What are the American Heart Association (AHA) guidelines for perioperative care in patients undergoing Coronary Artery Bypass Grafting (CABG)?

AHA Guidelines for Perioperative Care in CABG

According to the American Heart Association (AHA) guidelines, perioperative care for patients undergoing Coronary Artery Bypass Grafting (CABG) should focus on optimizing hemodynamic parameters, reducing complications, and implementing evidence-based medication protocols to improve outcomes.

Anesthesia and Intraoperative Management

• A fellowship-trained cardiac anesthesiologist or experienced board-certified practitioner credentialed in perioperative transesophageal echocardiography should provide or supervise anesthetic care for high-risk patients 1
• Volatile anesthetic-based regimens are useful for facilitating early extubation and reducing patient recall 1
• Intraoperative transesophageal echocardiography should be performed for evaluation of acute, persistent, and life-threatening hemodynamic disturbances that have not responded to treatment 1
• Intraoperative transesophageal echocardiography should be performed in patients undergoing concomitant valvular surgery 1
• Management should target optimizing determinants of coronary arterial perfusion (heart rate, diastolic or mean arterial pressure, and ventricular end-diastolic pressure) to reduce perioperative myocardial ischemia and infarction 1

Hemodynamic Monitoring

• Continuous electrocardiogram monitoring for arrhythmias should be performed for at least 48 hours in all patients after CABG 1
• Continuous ST-segment monitoring for ischemia detection is reasonable in the intraoperative period 1
• Pulmonary artery catheter placement is indicated in patients with cardiogenic shock undergoing CABG, preferably before anesthesia induction or surgical incision 1
• Pulmonary artery catheter placement is reasonable for monitoring hemodynamic status in patients with acute hemodynamic instability 1

Medication Management

• Beta-blockers should be reinstituted as soon as possible after CABG in all patients without contraindications to reduce the incidence of postoperative atrial fibrillation 1
• Beta-blockers should be prescribed to all CABG patients without contraindications at hospital discharge 1
• Preoperative use of beta-blockers, particularly in patients with LVEF >30%, can reduce in-hospital mortality 1
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers given before CABG are recommended 1
• Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG 1

Prevention of Complications

Neurological Complications

• Efforts should be made to reduce the risk of brain dysfunction, including careful management of cardiopulmonary bypass time 1
• Carotid disease screening and appropriate management are important for neurologic risk reduction 1

Infection Prevention

• Strategies to reduce perioperative infection should be implemented, including appropriate antibiotic prophylaxis 1
• Cephalosporin antibiotics are commonly used for postoperative infection prophylaxis 1

Bleeding Management

• Strategies to reduce postoperative bleeding and transfusion should be implemented 1
• Autologous blood donation before cardiopulmonary bypass and autotransfusion may be considered 1

Emergency CABG Indications

• Emergency CABG is recommended in patients with acute MI when primary PCI has failed or cannot be performed, coronary anatomy is suitable, and persistent ischemia or hemodynamic instability is present 1
• Emergency CABG is recommended for patients undergoing repair of postinfarction mechanical complications (ventricular septal rupture, mitral valve insufficiency due to papillary muscle infarction/rupture, or free wall rupture) 1
• Emergency CABG is recommended for patients with cardiogenic shock who are suitable candidates, regardless of time interval from MI to shock onset 1
• Emergency CABG is recommended for patients with life-threatening ventricular arrhythmias (believed to be ischemic) with left main stenosis ≥50% and/or 3-vessel CAD 1

Quality Improvement

• All cardiac surgery programs should participate in a state, regional, or national clinical data registry and receive periodic reports of risk-adjusted outcomes 1
• When credible risk-adjusted outcomes data are unavailable, volume can be useful as a structural metric of CABG quality 1
• Interdisciplinary communication and patient safety in the perioperative environment should be improved through formalized checklist-guided multidisciplinary communication 1

Postoperative Care

• Smoking cessation education and therapy should be offered to all smokers during CABG hospitalization 1
• Cognitive behavior therapy or collaborative care can be beneficial for patients with clinical depression after CABG 1
• High thoracic epidural anesthesia/analgesia for routine analgesic use has uncertain effectiveness 1
• Routine early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support should be avoided 1

Common Pitfalls and Caveats

• Avoid early extubation in facilities with limited backup for airway emergencies 1
• Be cautious with the safety of preoperative administration of ACE inhibitors or angiotensin-receptor blockers in patients on chronic therapy 1
• Monitor for and aggressively treat postoperative atrial fibrillation, which is a common complication 1, 2
• Be vigilant for sternal wound infections, pneumonia, thromboembolic phenomena, graft failure, and other postoperative complications 2
• Recognize that emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion 1