This requires close interaction between the anesthesiologist and surgeon, particularly when manipulation of the heart or great vessels is likely to induce hemodynamic instability. During on-pump CABG, particular care is required during vascular cannulation and weaning from CPB; with off-pump CABG, the hemodynamic alterations often caused by dis- placement or verticalization of the heart and application of stabilizer devices on the epicardium, with resultant changes in heart rate, cardiac output, and systemic vascular resistance, should be monitored carefully and managed appropriately. In the United States, nearly all patients undergoing CABG receive general anesthesia with endotracheal intubation uti- lizing volatile halogenated general anesthetics with opioid supplementation. Intravenous benzodiazepines often are given as premedication or for induction of anesthesia, along with other agents such as propofol or etomidate. Nondepo- larizing neuromuscular-blocking agents, particularly nonva- golytic agents with intermediate duration of action, are preferred to the longer-acting agent, pancuronium.


Nondepo- larizing neuromuscular-blocking agents, particularly nonva- golytic agents with intermediate duration of action, are preferred to the longer-acting agent, pancuronium. Use of the latter is associated with higher intraoperative heart rates and a higher incidence of residual neuromuscular depression in the early postoperative period, with a resultant delay in extubation.23,34 In addition, low concentrations of volatile anesthetic usually are administered via the venous oxygenator during CPB, facilitating amnesia and reducing systemic vascular resistance. Outside the United States, alternative anesthetic tech- niques, particularly total intravenous anesthesia via propofol and opioid infusions with benzodiazepine supplementation with or without high thoracic epidural anesthesia, are com- monly used. The use of high thoracic epidural anesthesia exerts salutary effects on the coronary circulation as well as myocardial and pulmonary function, attenuates the stress response, and provides prolonged postoperative analge- sia.24,25,35 In the United States, however, concerns about the potential for neuraxial bleeding (particularly in the setting of heparinization, platelet inhibitors, and CPB-induced throm- bocytopenia), local anesthetic toxicity, and logistical issues related to the timing of epidural catheter insertion and management have resulted in limited use of these tech- niques.22 Their selective use in patients with severe pulmo- nary dysfunction (Section 6.5) or chronic pain syndromes may be considered.


The use of high thoracic epidural anesthesia exerts salutary effects on the coronary circulation as well as myocardial and pulmonary function, attenuates the stress response, and provides prolonged postoperative analge- sia.24,25,35 In the United States, however, concerns about the potential for neuraxial bleeding (particularly in the setting of heparinization, platelet inhibitors, and CPB-induced throm- bocytopenia), local anesthetic toxicity, and logistical issues related to the timing of epidural catheter insertion and management have resulted in limited use of these tech- niques.22 Their selective use in patients with severe pulmo- nary dysfunction (Section 6.5) or chronic pain syndromes may be considered. Although meta-analyses of randomized controlled trials (RCTs) of high thoracic epidural anesthesia/ analgesia in CABG patients (particularly on-pump) have yielded inconsistent results on morbidity and mortality rates, it does appear to reduce time to extubation, pain, and pulmonary complications.36 38 Of interest, although none of the RCTs have reported the occurrence of epidural hematoma or abscess, these entities occur on occasion.38 Finally, the use of other regional anesthetic approaches for postoperative analgesia, such as parasternal block, has been reported.39 Over the past decade, early extubation strategies ( fast- track anesthesia) often have been used in low- to medium- risk CABG patients.


