Does a patient with native valves undergoing preoperative optimization for potential Coronary Artery Bypass Grafting (CABG) require preoperative antibiotics for tooth extraction?

From the Guidelines

Preoperative antibiotics are not necessary for this patient undergoing tooth extraction before potential CABG surgery, as the patient has all native valves and does not meet the criteria for antibiotic prophylaxis according to current guidelines. The American Heart Association 1 and other international societies have published recommendations and guidelines for the prevention of infective endocarditis, which emphasize that antibiotic prophylaxis is only recommended for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. These conditions include prosthetic heart valves, a past history of infective endocarditis, cardiac valvulopathy after cardiac transplantation, and certain congenital heart defects 1.

Since the patient in question has all native valves and no prosthetic cardiac valves, they do not meet the criteria for antibiotic prophylaxis. The risk of adverse effects from antibiotics outweighs the benefit in preventing infective endocarditis in this population 1.

Some key points to consider in this decision include:

• The patient's native valves do not pose a high risk for adverse outcomes from infective endocarditis
• The American Heart Association no longer recommends antibiotic prophylaxis for patients with coronary artery disease undergoing dental procedures
• Antibiotic prophylaxis would only be indicated if the patient had prosthetic cardiac valves, a history of infective endocarditis, certain congenital heart defects, or cardiac transplant with valve regurgitation
• Good oral hygiene and dental health before cardiac surgery are important to minimize any potential sources of infection

Overall, standard dental care without antibiotic prophylaxis is appropriate for this patient. However, it's essential to ensure good oral hygiene and dental health before cardiac surgery to minimize any potential sources of infection 1.

From the Research

Patient Preop Optimization for CABG with Tooth Extraction

• The patient has all native valves and is scheduled for a potential Coronary Artery Bypass Grafting (CABG) procedure, with a need for tooth extraction prior to the surgery.
• The question arises whether the patient requires preoperative antibiotics for the tooth extraction.

Current Guidelines and Studies

• According to the European Society of Cardiology (ESC) guidelines, as mentioned in the study 2, antibiotic prophylaxis should only be reserved for specific dental procedures with interruption of consistency of the oral mucosa, such as extractions, and should be reserved for patients with the highest risk of developing infective endocarditis.
• A study published in the Journal of the American College of Cardiology 3 found a significant temporal association between invasive dental procedures (IDPs) and subsequent infective endocarditis (IE) in high-IE-risk individuals, and a significant association between antibiotic prophylaxis (AP) use and reduced IE incidence following these procedures.
• Another study published in Oral Diseases 4 also found that invasive dental procedures, particularly extractions and oral surgery, were significantly associated with endocarditis in high-risk individuals, but antibiotic prophylaxis significantly reduced endocarditis incidence following these procedures.

Relevance to the Patient's Condition

• Since the patient has all native valves and is not considered high-risk for infective endocarditis based on the provided information, the need for preoperative antibiotics for tooth extraction may not be necessary according to the current guidelines.
• However, it is essential to consider the patient's overall health condition and the specific circumstances of the tooth extraction procedure to determine the best course of action.
• The studies 3 and 4 suggest that antibiotic prophylaxis may be beneficial in reducing the risk of infective endocarditis in high-risk individuals undergoing invasive dental procedures, but the patient's native valves may not pose a significant risk in this case.

Additional Considerations

• A study published in the American Journal of Cardiology 5 found that concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis did not affect perioperative or long-term mortality, but may be associated with higher postoperative stroke.
• This information may be relevant to the patient's upcoming CABG procedure, but does not directly address the question of preoperative antibiotics for tooth extraction.