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Clinical guideline| Volume 143, ISSUE 1, P4-34, January 2012

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2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary

A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Open AccessDOI:https://doi.org/10.1016/j.jtcvs.2011.10.015
2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary
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      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 properly 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 Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations 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 considered, 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.
      ACCF/AHA Task Force on Practice Guidelines
      Methodologies and Policies from the ACCF/AHA Task Force on Practice Guidelines.
      http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf
      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 available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations 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 committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations 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, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.
      Table 1Applying 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. 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 diabetes, 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 comparisons of the treatments or strategies being evaluated.
      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 patient 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 influence 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. 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 rescue 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. Additionally, to ensure complete transparency, writing committee members’ comprehensive 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 committee 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.
      Institute of Medicine
      Finding What Works in Health Care: Standards for Systematic Reviews.
      The National Academies Press, Washington, DC2011
      , 
      Institute of Medicine
      Clinical Practice Guidelines We Can Trust.
      The National Academies Press, Washington, DC2011
      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. Introduction

      1.1 Methodology and Evidence Review

      Whenever possible, the recommendations listed in this document 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 evidence conducted in human subjects that were published in English. Key search words included but were not limited to: analgesia, anastomotic techniques, antiplatelet agents, automated proximal clampless anastomosis device, asymptomatic ischemia, Cardica C-port, cost effectiveness, depressed left ventricular (LV) function, distal anastomotic techniques, direct proximal anastomosis on aorta, distal anastomotic devices, emergency coronary artery bypass graft (CABG) and ST-elevation myocardial infarction (STEMI), heart failure, interrupted sutures, LV systolic dysfunction, magnetic connectors, PAS-Port automated proximal clampless anastomotic device, patency, proximal connectors, renal disease, sequential anastomosis, sternotomy, symmetry connector, symptomatic ischemia, proximal connectors, sequential anastomosis, T grafts, thoracotomy, 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 representative but not all-inclusive.
      The guideline is focused on the safe, appropriate, and efficacious performance of CABG. The STEMI, percutaneous coronary intervention (PCI), and CABG guidelines were written concurrently, with additional collaboration from the Stable Ischemic Heart Disease (SIHD) guideline writing committee. This allowed greater collaboration among the different writing committees on topics such as PCI in STEMI and revascularization strategies in patients with coronary artery disease (CAD) (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures).
      In accordance with the direction of the Task Force and feedback from readers, in this iteration of the guideline, the amount of text has been shortened, and emphasis has been placed on summary statements rather than detailed discussion of numerous individual trials. Online supplemental evidence and summary tables have been created to document the studies and data considered for new or changed guideline recommendations.
      Because the executive summary contains only the recommendations, the reader is encouraged to consult the full-text guideline
      • Hillis L.D.
      • Smith P.K.
      • Anderson J.L.
      • et al.
      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.
      J Am Coll Cardiol. 2011; (published online before print November 7, 2011, doi:10.1016/j.jacc.2011.08.009. Accessed November 7, 2011)
      for additional detail on the recommendations and guidance on the care of the patient undergoing 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 representatives from the ACCF, AHA, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, 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 Interventional Scientific Council, and Southern Thoracic Surgical Association. All information on reviewers’ RWIs was distributed to the writing committee and is published in this document (Appendix 2. This document was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS.

      2. Procedural Considerations: Recommendations

      2.1 Anesthetic Considerations

      Class I
      • 1.
        Anesthetic management directed toward early postoperative extubation and accelerated recovery of low- to medium-risk patients undergoing uncomplicated CABG is recommended.

        Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients. Cochrane Database Syst Rev. 2003;CD003587-10.1002/14651858.CD003587.

        , 
        • Myles P.S.
        • Daly D.J.
        • Djaiani G.
        • et al.
        A systematic review of the safety and effectiveness of fast-track cardiac anesthesia.
        Anesthesiology. 2003; 99: 982-987
        , 
        • van Mastrigt G.A.
        • Maessen J.G.
        • Heijmans J.
        • et al.
        Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials.
        Crit Care Med. 2006; 34: 1624-1634
        (Level of Evidence: B)
      • 2.
        Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.
        • Bainbridge D.
        • Martin J.E.
        • Cheng D.C.
        Patient-controlled versus nurse-controlled analgesia after cardiac surgery—a meta-analysis.
        Can J Anaesth. 2006; 53: 492-499
        , 
        • Brennan F.
        • Carr D.B.
        • Cousins M.
        Pain management: a fundamental human right.
        Anesth Analg. 2007; 105: 205-221
        , 
        • Lahtinen P.
        • Kokki H.
        • Hynynen M.
        Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity.
        Anesthesiology. 2006; 105: 794-800
        , 
        • Serfontein L.
        Awareness in cardiac anesthesia.
        Curr Opin Anaesthesiol. 2010; 23: 103-108
        , 
        • Taillefer M.-C.
        • Carrier M.
        • Belisle S.
        • et al.
        Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: a cross-sectional study.
        J Thorac Cardiovasc Surg. 2006; 131: 1274-1280
        (Level of Evidence: B)
      • 3.
        Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication).
        • Martinez E.A.
        • Marsteller J.A.
        • Thompson D.A.
        • et al.
        The Society of Cardiovascular Anesthesiologists’ FOCUS initiative: Locating Errors through Networked Surveillance (LENS) project vision.
        Anesth Analg. 2010; 110: 307-311
        , 
        • Wadhera R.K.
        • Parker S.H.
        • Burkhart H.M.
        • et al.
        Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass.
        J Thorac Cardiovasc Surg. 2010; 139: 312-319
        , 
        • Neily J.
        • Mills P.D.
        • Young-Xu Y.
        • et al.
        Association between implementation of a medical team training program and surgical mortality.
        JAMA. 2010; 304: 1693-1700
        , 
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • et al.
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499
        (Level of Evidence: B)
      • 4.
        A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocardiography is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk.
        • Cahalan M.K.
        • Stewart W.
        • Pearlman A.
        • et al.
        American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography.
        J Am Soc Echocardiogr. 2002; 15: 647-652
        , 
        • Mathew J.P.
        • Glas K.
        • Troianos C.A.
        • et al.
        American Society of Echocardiography/Society of Cardiovascular Anesthesiologists recommendations and guidelines for continuous quality improvement in perioperative echocardiography.
        J Am Soc Echocardiogr. 2006; 19: 1303-1313
        , 
        • Thys D.M.
        Cardiac anesthesia: thirty years later—the second annual Arthur E. Weyman lecture.
        Anesth Analg. 2009; 109: 1782-1790
        (Level of Evidence: C)
      Class IIa
      • 1.
        Volatile anesthestic-based regimens can be useful in facilitating early extubation and reducing patient recall.
        • Myles P.S.
        • Daly D.J.
        • Djaiani G.
        • et al.
        A systematic review of the safety and effectiveness of fast-track cardiac anesthesia.
        Anesthesiology. 2003; 99: 982-987
        , 
        • Dowd N.P.
        • Cheng D.C.
        • Karski J.M.
        • et al.
        Intraoperative awareness in fast-track cardiac anesthesia.
        Anesthesiology. 1998; 89: 1068-1073
        , 
        • Groesdonk H.V.
        • Pietzner J.
        • Borger M.A.
        • et al.
        The incidence of intraoperative awareness in cardiac surgery fast-track treatment.
        J Cardiothorac Vasc Anesth. 2010; 24: 785-789
        , 
        • Cheng D.C.
        • Karski J.
        • Peniston C.
        • et al.
        Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: a prospective, randomized, controlled trial.
        Anesthesiology. 1996; 85: 1300-1310
        (Level of Evidence: A)
      Class IIb
      • 1.
        The effectiveness of high thoracic epidural anesthesia/analgesia for routine analgesic use is uncertain.
        • Horlocker T.T.
        • Wedel D.J.
        • Rowlingson J.C.
        • et al.
        Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).
        Reg Anesth Pain Med. 2010; 35: 64-101
        , 
        • Murphy G.S.
        • Szokol J.W.
        • Marymont J.H.
        • et al.
        Recovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium.
        Anesth Analg. 2003; 96: 1301-1307
        , 
        • Nygard E.
        • Kofoed K.F.
        • Freiberg J.
        • et al.
        Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease.
        Circulation. 2005; 111: 2165-2170
        , 
        • Tenenbein P.K.
        • Debrouwere R.
        • Maguire D.
        • et al.
        Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery.
        Can J Anaesth. 2008; 55: 344-350
        (Level of Evidence: B)
      Class III: Harm
      • 1.
        Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.
        • Nussmeier N.A.
        • Whelton A.A.
        • Brown M.T.
        • et al.
        Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery.
        N Engl J Med. 2005; 352: 1081-1091
        , 
        • Ott E.
        • Nussmeier N.A.
        • Duke P.C.
        • et al.
        Efficacy and safety of the cyclooxygenase 2 inhibitors parecoxib and valdecoxib in patients undergoing coronary artery bypass surgery.
        J Thorac Cardiovasc Surg. 2003; 125: 1481-1492
        (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)