Although meta-analyses of randomized controlled trials (RCTs) of high thoracic epidural anesthesia/ analgesia in CABG patients (particularly on-pump) have yielded inconsistent results on morbidity and mortality rates, it does appear to reduce time to extubation, pain, and pulmonary complications.36 38 Of interest, although none of the RCTs have reported the occurrence of epidural hematoma or abscess, these entities occur on occasion.38 Finally, the use of other regional anesthetic approaches for postoperative analgesia, such as parasternal block, has been reported.39 Over the past decade, early extubation strategies ( fast- track anesthesia) often have been used in low- to medium- risk CABG patients. These strategies allow a shorter time to extubation, a decreased length of intensive care unit (ICU) stay, and variable effects on length of hospital stay.4 6 Immediate extubation in the operating room, with or without markedly accelerated postoperative recovery pathways (eg, ultra-fast-tracking, rapid recovery protocol, short-stay intensive care ) have been used safely, with low rates of reintubation and no influence on quality of life.40 44 Obser- vational data suggest that physician judgment in triaging lower-risk patients to early or immediate extubation works well, with rates of reintubation 1%.45 Certain factors appear to predict fast-track failure, including previous cardiac surgery, use of intra-aortic balloon counterpulsation, and possibly advanced patient age. Provision of adequate perioperative analgesia is important in enhancing patient mobilization, preventing pulmonary complications, and improving the patient s psychological well-being.9,11 The intraoperative use of high-dose morphine (40 mg) may offer superior postoperative pain relief and enhance patient well-being compared with fentanyl (despite similar times to extubation).46 The safety of nonsteroidal anti-inflammatory agents for analgesia is controversial, with greater evidence for adverse cardiovascular events with the selective cyclooxygenase-2 inhibitors than the nonselective agents.


Provision of adequate perioperative analgesia is important in enhancing patient mobilization, preventing pulmonary complications, and improving the patient s psychological well-being.9,11 The intraoperative use of high-dose morphine (40 mg) may offer superior postoperative pain relief and enhance patient well-being compared with fentanyl (despite similar times to extubation).46 The safety of nonsteroidal anti-inflammatory agents for analgesia is controversial, with greater evidence for adverse cardiovascular events with the selective cyclooxygenase-2 inhibitors than the nonselective agents. A 2007 AHA Scien- tific statement presented a stepped-care approach to the management of musculoskeletal pain in patients with or at risk for coronary artery disease (CAD), with the goal of limiting the use of these agents to patients in whom safer therapies fail.47 In patients hospitalized with unstable angina (UA) and non ST-elevation myocardial infarction (NSTEMI), these agents should be discontinued promptly and reinstituted later according to the stepped-care approach.48 In the setting of cardiac surgery, nonsteroidal anti- inflammatory agents previously were used for perioperative analgesia.


A 2007 AHA Scien- tific statement presented a stepped-care approach to the management of musculoskeletal pain in patients with or at risk for coronary artery disease (CAD), with the goal of limiting the use of these agents to patients in whom safer therapies fail.47 In patients hospitalized with unstable angina (UA) and non ST-elevation myocardial infarction (NSTEMI), these agents should be discontinued promptly and reinstituted later according to the stepped-care approach.48 In the setting of cardiac surgery, nonsteroidal anti- inflammatory agents previously were used for perioperative analgesia. A meta-analysis of 20 trials of patients undergoing thoracic or cardiac surgery, which evaluated studies published before 2005, reported significant reductions in pain scores, with no increase in adverse outcomes.49 Subsequently, 2 RCTs, both studying the oral cyclooxygenase-2 inhibitor valdecoxib and its intravenous prodrug, parecoxib, reported a higher incidence of sternal infections in 1 trial and a significant increase in adverse cardiovascular events in the other.26,27 On the basis of the results of these 2 studies (as well as other nonsurgical reports of increased risk with cyclooxygenase-2 selective agents), the U.S. Food and Drug Administration in 2005 issued a black box warning for all nonsteroidal anti-inflammatory agents (except aspirin) immediately after CABG.50 The concurrent administra- tion of ibuprofen with aspirin has been shown to attenuate the latter s inhibition of platelet aggregation, likely because of competitive inhibition of cyclooxygenase at the platelet-receptor Observational analyses in patients undergoing noncardiac surgery have shown a significant reduction in perioperative death with the use of checklists, multidisciplinary surgical care, intraoperative time-outs, postsurgical debriefings, and other communication strategies.14,15 Such methodology is being used increasingly in CABG patients.12 14 In contrast to extensive literature on the role of the surgeon in determining outcomes with CABG, limited data on the influence of the anesthesiologist are available.


