Coronary Artery Bypass Grafting

Several retrospective and registry-based studies have examined outcomes of patients with prior CABG who subsequently required a major noncardiac surgical procedure. Among patients with remote CABG, noncardiac surgery appears safe. Among 1961 patients monitored in the Coronary Artery Surgery Study (CASS) registry, patients with prior CABG had signifi-

Relative risk

Favors control

Event rate

Event rate

Treated

Control

0/30

1/31

0/18

0/6

1/145

2/152

0/11

1/10

4/197

1/103

8/454

20/450

0/22

1/19

13/877

26/771

Favors a-2 agonists cantly reduced postoperative mortality (1.7% vs. 3.3%; P = .03) and MI (0.8% vs. 2.7%; P = .002) after noncardiac surgery, compared to patients with medically managed coronary disease. The mean duration between CABG and subsequent noncardiac surgery in this study was 4.1 years. Other observational reports have indicated that, for patients with prior CABG, mortality rates associated with noncardiac surgery are comparable to those observed among patients without evidence of coronary disease.

Although a history of remote CABG may be protective during future surgical procedures, the role of CABG undertaken as a preemptive measure among patients discovered to possess severe coronary artery disease during a preoperative risk assessment remains unproven. Performance of CABG can substantially delay subsequent noncardiac surgery, and prophylactic CABG may not be feasible if the required noncar-diac surgical procedure is urgent or semiurgent. Attempting to perform noncardiac surgery very shortly after CABG may be associated with further increased operative risks. For example, in one observational report, patients undergoing vascular surgery within 1 month after CABG demonstrated a fivefold increase in operative mortality compared with matched controls who underwent vascular surgery without preceding CABG (20.6% vs. 3.9%; P < .005).32

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