      2.2 Bypass Graft Conduit

      Class I
      • 1.
        If possible, the left internal mammary artery (LIMA) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD artery is indicated.
        • Boylan M.J.
        • Lytle B.W.
        • Loop F.D.
        • et al.
        Surgical treatment of isolated left anterior descending coronary stenosis: comparison of left internal mammary artery and venous autograft at 18 to 20 years of follow-up.
        J Thorac Cardiovasc Surg. 1994; 107: 657-662
        , 
        • Cameron A.
        • Davis K.B.
        • Green G.
        • et al.
        Coronary bypass surgery with internal-thoracic-artery grafts: effects on survival over a 15-year period.
        N Engl J Med. 1996; 334: 216-219
        , 
        • Loop F.D.
        • Lytle B.W.
        • Cosgrove D.M.
        • et al.
        Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.
        N Engl J Med. 1986; 314: 1-6
        , 
        • Sabik J.F.I.
        • Lytle B.W.
        • Blackstone E.H.
        • et al.
        Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.
        Ann Thorac Surg. 2005; 79: 544-551
        (Level of Evidence: B)
      Class IIa
      • 1.
        The right internal mammary artery is probably indicated to bypass the LAD artery when the LIMA is unavailable or unsuitable as a bypass conduit. (Level of Evidence: C)
      • 2.
        When anatomically and clinically suitable, use of a second internal mammary artery to graft the left circumflex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention.
        • Lytle B.W.
        • Blackstone E.H.
        • Loop F.D.
        • et al.
        Two internal thoracic artery grafts are better than one.
        J Thorac Cardiovasc Surg. 1999; 117: 855-872
        , 
        • Lytle B.W.
        • Blackstone E.H.
        • Sabik J.F.
        • et al.
        The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.
        Ann Thorac Surg. 2004; 78: 2005-2012
        , 
        • Sabik J.F.I.
        • Blackstone E.H.
        • Gillinov A.M.
        • et al.
        Influence of patient characteristics and arterial grafts on freedom from coronary reoperation.
        J Thorac Cardiovasc Surg. 2006; 131: 90-98
        , 
        • Sabik J.F.I.
        • Stockins A.
        • Nowicki E.R.
        • et al.
        Does location of the second internal thoracic artery graft influence outcome of coronary artery bypass grafting?.
        Circulation. 2008; 118: S210-S215
        , 
        • Stevens L.M.
        • Carrier M.
        • Perrault L.P.
        • et al.
        Single versus bilateral internal thoracic artery grafts with concomitant saphenous vein grafts for multivessel coronary artery bypass grafting: effects on mortality and event-free survival.
        J Thorac Cardiovasc Surg. 2004; 127: 1408-1415
        (Level of Evidence: B)
      Class IIb
      • 1.
        Complete arterial revascularization may be reasonable in patients less than or equal to 60 years of age with few or no comorbidities. (Level of Evidence: C)
      • 2.
        Arterial grafting of the right coronary artery may be reasonable when a critical (≥90%) stenosis is present.
        • Sabik J.F.I.
        • Lytle B.W.
        • Blackstone E.H.
        • et al.
        Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.
        Ann Thorac Surg. 2005; 79: 544-551
        , 
        • Sabik J.F.I.
        • Stockins A.
        • Nowicki E.R.
        • et al.
        Does location of the second internal thoracic artery graft influence outcome of coronary artery bypass grafting?.
        Circulation. 2008; 118: S210-S215
        , 
        • Sabik J.F.I.
        • Lytle B.W.
        • Blackstone E.H.
        • et al.
        Does competitive flow reduce internal thoracic artery graft patency?.
        Ann Thorac Surg. 2003; 76: 1490-1496
        (Level of Evidence: B)
      • 3.
        Use of a radial artery graft may be reasonable when grafting left-sided coronary arteries with severe stenoses (>70%) and right-sided arteries with critical stenoses (≥90%) that perfuse LV myocardium.
        • Acar C.
        • Ramsheyi A.
        • Pagny J.Y.
        • et al.
        The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years.
        J Thorac Cardiovasc Surg. 1998; 116: 981-989
        , 
        • Maniar H.S.
        • Sundt T.M.
        • Barner H.B.
        • et al.
        Effect of target stenosis and location on radial artery graft patency.
        J Thorac Cardiovasc Surg. 2002; 123: 45-52
        , 
        • Moran S.V.
        • Baeza R.
        • Guarda E.
        • et al.
        Predictors of radial artery patency for coronary bypass operations.
        Ann Thorac Surg. 2001; 72: 1552-1556
        , 
        • Possati G.
        • Gaudino M.
        • Alessandrini F.
        • et al.
        Midterm clinical and angiographic results of radial artery grafts used for myocardial revascularization.
        J Thorac Cardiovasc Surg. 1998; 116: 1015-1021
        , 
        • Royse A.G.
        • Royse C.F.
        • Tatoulis J.
        • et al.
        Postoperative radial artery angiography for coronary artery bypass surgery.
        Eur J Cardiothorac Surg. 2000; 17: 294-304
        , 
        • Desai N.D.
        • Cohen E.A.
        • Naylor C.D.
        • et al.
        A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts.
        N Engl J Med. 2004; 351: 2302-2309
        (Level of Evidence: B)
      Class III: Harm
      • 1.
        An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%).
        • Sabik J.F.I.
        • Lytle B.W.
        • Blackstone E.H.
        • et al.
        Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.
        Ann Thorac Surg. 2005; 79: 544-551
        (Level of Evidence: C)

      2.3 Intraoperative Transesophageal Echocardiography

      Class I
      • 1.
        Intraoperative transesophageal echocardiography should be performed for evaluation of acute, persistent, and life-threatening hemodynamic disturbances that have not responded to treatment.
        • Eltzschig H.K.
        • Rosenberger P.
        • Loffler M.
        • et al.
        Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.
        Ann Thorac Surg. 2008; 85: 845-852
        , 
        • Savage R.M.
        • Lytle B.W.
        • Aronson S.
        • et al.
        Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting.
        Ann Thorac Surg. 1997; 64: 368-373
        (Level of Evidence: B)
      • 2.
        Intraoperative transesophageal echocardiography should be performed in patients undergoing concomitant valvular surgery.
        • Eltzschig H.K.
        • Rosenberger P.
        • Loffler M.
        • et al.
        Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.
        Ann Thorac Surg. 2008; 85: 845-852
        , 
        Practice guidelines for perioperative transesophageal echocardiography An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.
        Anesthesiology. 2010; 112: 1084-1096
        (Level of Evidence: B)
      Class IIa
      • 1.
        Intraoperative transesophageal echocardiography is reasonable for monitoring of hemodynamic status, ventricular function, regional wall motion, and valvular function in patients undergoing CABG.
        • Savage R.M.
        • Lytle B.W.
        • Aronson S.
        • et al.
        Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting.
        Ann Thorac Surg. 1997; 64: 368-373
        , 
        • Bergquist B.D.
        • Bellows W.H.
        • Leung J.M.
        Transesophageal echocardiography in myocardial revascularization: II Influence on intraoperative decision making.
        Anesth Analg. 1996; 82: 1139-1145
        , 
        • Moises V.A.
        • Mesquita C.B.
        • Campos O.
        • et al.
        Importance of intraoperative transesophageal echocardiography during coronary artery surgery without cardiopulmonary bypass.
        J Am Soc Echocardiogr. 1998; 11: 1139-1144
        , 
        • Qaddoura F.E.
        • Abel M.D.
        • Mecklenburg K.L.
        • et al.
        Role of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery.
        Ann Thorac Surg. 2004; 78: 1586-1590
        , 
        • Swaminathan M.
        • Morris R.W.
        • De Meyts D.D.
        • et al.
        Deterioration of regional wall motion immediately after coronary artery bypass graft surgery is associated with long-term major adverse cardiac events.
        Anesthesiology. 2007; 107: 739-745
        , 
        • Wang J.
        • Filipovic M.
        • Rudzitis A.
        • et al.
        Transesophageal echocardiography for monitoring segmental wall motion during off-pump coronary artery bypass surgery.
        Anesth Analg. 2004; 99: 965-973
        , 
        • Zimarino M.
        • Gallina S.
        • Di Fulvio M.
        • et al.
        Intraoperative ischemia and long-term events after minimally invasive coronary surgery.
        Ann Thorac Surg. 2004; 78: 135-141
        (Level of Evidence: B)