A meta-analysis of 20 trials of patients undergoing thoracic or cardiac surgery, which evaluated studies published before 2005, reported significant reductions in pain scores, with no increase in adverse outcomes.49 Subsequently, 2 RCTs, both studying the oral cyclooxygenase-2 inhibitor valdecoxib and its intravenous prodrug, parecoxib, reported a higher incidence of sternal infections in 1 trial and a significant increase in adverse cardiovascular events in the other.26,27 On the basis of the results of these 2 studies (as well as other nonsurgical reports of increased risk with cyclooxygenase-2 selective agents), the U.S. Food and Drug Administration in 2005 issued a black box warning for all nonsteroidal anti-inflammatory agents (except aspirin) immediately after CABG.50 The concurrent administra- tion of ibuprofen with aspirin has been shown to attenuate the latter s inhibition of platelet aggregation, likely because of competitive inhibition of cyclooxygenase at the platelet-receptor Observational analyses in patients undergoing noncardiac surgery have shown a significant reduction in perioperative death with the use of checklists, multidisciplinary surgical care, intraoperative time-outs, postsurgical debriefings, and other communication strategies.14,15 Such methodology is being used increasingly in CABG patients.12 14 In contrast to extensive literature on the role of the surgeon in determining outcomes with CABG, limited data on the influence of the anesthesiologist are available. Of 2 such reports from single centers in the 1980s, 1 suggested that the failure to control heart rate to 110 beats per minute was associated with a higher mortality rate, and the other suggested that increasing duration of CPB adversely influenced outcome.52,53 Another observational analysis of data from vascular surgery patients suggested that anesthetic specialization was independently associated with a reduction in mortality rate.54 To meet the challenges of providing care for the increasingly higher-risk patients undergoing CABG, efforts have been di- rected at enhancing the experience of trainees, particularly in the use of newer technologies such as TEE.


Of 2 such reports from single centers in the 1980s, 1 suggested that the failure to control heart rate to 110 beats per minute was associated with a higher mortality rate, and the other suggested that increasing duration of CPB adversely influenced outcome.52,53 Another observational analysis of data from vascular surgery patients suggested that anesthetic specialization was independently associated with a reduction in mortality rate.54 To meet the challenges of providing care for the increasingly higher-risk patients undergoing CABG, efforts have been di- rected at enhancing the experience of trainees, particularly in the use of newer technologies such as TEE. Cardiac anesthesiolo- gists, in collaboration with cardiologists and surgeons, have implemented national training and certification processes for practitioners in the use of perioperative TEE (Section 2.1.7).164,165 Accreditation of cardiothoracic anesthesia fellow- ship programs from the Accreditation Council for Graduate Medical Education was initiated in 2004, and efforts are ongoing to obtain formal subspecialty certification.18 2.1.2. Use of CPB Several adverse outcomes have been attributed to CPB, including 1) neurological deficits (eg, stroke, coma, postop- erative neurocognitive dysfunction); 2) renal dysfunction; and 3) the Systemic inflammatory Response Syndrome (SIRS). The SIRS is manifested as generalized systemic inflammation occurring after a major morbid event, such as trauma, infection, or major surgery. It is often particularly apparent after on-pump cardiac surgery, during which surgi- cal trauma, contact of blood with nonphysiological surfaces (eg, pump tubing, oxygenator surfaces), myocardial ischemia and reperfusion, and hypothermia combine to cause a dra- matic release of cytokines (eg, interleukin [IL] 6 and IL8) and other mediators of inflammation.55 Some investigators have used serum concentrations of S100 beta as a marker of brain injury56 and have correlated increased serum levels with the number of microemboli exiting the CPB circuit during CABG.


