CABG Strategies After Acute Coronary Syndrome

Indications and Contraindications

The American College of Cardiology recommends emergency CABG for ACS patients when primary PCI has failed or cannot be performed, with persistent ischemia of a significant myocardial area or hemodynamic instability refractory to medical therapy 1, 2
Emergency CABG is indicated for failed or impossible PCI with persistent ischemia of significant myocardium and/or hemodynamic instability despite maximal medical therapy, as recommended by the American Heart Association 1, 2
The American College of Cardiology recommends emergency CABG for mechanical complications, including ventricular septal rupture, mitral valve insufficiency from papillary muscle infarction/rupture, or free wall rupture 1, 2
Cardiogenic shock in patients suitable for CABG is an indication for emergency CABG, regardless of time interval from MI to shock onset or MI to CABG, as stated by the American Heart Association 1, 2
Life-threatening ventricular arrhythmias of ischemic origin with left main stenosis ≥50% and/or 3-vessel CAD are an indication for emergency CABG 1
The American College of Cardiology recommends against emergency CABG in patients without ischemia or threatened occlusion after failed PCI 1
Emergency CABG is not recommended for patients with persistent angina with small viable myocardium and hemodynamic stability 1, 2

The American College of Cardiology suggests that CABG can be performed as an early revascularization strategy within 24-48 hours for high-risk NSTE-ACS patients, though PCI is generally preferred initially 3
The decision between immediate versus staged CABG depends on hemodynamic stability and extent of jeopardized myocardium, as recommended by the American Heart Association 1, 2
Radial access is the standard approach for initial coronary angiography unless procedural contraindications exist, according to the European Society of Cardiology 4, 3
Complete revascularization should be achieved whenever possible, as recommended by the American College of Cardiology 3

The American College of Cardiology recommends using the left internal mammary artery (LIMA) to LAD for improved survival and patency 5
The radial artery is recommended over saphenous vein for the second most important non-LAD vessel to improve long-term outcomes, as stated by the American College of Cardiology 5
Oral calcium channel blockers should be used for the first postoperative year following radial artery grafting, as recommended by the American College of Cardiology 5
Recent potent antiplatelet therapy significantly increases surgical bleeding risk, according to the American College of Cardiology 6
Clopidogrel should be withheld 5 days before surgery when possible, as recommended by the American College of Cardiology 6

Intra-aortic balloon pump (IABP) can stabilize patients preoperatively, but routine IABP use in cardiogenic shock without mechanical complications is not recommended, as stated by the European Society of Cardiology 4, 3
Intraoperative transesophageal echocardiography is recommended for monitoring hemodynamic status, ventricular function, and regional wall motion, according to the American Heart Association 1