      2.4 Preconditioning/Management of Myocardial Ischemia

      Class I
      • 1.
        Management targeted at optimizing the determinants of coronary arterial perfusion (eg, heart rate, diastolic or mean arterial pressure, and right ventricular or LV end-diastolic pressure) is recommended to reduce the risk of perioperative myocardial ischemia and infarction.
        • Dyub A.M.
        • Whitlock R.P.
        • Abouzahr L.L.
        • et al.
        Preoperative intra-aortic balloon pump in patients undergoing coronary bypass surgery: a systematic review and meta-analysis.
        J Card Surg. 2008; 23: 79-86
        , 
        • Heusch G.
        Heart rate in the pathophysiology of coronary blood flow and myocardial ischaemia: benefit from selective bradycardic agents.
        Br J Pharmacol. 2008; 153: 1589-1601
        , 
        • Slogoff S.
        • Keats A.S.
        Does perioperative myocardial ischemia lead to postoperative myocardial infarction?.
        Anesthesiology. 1985; 62: 107-114
        , 
        • Gibbons R.J.
        • Balady G.J.
        • Bricker J.T.
        • et al.
        ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) [published correction appears in J Am Coll Cardiol. 2006;48:1731].
        J Am Coll Cardiol. 2002; 40: 1531-1540
        , 
        • Lavana J.D.
        • Fraser J.F.
        • Smith S.E.
        • et al.
        Influence of timing of intraaortic balloon placement in cardiac surgical patients.
        J Thorac Cardiovasc Surg. 2010; 140: 80-85
        (Level of Evidence: B)
      Class IIa
      • 1.
        Volatile-based anesthesia can be useful in reducing the risk of perioperative myocardial ischemia and infarction.
        • Landoni G.
        • Biondi-Zoccai G.G.
        • Zangrillo A.
        • et al.
        Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials.
        J Cardiothorac Vasc Anesth. 2007; 21: 502-511
        , 
        • Lucchinetti E.
        • Hofer C.
        • Bestmann L.
        • et al.
        Gene regulatory control of myocardial energy metabolism predicts postoperative cardiac function in patients undergoing off-pump coronary artery bypass graft surgery: inhalational versus intravenous anesthetics.
        Anesthesiology. 2007; 106: 444-457
        , 
        • Yao Y.T.
        • Li L.H.
        Sevoflurane versus propofol for myocardial protection in patients undergoing coronary artery bypass grafting surgery: a meta-analysis of randomized controlled trials.
        Chin Med Sci J. 2009; 24: 133-141
        , 
        • Yu C.H.
        • Beattie W.S.
        The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG: a meta-analysis.
        Can J Anaesth. 2006; 53: 906-918
        (Level of Evidence: A)
      Class IIb
      • 1.
        The effectiveness of prophylactic pharmacological therapies or controlled reperfusion strategies aimed at inducing preconditioning or attenuating the adverse consequences of myocardial reperfusion injury or surgically induced systemic inflammation is uncertain.
        • Rabi D.
        • Clement F.
        • McAlister F.
        • et al.
        Effect of perioperative glucose-insulin-potassium infusions on mortality and atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis.
        Can J Cardiol. 2010; 26: 178-184
        , 
        • Buckberg G.D.
        Controlled reperfusion after ischemia may be the unifying recovery denominator.
        J Thorac Cardiovasc Surg. 2010; 140: 12-18
        , 
        • Alexander J.H.
        • Emery Jr., R.
        • Carrier M.
        • et al.
        Efficacy and safety of pyridoxal 5’-phosphate (MC-1) in high-risk patients undergoing coronary artery bypass graft surgery: the MEND-CABG II randomized clinical trial.
        JAMA. 2008; 299: 1777-1787
        , 
        • Mangano D.T.
        Effects of acadesine on myocardial infarction, stroke, and death following surgery: a meta-analysis of the 5 international randomized trials: the Multicenter Study of Perioperative Ischemia (McSPI) Research Group.
        JAMA. 1997; 277: 325-332
        , 
        • Mangano D.T.
        • Miao Y.
        • Tudor I.C.
        • et al.
        Post-reperfusion myocardial infarction: long-term survival improvement using adenosine regulation with acadesine.
        J Am Coll Cardiol. 2006; 48: 206-214
        , 
        • Shernan S.K.
        • Fitch J.C.
        • Nussmeier N.A.
        • et al.
        Impact of pexelizumab, an anti-C5 complement antibody, on total mortality and adverse cardiovascular outcomes in cardiac surgical patients undergoing cardiopulmonary bypass.
        Ann Thorac Surg. 2004; 77: 942-949
        , 
        • Smith P.K.
        • Shernan S.K.
        • Chen J.C.
        • et al.
        Effects of C5 complement inhibitor pexelizumab on outcome in high-risk coronary artery bypass grafting: Combined results from the PRIMO-CABG I and II trials.
        J Thorac Cardiovasc Surg. 2010; 142: 89-98
        , 
        • Testa L.
        • Van Gaal W.J.
        • Bhindi R.
        • et al.
        Pexelizumab in ischemic heart disease: a systematic review and meta-analysis on 15,196 patients.
        J Thorac Cardiovasc Surg. 2008; 136: 884-893
        (Level of Evidence: A)
      • 2.
        Mechanical preconditioning might be considered to reduce the risk of perioperative myocardial ischemia and infarction in patients undergoing off-pump CABG.
        • Laurikka J.
        • Wu Z.K.
        • Iisalo P.
        • et al.
        Regional ischemic preconditioning enhances myocardial performance in off-pump coronary artery bypass grafting.
        Chest. 2002; 121: 1183-1189
        , 
        • Penttila H.J.
        • Lepojarvi M.V.
        • Kaukoranta P.K.
        • et al.
        Ischemic preconditioning does not improve myocardial preservation during off-pump multivessel coronary operation.
        Ann Thorac Surg. 2003; 75: 1246-1252
        , 
        • Walsh S.R.
        • Tang T.Y.
        • Kullar P.
        • et al.
        Ischaemic preconditioning during cardiac surgery: systematic review and meta-analysis of perioperative outcomes in randomised clinical trials.
        Eur J Cardiothorac Surg. 2008; 34: 985-994
        (Level of Evidence: B)
      • 3.
        Remote ischemic preconditioning strategies using peripheral-extremity occlusion/reperfusion might be considered to attenuate the adverse consequences of myocardial reperfusion injury.
        • Hausenloy D.J.
        • Mwamure P.K.
        • Venugopal V.
        • et al.
        Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial.
        Lancet. 2007; 370: 575-579
        , 
        • Rahman I.A.
        • Mascaro J.G.
        • Steeds R.P.
        • et al.
        Remote ischemic preconditioning in human coronary artery bypass surgery: from promise to disappointment?.
        Circulation. 2010; 122: S53-S59
        , 
        • Venugopal V.
        • Hausenloy D.J.
        • Ludman A.
        • et al.
        Remote ischaemic preconditioning reduces myocardial injury in patients undergoing cardiac surgery with cold-blood cardioplegia: a randomised controlled trial.
        Heart. 2009; 95: 1567-1571
        (Level of Evidence: B)
      • 4.
        The effectiveness of postconditioning strategies to attenuate the adverse consequences of myocardial reperfusion injury is uncertain.
        • Luo W.
        • Li B.
        • Chen R.
        • et al.
        Effect of ischemic postconditioning in adult valve replacement.
        Eur J Cardiothorac Surg. 2008; 33: 203-208
        , 
        • Ovize M.
        • Baxter G.F.
        • Di Lisa F.
        • et al.
        Postconditioning and protection from reperfusion injury: where do we stand? Position paper from the Working Group of Cellular Biology of the Heart of the European Society of Cardiology.
        Cardiovasc Res. 2010; 87: 406-423
        (Level of Evidence: C)