It is often particularly apparent after on-pump cardiac surgery, during which surgi- cal trauma, contact of blood with nonphysiological surfaces (eg, pump tubing, oxygenator surfaces), myocardial ischemia and reperfusion, and hypothermia combine to cause a dra- matic release of cytokines (eg, interleukin [IL] 6 and IL8) and other mediators of inflammation.55 Some investigators have used serum concentrations of S100 beta as a marker of brain injury56 and have correlated increased serum levels with the number of microemboli exiting the CPB circuit during CABG. In contrast, others have noted the increased incidence of microemboli with on-pump CABG (relative to off-pump CABG) but have failed to show a corresponding worsening of neurocognitive function 1 week to 6 months postopera- tively.57,58 Blood retrieved from the operative field during on-pump CABG contains lipid material and particulate mat- ter, which have been implicated as possible causes of post- operative neurocognitive dysfunction. Although a study59 reported that CPB-associated neurocognitive dysfunction can be mitigated by the routine processing of shed blood with a cell saver before its reinfusion, another study60 failed to show such an improvement. It has been suggested that CPB leads to an increased incidence of postoperative renal failure requiring dialysis, but a large RCT comparing on-pump and off-pump CABG showed no difference in its occurrence.61 Of interest, this study failed to show a decreased incidence of postoperative adverse neurological events (stroke, coma, or neurocognitive deficit) in those undergoing off-pump CABG. The occurrence of SIRS in patients undergoing CPB has led to the development of strategies designed to prevent or to minimize its occurrence.


The occurrence of SIRS in patients undergoing CPB has led to the development of strategies designed to prevent or to minimize its occurrence. Many reports have focused on the increased serum concentrations of cytokines (eg, IL-2R, IL-6, IL-8, tumor necrosis factor alpha) and other modulators of inflammation (eg, P-selectin, sE-selectin, soluble intercellular adhesion molecule-1, plasma endothelial cell adhesion molecule-1, and plasma malondialdehyde), which reflect leukocyte and platelet activation, in triggering the onset of SIRS. A study showed a greater upregulation of neutrophil CD11b expression (a marker of leukocyte activation) in patients who sustained a 50% increase in the serum creatinine concentration after CPB, thereby implicating acti- vated neutrophils in the pathophysiology of SIRS and the occurrence of post-CPB renal dysfunction.62 Modulating neutrophil activation to reduce the occurrence of SIRS has been investigated; however, the results have been inconsis- tent. Preoperative intravenous methylprednisolone (10 mg/ kg) caused a reduction in the serum concentrations of many of these cytokines after CPB, but this reduction was not associ- ated with improved hemodynamic variables, diminished blood loss, less use of inotropic agents, shorter duration of ventilation, or shorter ICU length of stay.63 Similarly, the use of intravenous immunoglobulin G in patients with post-CPB SIRS has not been associated with decreased rates of short- term morbidity or 28-day mortality.64 Other strategies to mitigate the occurrence of SIRS after CPB have been evaluated, including the use of 1) CPB circuits (including oxygenators) coated with materials known to reduce complement and leukocyte activation; 2) CPB tubing that is covalently bonded to heparin; and 3) CPB tubing coated with polyethylene oxide polymer or Poly (2-methoxyethylacrylate).


