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Surgical Revascularization
High-risk
patients with LV systolic dysfunction, patients
with diabetes mellitus and those with two-vessel
disease with severe proximal LAD involvement of
three-vessel or left main disease should be considered
for Coronary Artery Bypass Graft (CABG). Compared
with these high-risk patients, low-risk patients
will receive negligibly or very modestly increased
chances of survival with CABG, which is associated
with short-term procedural risks when compared to
PCI or medical therapy. Therefore, in low-risk patients,
quality of life and patient preferences are given
more weight than are strict clinical outcomes in
the selection of treatment strategy.1
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Given
this, the AHA/CDC guidelines suggest that CABG should
be limited to patients who have suitable coronary
anatomy and who are not candidates for or have failed
thrombolytic therapy/PTCA and who are within 4 to
6 hours of the onset of an MI.1,2
In the setting of cardiogenic shock complicating
an acute MI, emergency CABG has been used after
other interventions have failed or have not been
indicated.2
Emergency CABG is indicated for most patients with
acute MI who have persistent angina pectoris or
hemodynamic instability following failed PTCA. CABG,
optimally performed within 2 to 3 hours, can limit
myocardial necrosis. However, mortality and morbidity
rates exceed those for elective CABG, specifically
when evaluating postoperative hemorrhage, the need
for blood products and perioperative MI. Operative
mortality is increased in patients with unstable
hemodynamic status, myocardial ischemia, multivessel
disease and prior CABG.2
Elective CABG after acute MI would be expected to
improve long-term survival in patients with MI who
have left main coronary artery stenosis greater
than 50%, three-vessel disease, two-vessel disease
with proximal left anterior descending coronary
artery stenosis, or two-vessel disease not amenable
to PTCA and reduced injection fraction. The optimal
timing of surgery has not been established, although
recent retrospective reports have suggested that
elective CABG may be carried out 3 to 7 days after
MI with operative mortality approaching that for
elective CABG. Risk of operation is increased for
patients with emergency or urgent surgery, older
age, or ventricular function.2
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