      2.5 Clinical Subsets

      2.5.1 CABG in Patients With Acute Myocardial Infarction

      Class I
      • 1.
        Emergency CABG is recommended in patients with acute myocardial infarction (MI) in whom (1) primary PCI has failed or cannot be performed, (2) coronary anatomy is suitable for CABG, and (3) persistent ischemia of a significant area of myocardium at rest and/or hemodynamic instability refractory to nonsurgical therapy is present.
        • Alexiou K.
        • Kappert U.
        • Staroske A.
        • et al.
        Coronary surgery for acute coronary syndrome: which determinants of outcome remain?.
        Clin Res Cardiol. 2008; 97: 601-608
        , 
        • Chiu F.C.
        • Chang S.N.
        • Lin J.W.
        • et al.
        Coronary artery bypass graft surgery provides better survival in patients with acute coronary syndrome or ST-segment elevation myocardial infarction experiencing cardiogenic shock after percutaneous coronary intervention: a propensity score analysis.
        J Thorac Cardiovasc Surg. 2009; 138: 1326-1330
        , 
        • DeWood M.A.
        • Spores J.
        • Berg Jr., R.
        • et al.
        Acute myocardial infarction: a decade of experience with surgical reperfusion in 701 patients.
        Circulation. 1983; 68: II8-II16
        , 
        • Donatelli F.
        • Benussi S.
        • Triggiani M.
        • et al.
        Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.
        Eur J Cardiothorac Surg. 1997; 11: 228-233
        , 
        • Filizcan U.
        • Kurc E.
        • Cetemen S.
        • et al.
        Mortality predictors in ST-elevated myocardial infarction patients undergoing coronary artery bypass grafting.
        Angiology. 2011; 62: 68-73
        (Level of Evidence: B)
      • 2.
        Emergency CABG is recommended in patients undergoing surgical repair of a postinfarction mechanical complication of MI, such as ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction and/or rupture, or free wall rupture.
        • Chevalier P.
        • Burri H.
        • Fahrat F.
        • et al.
        Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation.
        Eur J Cardiothorac Surg. 2004; 26: 330-335
        , 
        • Lemery R.
        • Smith H.C.
        • Giuliani E.R.
        • et al.
        Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention.
        Am J Cardiol. 1992; 70: 147-151
        , 
        • Russo A.
        • Suri R.M.
        • Grigioni F.
        • et al.
        Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture.
        Circulation. 2008; 118: 1528-1534
        , 
        • Shamshad F.
        • Kenchaiah S.
        • Finn P.V.
        • et al.
        Fatal myocardial rupture after acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT).
        Am Heart J. 2010; 160: 145-151
        , 
        • Tavakoli R.
        • Weber A.
        • Brunner-La Rocca H.
        • et al.
        Results of surgery for irreversible moderate to severe mitral valve regurgitation secondary to myocardial infarction.
        Eur J Cardiothorac Surg. 2002; 21: 818-824
        (Level of Evidence: B)
      • 3.
        Emergency CABG is recommended in patients with cardiogenic shock and who are suitable for CABG irrespective of the time interval from MI to onset of shock and time from MI to CABG.
        • Donatelli F.
        • Benussi S.
        • Triggiani M.
        • et al.
        Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.
        Eur J Cardiothorac Surg. 1997; 11: 228-233
        , 
        • Hochman J.S.
        • Sleeper L.A.
        • Webb J.G.
        • et al.
        Early revascularization in acute myocardial infarction complicated by cardiogenic shock: SHOCK Investigators: Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock.
        N Engl J Med. 1999; 341: 625-634
        , 
        • Mehta R.H.
        • Lopes R.D.
        • Ballotta A.
        • et al.
        Percutaneous coronary intervention or coronary artery bypass surgery for cardiogenic shock and multivessel coronary artery disease?.
        Am Heart J. 2010; 159: 141-147
        , 
        • White H.D.
        • Assmann S.F.
        • Sanborn T.A.
        • et al.
        Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial.
        Circulation. 2005; 112: 1992-2001
        (Level of Evidence: B)
      • 4.
        Emergency CABG is recommended in patients with life-threatening ventricular arrhythmias (believed to be ischemic in origin) in the presence of left main stenosis greater than or equal to 50% and/or 3-vessel CAD.
        • Ngaage D.L.
        • Cale A.R.
        • Cowen M.E.
        • et al.
        Early and late survival after surgical revascularization for ischemic ventricular fibrillation/tachycardia.
        Ann Thorac Surg. 2008; 85: 1278-1281
        (Level of Evidence: C)
      Class IIa
      • 1.
        The use of CABG is reasonable as a revascularization strategy in patients with multivessel CAD with recurrent angina or MI within the first 48 hours of STEMI presentation as an alternative to a more delayed strategy.
        • Alexiou K.
        • Kappert U.
        • Staroske A.
        • et al.
        Coronary surgery for acute coronary syndrome: which determinants of outcome remain?.
        Clin Res Cardiol. 2008; 97: 601-608
        , 
        • DeWood M.A.
        • Spores J.
        • Berg Jr., R.
        • et al.
        Acute myocardial infarction: a decade of experience with surgical reperfusion in 701 patients.
        Circulation. 1983; 68: II8-II16
        , 
        • Filizcan U.
        • Kurc E.
        • Cetemen S.
        • et al.
        Mortality predictors in ST-elevated myocardial infarction patients undergoing coronary artery bypass grafting.
        Angiology. 2011; 62: 68-73
        , 
        • Parikh S.V.
        • de Lemos J.A.
        • Jessen M.E.
        • et al.
        Timing of in-hospital coronary artery bypass graft surgery for non-ST-segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines).
        J Am Coll Cardiol Intv. 2010; 3: 419-427
        (Level of Evidence: B)
      • 2.
        Early revascularization with PCI or CABG is reasonable for selected patients greater than 75 years of age with ST-segment elevation or left bundle branch block who are suitable for revascularization irrespective of the time interval from MI to onset of shock.
        • Lim H.S.
        • Farouque O.
        • Andrianopoulos N.
        • et al.
        Survival of elderly patients undergoing percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock.
        J Am Coll Cardiol Intv. 2009; 2: 146-152
        , 
        • Amin A.P.
        • Nathan S.
        • Prodduturi P.
        • et al.
        Survival benefit from early revascularization in elderly patients with cardiogenic shock after acute myocardial infarction: a cohort study.
        J Invasive Cardiol. 2009; 21: 305-312
        , 
        • Migliorini A.
        • Moschi G.
        • Valenti R.
        • et al.
        Routine percutaneous coronary intervention in elderly patients with cardiogenic shock complicating acute myocardial infarction.
        Am Heart J. 2006; 152: 903-908
        , 
        • Hochman J.S.
        • Buller C.E.
        • Sleeper L.A.
        • et al.
        Cardiogenic shock complicating acute myocardial infarction-etiologies, management and outcome: a report from the SHOCK Trial Registry: SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?.
        J Am Coll Cardiol. 2000; 36: 1063-1070
        , 
        • Dzavik V.
        • Sleeper L.A.
        • Cocke T.P.
        • et al.
        Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.
        Eur Heart J. 2003; 24: 828-837
        (Level of Evidence: B)
      Class III: Harm
      • 1.
        Emergency CABG should not be performed in patients with persistent angina and a small area of viable myocardium who are stable hemodynamically. (Level of Evidence: C)
      • 2.
        Emergency CABG should not be performed in patients with no-reflow (successful epicardial reperfusion with unsuccessful microvascular reperfusion). (Level of Evidence: C)