Preoperative intravenous methylprednisolone (10 mg/ kg) caused a reduction in the serum concentrations of many of these cytokines after CPB, but this reduction was not associ- ated with improved hemodynamic variables, diminished blood loss, less use of inotropic agents, shorter duration of ventilation, or shorter ICU length of stay.63 Similarly, the use of intravenous immunoglobulin G in patients with post-CPB SIRS has not been associated with decreased rates of short- term morbidity or 28-day mortality.64 Other strategies to mitigate the occurrence of SIRS after CPB have been evaluated, including the use of 1) CPB circuits (including oxygenators) coated with materials known to reduce complement and leukocyte activation; 2) CPB tubing that is covalently bonded to heparin; and 3) CPB tubing coated with polyethylene oxide polymer or Poly (2-methoxyethylacrylate). Leukocyte depletion via special- ized filters in the CPB circuits has been shown to reduce the plasma concentrations of P-selectin, intercellular adhesion molecule-1, IL-8, plasma endothelial cell adhesion molecule-1, and plasma malondialdehyde after CPB.65 Finally, closed mini-circuits for CPB have been developed in an attempt to minimize the blood air interface and blood contact with nonbiological surfaces, both of which promote cytokine elaboration, but it is uncertain if these maneuvers and techniques have a discernible effect on outcomes after CABG. 2.1.3. Off-Pump CABG Versus Traditional On-Pump CABG Since the first CABG was performed in the late 1960s, the standard surgical approach has included the use of cardiac arrest coupled with CPB (so-called on-pump CABG), thereby Hillis et al 2011 ACCF/AHA CABG Guideline e659 optimizing the conditions for construction of vascular anas- tomoses to all diseased coronary arteries without cardiac motion or hemodynamic compromise. Such on-pump CABG has become the gold standard and is performed in about 80% of subjects undergoing the procedure in the United States.


Such on-pump CABG has become the gold standard and is performed in about 80% of subjects undergoing the procedure in the United States. Despite the excellent results that have been achieved, the use of CPB and the associated manipulation of the ascending aorta are linked with certain perioperative complications, including myonecrosis during aortic occlusion, cerebrovascu- lar accidents, generalized neurocognitive dysfunction, renal dysfunction, and SIRS. In an effort to avoid these complica- tions, off-pump CABG was developed.58,66 Off-pump CABG is performed on the beating heart with the use of stabilizing devices (which minimize cardiac motion); in addition, it incorporates techniques to minimize myocardial ischemia and systemic hemodynamic compromise. As a result, the need for CPB is obviated. This technique does not necessarily de- crease the need for manipulation of the ascending aorta during construction of the proximal anastomoses. To date, the results of several RCTs comparing on-pump and off-pump CABG in various patient populations have been published.61,67,68 In addition, registry data and the results of meta-analyses have been used to assess the relative efficacies of the 2 techniques.69,70 In 2005, an AHA Scientific statement comparing the 2 techniques concluded that both procedures usually result in excellent outcomes and that neither technique should be considered superior to the other.71 At the same time, several differences were noted. Off-pump CABG was associated with less bleeding, less renal dysfunction, a shorter length of hospital stay, and less neurocognitive dysfunction. The inci- dence of perioperative stroke was similar with the 2 techniques. On-pump CABG was noted to be less technically complex and allowed better access to diseased coronary arteries in certain anatomic locations (eg, those on the lateral LV wall) as well as better long-term graft patency.


On-pump CABG was noted to be less technically complex and allowed better access to diseased coronary arteries in certain anatomic locations (eg, those on the lateral LV wall) as well as better long-term graft patency. In 2009, the results of the largest RCT to date comparing on-pump CABG to off-pump CABG, the ROOBY (Random- ized On/Off Bypass) trial, were published, reporting the outcomes for 2203 patients (99% men) at 18 Veterans Affairs Medical Centers.61 The primary short-term endpoint, a com- posite of death or complications (reoperation, new mechani- cal support, cardiac arrest, coma, stroke, or renal failure) within 30 days of surgery, occurred with similar frequency (5.6% for on-pump CABG; 7.0% for off-pump CABG; P 0.19). The primary long-term endpoint, a composite of death from any cause, a repeat revascularization procedure, or a nonfatal myocardial infarction (MI) within 1 year of surgery, occurred more often in those undergoing off-pump CABG (9.9%) than in those having on-pump CABG (7.4%; P 0.04). Neuropsychological outcomes and resource utiliza- tion were similar between the 2 groups. One year after surgery, graft patency was higher in the on-pump group (87.8% versus 82.6%; P 0.01). In short, the ROOBY inves- tigators failed to show an advantage of off-pump CABG compared with on-pump CABG in a patient population considered to be at low risk. Instead, use of the on-pump technique was associated with better 1-year composite out- comes and 1-year graft patency rates, with no difference in neuropsychological outcomes or resource utilization.