      2.5.2 Life-Threatening Ventricular Arrhythmias

      Class I
      • 1.
        CABG is recommended in patients with resuscitated sudden cardiac death or sustained ventricular tachycardia thought to be caused by significant CAD (≥50% stenosis of left main coronary artery and/or ≥70% stenosis of 1, 2, or all 3 epicardial coronary arteries) and resultant myocardial ischemia.
        • Ngaage D.L.
        • Cale A.R.
        • Cowen M.E.
        • et al.
        Early and late survival after surgical revascularization for ischemic ventricular fibrillation/tachycardia.
        Ann Thorac Surg. 2008; 85: 1278-1281
        , 
        • Every N.R.
        • Fahrenbruch C.E.
        • Hallstrom A.P.
        • et al.
        Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest.
        J Am Coll Cardiol. 1992; 19: 1435-1439
        , 
        • Kelly P.
        • Ruskin J.N.
        • Vlahakes G.J.
        • et al.
        Surgical coronary revascularization in survivors of prehospital cardiac arrest: its effect on inducible ventricular arrhythmias and long-term survival.
        J Am Coll Cardiol. 1990; 15: 267-273
        (Level of Evidence: B)
      Class III: Harm
      • 1.
        CABG should not be performed in patients with ventricular tachycardia with scar and no evidence of ischemia. (Level of Evidence: C)

      2.5.3 Emergency CABG After Failed PCI

      Class I
      • 1.
        Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk.
        • Barakate M.S.
        • Bannon P.G.
        • Hughes C.F.
        • et al.
        Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years’ experience.
        Ann Thorac Surg. 2003; 75: 1400-1405
        , 
        • Roy P.
        • de Labriolle A.
        • Hanna N.
        • et al.
        Requirement for emergent coronary artery bypass surgery following percutaneous coronary intervention in the stent era.
        Am J Cardiol. 2009; 103: 950-953
        (Level of Evidence: B)
      • 2.
        Emergency CABG is recommended after failed PCI for hemodynamic compromise in patients without impairment of the coagulation system and without a previous sternotomy.
        • Barakate M.S.
        • Bannon P.G.
        • Hughes C.F.
        • et al.
        Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years’ experience.
        Ann Thorac Surg. 2003; 75: 1400-1405
        , 
        • Craver J.M.
        • Weintraub W.S.
        • Jones E.L.
        • et al.
        Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty: a 10-year experience.
        Ann Surg. 1992; 215: 425-433
        , 
        • Stamou S.C.
        • Hill P.C.
        • Haile E.
        • et al.
        Clinical outcomes of nonelective coronary revascularization with and without cardiopulmonary bypass.
        J Thorac Cardiovasc Surg. 2006; 131: 28-33
        (Level of Evidence: B)
      Class IIa
      • 1.
        Emergency CABG is reasonable after failed PCI for retrieval of a foreign body (most likely a fractured guidewire or stent) in a crucial anatomic location. (Level of Evidence: C)
      • 2.
        Emergency CABG can be beneficial after failed PCI for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy. (Level of Evidence: C)
      Class IIb
      • 1.
        Emergency CABG might be considered after failed PCI for hemodynamic compromise in patients with previous sternotomy. (Level of Evidence: C)
      Class III: Harm
      • 1.
        Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion. (Level of Evidence: C)
      • 2.
        Emergency CABG should not be performed after failed PCI if revascularization is impossible because of target anatomy or a no-reflow state. (Level of Evidence: C)

      2.5.4 CABG in Association With Other Cardiac Procedures

      Class I
      • 1.
        CABG is recommended in patients undergoing noncoronary cardiac surgery with greater than or equal to 50% luminal diameter narrowing of the left main coronary artery or greater than or equal to 70% luminal diameter narrowing of other major coronary arteries. (Level of Evidence: C)
      Class IIa
      • 1.
        The use of the LIMA is reasonable to bypass a significantly narrowed LAD artery in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C)
      • 2.
        CABG of moderately diseased coronary arteries (>50% luminal diameter narrowing) is reasonable in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C)

      3. CAD Revascularization: Recommendations

      Recommendations and text in this section are the result of extensive collaborative discussions between the PCI and CABG writing committees as well as key members of the SIHD and Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) writing committees. Certain issues, such as older versus more contemporary studies, primary analyses versus subgroup analyses, and prospective versus post hoc analyses, have been carefully weighed in designating COR and LOE; they are addressed in the appropriate corresponding text.
      • Hillis L.D.
      • Smith P.K.
      • Anderson J.L.
      • et al.
      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.
      J Am Coll Cardiol. 2011; (published online before print November 7, 2011, doi:10.1016/j.jacc.2011.08.009. Accessed November 7, 2011)
      The goals of revascularization for patients with CAD are to (1) to improve survival and (2) to relieve symptoms. The following text contains recommendations for revascularization toimprove survival and symptoms. These recommendations are summarized in Table 2, Table 3.
      Table 2Revascularization to improve survival compared with medical therapy
      CABG, Coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not applicable; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main; VT, ventricular tachycardia. ∗In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI
      • Sorajja P.
      • Chareonthaitawee P.
      • Rajagopalan N.
      • et al.
      Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting.
      Circulation. 2005; 112: I311-I316
      , 
      The BARI Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI).
      Circulation. 1997; 96: 1761-1769
      , 
      The BARI Investigators
      The final 10-year follow-up results from the BARI randomized trial.
      J Am Coll Cardiol. 2007; 49: 1600-1606
      , 
      • Banning A.P.
      • Westaby S.
      • Morice M.C.
      • et al.
      Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents.
      J Am Coll Cardiol. 2010; 55: 1067-1075
      , 
      • Hoffman S.N.
      • TenBrook J.A.
      • Wolf M.P.
      • et al.
      A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes.
      J Am Coll Cardiol. 2003; 41: 1293-1304
      , 
      • Hueb W.
      • Lopes N.H.
      • Gersh B.J.
      • et al.
      Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease.
      Circulation. 2007; 115: 1082-1089
      , 
      • Malenka D.J.
      • Leavitt B.J.
      • Hearne M.J.
      • et al.
      Comparing long-term survival of patients with multivessel coronary disease after CABG or PCI: analysis of BARI-like patients in northern New England.
      Circulation. 2005; 112: I371-I376
      , 
      • Niles N.W.
      • McGrath P.D.
      • Malenka D.
      • et al.
      Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study.
      Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001; 37: 1008-1015
      , 
      • Weintraub W.S.
      • Stein B.
      • Kosinski A.
      • et al.
      Outcome of coronary bypass surgery versus coronary angioplasty in diabetic patients with multivessel coronary artery disease.
      J Am Coll Cardiol. 1998; 31: 10-19
      (Class IIa/LOE: B).
      Table 3Revascularization to improve symptoms with significant anatomic (≥50% left main or ≥70% non–left main CAD) or physiological (FFR≤0.80) coronary artery stenoses
      CABG, Coronary artery bypass graft; CAD, coronary artery disease; COR, class of recommendation; FFR, fractional flow reserve; GDMT, guideline-directed medical therapy; LOE, level of evidence; N/A, not applicable; PCI, percutaneous coronary intervention; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TMR, transmyocardial laser revascularization.
      Revascularization recommendations in this section are predominantly based on studies of patients with symptomatic SIHD and should be interpreted in this context. As discussed later in this section, recommendations on the type of revascularization are, in general, applicable to patients with UA/NSTEMI. In some cases (eg, unprotected left main CAD), specific recommendations are made for patients with UA/NSTEMI or STEMI.

      3.1 Heart Team Approach to Revascularization Decisions

      Class I
      • 1.
        A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.
        • Feit F.
        • Brooks M.M.
        • Sopko G.
        • et al.
        Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial.
        BARI Investigators. Circulation. 2000; 101: 2795-2802
        , 
        • King S.B.I.
        • Barnhart H.X.
        • Kosinski A.S.
        • et al.
        Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes: Emory Angioplasty versus Surgery Trial Investigators.
        Am J Cardiol. 1997; 79: 1453-1459
        , 
        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • et al.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        (Level of Evidence: C)
      Class IIa
      • 1.
        Calculation of the STS and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD.
        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • et al.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        , 
        • Chakravarty T.
        • Buch M.H.
        • Naik H.
        • et al.
        Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.
        Am J Cardiol. 2011; 107: 360-366
        , 
        • Grover F.L.
        • Shroyer A.L.
        • Hammermeister K.
        • et al.
        A decade’s experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases.
        Ann Surg. 2001; 234: 464-472
        , 
        • Kim Y.H.
        • Park D.W.
        • Kim W.J.
        • et al.
        Validation of SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.
        J Am Coll Cardiol Intv. 2010; 3: 612-623
        , 
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        • et al.
        Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.
        Circulation. 2010; 121: 2645-2653
        , 
        • Shahian D.M.
        • O’Brien S.M.
        • Filardo G.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1—coronary artery bypass grafting surgery.
        Ann Thorac Surg. 2009; 88 1 Suppl: S2-S22
        , 
        • Shahian D.M.
        • O’Brien S.M.
        • Normand S.L.
        • et al.
        Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score.
        J Thorac Cardiovasc Surg. 2010; 139: 273-282
        , 
        • Welke K.F.
        • Peterson E.D.
        • Vaughan-Sarrazin M.S.
        • et al.
        Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001.
        Ann Thorac Surg. 2007; 84: 1538-1546
        (Level of Evidence: B)

      3.2 Revascularization to Improve Survival

      Left Main CAD Revascularization
      Class I
      • 1.
        CABG to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis.
        • Caracciolo E.A.
        • Davis K.B.
        • Sopko G.
        • et al.
        Comparison of surgical and medical group survival in patients with left main coronary artery disease: long-term CASS experience.
        Circulation. 1995; 91: 2325-2334
        , 
        • Chaitman B.R.
        • Fisher L.D.
        • Bourassa M.G.
        • et al.
        Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease: report of the Collaborative Study in Coronary Artery Surgery (CASS).
        Am J Cardiol. 1981; 48: 765-777
        , 
        • Dzavik V.
        • Ghali W.A.
        • Norris C.
        • et al.
        Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators.
        Am Heart J. 2001; 142: 119-126
        , 
        • Takaro T.
        • Hultgren H.N.
        • Lipton M.J.
        • et al.
        The VA cooperative randomized study of surgery for coronary arterial occlusive disease II Subgroup with significant left main lesions.
        Circulation. 1976; 54: III107-III117
        , 
        • Takaro T.
        • Peduzzi P.
        • Detre K.M.
        • et al.
        Survival in subgroups of patients with left main coronary artery disease: Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease.
        Circulation. 1982; 66: 14-22
        , 
        • Taylor H.A.
        • Deumite N.J.
        • Chaitman B.R.
        • et al.
        Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry.
        Circulation. 1989; 79: 1171-1179
        , 
        • Yusuf S.
        • Zucker D.
        • Peduzzi P.
        • et al.
        Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
        (Level of Evidence: B)
      Class IIa
      • 1.
        PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and (2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality ≥5%).
        • Chakravarty T.
        • Buch M.H.
        • Naik H.
        • et al.
        Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.
        Am J Cardiol. 2011; 107: 360-366
        , 
        • Kim Y.H.
        • Park D.W.
        • Kim W.J.
        • et al.
        Validation of SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.
        J Am Coll Cardiol Intv. 2010; 3: 612-623
        , 
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        • et al.
        Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.
        Circulation. 2010; 121: 2645-2653
        , 
        • Capodanno D.
        • Caggegi A.
        • Miano M.
        • et al.
        Global risk classification and clinical SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in patients undergoing percutaneous or surgical left main revascularization.
        J Am Coll Cardiol Intv. 2011; 4: 287-297
        , 
        • Hannan E.L.
        • Wu C.
        • Walford G.
        • et al.
        Drug-eluting stents vs coronary-artery bypass grafting in multivessel coronary disease.
        N Engl J Med. 2008; 358: 331-341
        , 
        • Ellis S.G.
        • Tamai H.
        • Nobuyoshi M.
        • et al.
        Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.
        Circulation. 1997; 96: 3867-3872
        , 
        • Biondi-Zoccai G.G.
        • Lotrionte M.
        • Moretti C.
        • et al.
        A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease.
        Am Heart J. 2008; 155: 274-283
        , 
        • Boudriot E.
        • Thiele H.
        • Walther T.
        • et al.
        Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis [published correction appears in J Am Coll Cardiol. 2011;57:1792].
        J Am Coll Cardiol. 2011; 57: 538-545
        , 
        • Brener S.J.
        • Galla J.M.
        • Bryant R.I.
        • et al.
        Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.
        Am J Cardiol. 2008; 101: 169-172
        , 
        • Buszman P.E.
        • Kiesz S.R.
        • Bochenek A.
        • et al.
        Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization.
        J Am Coll Cardiol. 2008; 51: 538-545
        , 
        • Chieffo A.
        • Morici N.
        • Maisano F.
        • et al.
        Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.
        Circulation. 2006; 113: 2542-2547
        , 
        • Chieffo A.
        • Magni V.
        • Latib A.
        • et al.
        5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: the Milan experience.
        J Am Coll Cardiol Intv. 2010; 3: 595-601
        , 
        • Lee M.S.
        • Kapoor N.
        • Jamal F.
        • et al.
        Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.
        J Am Coll Cardiol. 2006; 47: 864-870
        , 
        • Makikallio T.H.
        • Niemela M.
        • Kervinen K.
        • et al.
        Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting.
        Ann Med. 2008; 40: 437-443
        , 
        • Naik H.
        • White A.J.
        • Chakravarty T.
        • et al.
        A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis.
        J Am Coll Cardiol Intv. 2009; 2: 739-747
        , 
        • Palmerini T.
        • Marzocchi A.
        • Marrozzini C.
        • et al.
        Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry).
        Am J Cardiol. 2006; 98: 54-59
        , 
        • Park D.W.
        • Seung K.B.
        • Kim Y.H.
        • et al.
        Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry.
        J Am Coll Cardiol. 2010; 56: 117-124
        , 
        • Rodes-Cabau J.
        • Deblois J.
        • Bertrand O.F.
        • et al.
        Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians.
        Circulation. 2008; 118: 2374-2381
        , 
        • Sanmartin M.
        • Baz J.A.
        • Claro R.
        • et al.
        Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.
        Am J Cardiol. 2007; 100: 970-973
        , 

        Kappetein AP, Mohr FW, Feldman TE, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011;17:2125-34.

        , 
        • Seung K.B.
        • Park D.W.
        • Kim Y.H.
        • et al.
        Stents versus coronary-artery bypass grafting for left main coronary artery disease.
        N Engl J Med. 2008; 358: 1781-1792
        , 
        • White A.J.
        • Kedia G.
        • Mirocha J.M.
        • et al.
        Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis.
        J Am Coll Cardiol Intv. 2008; 1: 236-245
        , 
        The BARI Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI).
        Circulation. 1997; 96: 1761-1769
        (Level of Evidence: B)
      • 2.
        PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG.
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        • et al.
        Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.
        Circulation. 2010; 121: 2645-2653
        , 
        • Brener S.J.
        • Galla J.M.
        • Bryant R.I.
        • et al.
        Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.
        Am J Cardiol. 2008; 101: 169-172
        , 
        • Chieffo A.
        • Morici N.
        • Maisano F.
        • et al.
        Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.
        Circulation. 2006; 113: 2542-2547
        , 
        • Chieffo A.
        • Magni V.
        • Latib A.
        • et al.
        5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: the Milan experience.
        J Am Coll Cardiol Intv. 2010; 3: 595-601
        , 
        • Lee M.S.
        • Kapoor N.
        • Jamal F.
        • et al.
        Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.
        J Am Coll Cardiol. 2006; 47: 864-870
        , 
        • Rodes-Cabau J.
        • Deblois J.
        • Bertrand O.F.
        • et al.
        Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians.
        Circulation. 2008; 118: 2374-2381
        , 
        • Sanmartin M.
        • Baz J.A.
        • Claro R.
        • et al.
        Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.
        Am J Cardiol. 2007; 100: 970-973
        , 
        • Seung K.B.
        • Park D.W.
        • Kim Y.H.
        • et al.
        Stents versus coronary-artery bypass grafting for left main coronary artery disease.
        N Engl J Med. 2008; 358: 1781-1792
        , 
        • White A.J.
        • Kedia G.
        • Mirocha J.M.
        • et al.
        Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis.
        J Am Coll Cardiol Intv. 2008; 1: 236-245
        , 

        Deleted in proof.

        , 
        • Montalescot G.
        • Brieger D.
        • Eagle K.A.
        • et al.
        Unprotected left main revascularization in patients with acute coronary syndromes.
        Eur Heart J. 2009; 30: 2308-2317
        (Level of Evidence: B)
      • 3.
        PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than Thrombolysis In Myocardial Infarction grade 3, and PCI can be performed more rapidly and safely than CABG.
        • Ellis S.G.
        • Tamai H.
        • Nobuyoshi M.
        • et al.
        Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.
        Circulation. 1997; 96: 3867-3872
        , 
        • Lee M.S.
        • Tseng C.H.
        • Barker C.M.
        • et al.
        Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease.
        Ann Thorac Surg. 2008; 86: 29-34
        , 
        • Lee M.S.
        • Bokhoor P.
        • Park S.J.
        • et al.
        Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention.
        J Am Coll Cardiol Intv. 2010; 3: 791-795
        (Level of Evidence: C)
      Class IIb
      • 1.
        PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of <33, bifurcation left main CAD); and (2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%).
        • Chakravarty T.
        • Buch M.H.
        • Naik H.
        • et al.
        Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.
        Am J Cardiol. 2011; 107: 360-366
        , 
        • Kim Y.H.
        • Park D.W.
        • Kim W.J.
        • et al.
        Validation of SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.
        J Am Coll Cardiol Intv. 2010; 3: 612-623
        , 
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        • et al.
        Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.
        Circulation. 2010; 121: 2645-2653
        , 
        • Capodanno D.
        • Caggegi A.
        • Miano M.
        • et al.
        Global risk classification and clinical SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in patients undergoing percutaneous or surgical left main revascularization.
        J Am Coll Cardiol Intv. 2011; 4: 287-297
        , 
        • Hannan E.L.
        • Wu C.
        • Walford G.
        • et al.
        Drug-eluting stents vs coronary-artery bypass grafting in multivessel coronary disease.
        N Engl J Med. 2008; 358: 331-341
        , 
        • Ellis S.G.
        • Tamai H.
        • Nobuyoshi M.
        • et al.
        Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.
        Circulation. 1997; 96: 3867-3872
        , 
        • Biondi-Zoccai G.G.
        • Lotrionte M.
        • Moretti C.
        • et al.
        A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease.
        Am Heart J. 2008; 155: 274-283
        , 
        • Boudriot E.
        • Thiele H.
        • Walther T.
        • et al.
        Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis [published correction appears in J Am Coll Cardiol. 2011;57:1792].
        J Am Coll Cardiol. 2011; 57: 538-545
        , 
        • Brener S.J.
        • Galla J.M.
        • Bryant R.I.
        • et al.
        Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.
        Am J Cardiol. 2008; 101: 169-172
        , 
        • Buszman P.E.
        • Kiesz S.R.
        • Bochenek A.
        • et al.
        Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization.
        J Am Coll Cardiol. 2008; 51: 538-545
        , 
        • Chieffo A.
        • Morici N.
        • Maisano F.
        • et al.
        Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.
        Circulation. 2006; 113: 2542-2547
        , 
        • Chieffo A.
        • Magni V.
        • Latib A.
        • et al.
        5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: the Milan experience.
        J Am Coll Cardiol Intv. 2010; 3: 595-601
        , 
        • Lee M.S.
        • Kapoor N.
        • Jamal F.
        • et al.
        Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.
        J Am Coll Cardiol. 2006; 47: 864-870
        , 
        • Makikallio T.H.
        • Niemela M.
        • Kervinen K.
        • et al.
        Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting.
        Ann Med. 2008; 40: 437-443
        , 
        • Naik H.
        • White A.J.
        • Chakravarty T.
        • et al.
        A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis.
        J Am Coll Cardiol Intv. 2009; 2: 739-747
        , 
        • Palmerini T.
        • Marzocchi A.
        • Marrozzini C.
        • et al.
        Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry).
        Am J Cardiol. 2006; 98: 54-59
        , 
        • Park D.W.
        • Seung K.B.
        • Kim Y.H.
        • et al.
        Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry.
        J Am Coll Cardiol. 2010; 56: 117-124
        , 
        • Rodes-Cabau J.
        • Deblois J.
        • Bertrand O.F.
        • et al.
        Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians.
        Circulation. 2008; 118: 2374-2381
        , 
        • Sanmartin M.
        • Baz J.A.
        • Claro R.
        • et al.
        Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.
        Am J Cardiol. 2007; 100: 970-973
        , 

        Kappetein AP, Mohr FW, Feldman TE, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011;17:2125-34.

        , 
        • Seung K.B.
        • Park D.W.
        • Kim Y.H.
        • et al.
        Stents versus coronary-artery bypass grafting for left main coronary artery disease.
        N Engl J Med. 2008; 358: 1781-1792
        , 
        • White A.J.
        • Kedia G.
        • Mirocha J.M.
        • et al.
        Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis.
        J Am Coll Cardiol Intv. 2008; 1: 236-245
        , 
        • Park S.J.
        • Kim Y.H.
        • Park D.W.
        • et al.
        Randomized trial of stents versus bypass surgery for left main coronary artery disease.
        N Engl J Med. 2011; 364: 1718-1727
        (Level of Evidence: B)
      Class III: Harm
      • 1.
        PCI to improve survival should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG.
        • Chakravarty T.
        • Buch M.H.
        • Naik H.
        • et al.
        Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.
        Am J Cardiol. 2011; 107: 360-366
        , 
        • Kim Y.H.
        • Park D.W.
        • Kim W.J.
        • et al.
        Validation of SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.
        J Am Coll Cardiol Intv. 2010; 3: 612-623
        , 
        • Morice M.C.
        • Serruys P.W.
        • Kappetein A.P.
        • et al.
        Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.
        Circulation. 2010; 121: 2645-2653
        , 
        • Caracciolo E.A.
        • Davis K.B.
        • Sopko G.
        • et al.
        Comparison of surgical and medical group survival in patients with left main coronary artery disease: long-term CASS experience.
        Circulation. 1995; 91: 2325-2334
        , 
        • Chaitman B.R.
        • Fisher L.D.
        • Bourassa M.G.
        • et al.
        Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease: report of the Collaborative Study in Coronary Artery Surgery (CASS).
        Am J Cardiol. 1981; 48: 765-777
        , 
        • Dzavik V.
        • Ghali W.A.
        • Norris C.
        • et al.
        Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators.
        Am Heart J. 2001; 142: 119-126
        , 
        • Takaro T.
        • Hultgren H.N.
        • Lipton M.J.
        • et al.
        The VA cooperative randomized study of surgery for coronary arterial occlusive disease II Subgroup with significant left main lesions.
        Circulation. 1976; 54: III107-III117
        , 
        • Takaro T.
        • Peduzzi P.
        • Detre K.M.
        • et al.
        Survival in subgroups of patients with left main coronary artery disease: Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease.
        Circulation. 1982; 66: 14-22
        , 
        • Taylor H.A.
        • Deumite N.J.
        • Chaitman B.R.
        • et al.
        Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry.
        Circulation. 1989; 79: 1171-1179
        , 
        • Yusuf S.
        • Zucker D.
        • Peduzzi P.
        • et al.
        Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
        , 
        • Capodanno D.
        • Caggegi A.
        • Miano M.
        • et al.
        Global risk classification and clinical SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in patients undergoing percutaneous or surgical left main revascularization.
        J Am Coll Cardiol Intv. 2011; 4: 287-297
        , 
        • Hannan E.L.
        • Wu C.
        • Walford G.
        • et al.
        Drug-eluting stents vs coronary-artery bypass grafting in multivessel coronary disease.
        N Engl J Med. 2008; 358: 331-341
        (Level of Evidence: B)
      Non-Left Main CAD Revascularization
      Class I
      • 1.
        CABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal LAD artery) or in the proximal LAD plus 1 other major coronary artery.
        • Dzavik V.
        • Ghali W.A.
        • Norris C.
        • et al.
        Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators.
        Am Heart J. 2001; 142: 119-126
        , 
        • Yusuf S.
        • Zucker D.
        • Peduzzi P.
        • et al.
        Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
        , 
        • Jones R.H.
        • Kesler K.
        • Phillips III, H.R.
        • et al.
        Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease.
        J Thorac Cardiovasc Surg. 1996; 111: 1013-1025
        , 
        • Myers W.O.
        • Schaff H.V.
        • Gersh B.J.
        • et al.
        Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris A report from the Coronary Artery Surgery Study (CASS) registry.
        J Thorac Cardiovasc Surg. 1989; 97: 487-495
        , 
        • Smith P.K.
        • Califf R.M.
        • Tuttle R.H.
        • et al.
        Selection of surgical or percutaneous coronary intervention provides differential longevity benefit.
        Ann Thorac Surg. 2006; 82: 1420-1428
        , 
        • Varnauskas E.
        Twelve-year follow-up of survival in the randomized European Coronary Surgery Study.
        N Engl J Med. 1988; 319: 332-337
        (Level of Evidence: B)
      • 2.
        CABG or PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery. (CABG Level of Evidence: B;
        • Every N.R.
        • Fahrenbruch C.E.
        • Hallstrom A.P.
        • et al.
        Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest.
        J Am Coll Cardiol. 1992; 19: 1435-1439
        , 
        • Borger van der Burg A.E.
        • Bax J.J.
        • Boersma E.
        • et al.
        Impact of percutaneous coronary intervention or coronary artery bypass grafting on outcome after nonfatal cardiac arrest outside the hospital.
        Am J Cardiol. 2003; 91: 785-789
        , 

        Deleted in proof.

        , 
        • Kaiser G.A.
        • Ghahramani A.
        • Bolooki H.
        • et al.
        Role of coronary artery surgery in patients surviving unexpected cardiac arrest.
        Surgery. 1975; 78: 749-754
        PCI Level of Evidence: C
        • Borger van der Burg A.E.
        • Bax J.J.
        • Boersma E.
        • et al.
        Impact of percutaneous coronary intervention or coronary artery bypass grafting on outcome after nonfatal cardiac arrest outside the hospital.
        Am J Cardiol. 2003; 91: 785-789
        )
      Class IIa
      • 1.
        CABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium.
        • Di Carli M.F.
        • Maddahi J.
        • Rokhsar S.
        • et al.
        Long-term survival of patients with coronary artery disease and left ventricular dysfunction: implications for the role of myocardial viability assessment in management decisions.
        J Thorac Cardiovasc Surg. 1998; 116: 997-1004
        , 
        • Hachamovitch R.
        • Hayes S.W.
        • Friedman J.D.
        • et al.
        Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography.
        Circulation. 2003; 107: 2900-2907
        , 
        • Sorajja P.
        • Chareonthaitawee P.
        • Rajagopalan N.
        • et al.
        Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting.
        Circulation. 2005; 112: I311-I316
        , 
        • Davies R.F.
        • Goldberg A.D.
        • Forman S.
        • et al.
        Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.
        Circulation. 1997; 95: 2037-2043
        (Level of Evidence: B)
      • 2.
        CABG to improve survival is reasonable in patients with mild-moderate LV systolic dysfunction (ejection fraction 35% to 50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization.
        • Yusuf S.
        • Zucker D.
        • Peduzzi P.
        • et al.
        Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
        , 
        • Alderman E.L.
        • Fisher L.D.
        • Litwin P.
        • et al.
        Results of coronary artery surgery in patients with poor left ventricular function (CASS).
        Circulation. 1983; 68: 785-795
        , 
        • O’Connor C.M.
        • Velazquez E.J.
        • Gardner L.H.
        • et al.
        Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank).
        Am J Cardiol. 2002; 90: 101-107
        , 
        • Phillips H.R.
        • O’Connor C.M.
        • Rogers J.
        Revascularization for heart failure.
        Am Heart J. 2007; 153: 65-73
        , 
        • Tarakji K.G.
        • Brunken R.
        • McCarthy P.M.
        • et al.
        Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction.
        Circulation. 2006; 113: 230-237
        , 
        • Tsuyuki R.T.
        • Shrive F.M.
        • Galbraith P.D.
        • et al.
        Revascularization in patients with heart failure.
        CMAJ. 2006; 175: 361-365
        , 

        Deleted in proof.

        , 

        Deleted in proof.

        (Level of Evidence: B)
      • 3.
        CABG with a LIMA graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia.
        • Cameron A.
        • Davis K.B.
        • Green G.
        • et al.
        Coronary bypass surgery with internal-thoracic-artery grafts: effects on survival over a 15-year period.
        N Engl J Med. 1996; 334: 216-219
        , 
        • Loop F.D.
        • Lytle B.W.
        • Cosgrove D.M.
        • et al.
        Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.
        N Engl J Med. 1986; 314: 1-6
        , 
        • Yusuf S.
        • Zucker D.
        • Peduzzi P.
        • et al.
        Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
        , 
        • Smith P.K.
        • Califf R.M.
        • Tuttle R.H.
        • et al.
        Selection of surgical or percutaneous coronary intervention provides differential longevity benefit.
        Ann Thorac Surg. 2006; 82: 1420-1428
        (Level of Evidence: B)
      • 4.
        It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG.
        • Hannan E.L.
        • Wu C.
        • Walford G.
        • et al.
        Drug-eluting stents vs coronary-artery bypass grafting in multivessel coronary disease.
        N Engl J Med. 2008; 358: 331-341
        , 

        Kappetein AP, Mohr FW, Feldman TE, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011;17:2125-34.

        , 
        • Smith P.K.
        • Califf R.M.
        • Tuttle R.H.
        • et al.
        Selection of surgical or percutaneous coronary intervention provides differential longevity benefit.
        Ann Thorac Surg. 2006; 82: 1420-1428
        , 
        • Brener S.J.
        • Lytle B.W.
        • Casserly I.P.
        • et al.
        Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features.
        Circulation. 2004; 109: 2290-2295
        , 
        • Hannan E.L.
        • Racz M.J.
        • Walford G.
        • et al.
        Long-term outcomes of coronary-artery bypass grafting versus stent implantation.
        N Engl J Med. 2005; 352: 2174-2183
        (Level of Evidence: B)
      • 5.
        CABG is probably recommended in preference to PCI to improve survival in patients with multivessel CAD and diabetes mellitus, particularly if a LIMA graft can be anastomosed to the LAD artery.
        • Sorajja P.
        • Chareonthaitawee P.
        • Rajagopalan N.
        • et al.
        Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting.
        Circulation. 2005; 112: I311-I316
        , 
        The BARI Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI).
        Circulation. 1997; 96: 1761-1769
        , 
        The BARI Investigators
        The final 10-year follow-up results from the BARI randomized trial.
        J Am Coll Cardiol. 2007; 49: 1600-1606
        , 
        • Banning A.P.
        • Westaby S.
        • Morice M.C.
        • et al.
        Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents.
        J Am Coll Cardiol. 2010; 55