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Complications of Coronary Artery Bypass Grafting Surgery

Chapter · March 2014

DOI: 10.1007/978-3-642-37078-6_233

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 Complications of Coronary Artery
Bypass Grafting Surgery 83
Maziar Khorsandi, Kasra Shaikhrezai, and Vipin Zamvar

Contents Abstract
Early Postoperative Graft Occlusion More than 800,000 patients undergo coronary
and Myocardial Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . 2360 artery bypass grafting (CABG) each year
Low Cardiac Output Syndrome . . . . . . . . . . . . . . . . . 2361
worldwide (Nalysnyk et al. Heart
89:767–772, 2003). In the recent years, there
Mediastinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2361 have been major advances in techniques used
Deep Sternal Wound Infection . . . . . . . . . . . . . . . . . . . 2363 in CABG surgery in order to assure better
Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2363 success rates and reduce complication rates.
Thus, there has been a move toward arterial
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2364
graft revascularization as compared to venous
Postoperative Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . 2365 grafts in order to allow longer patency rates. In
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2366 addition, newer methods such as minimal
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2366
access and off-cardiopulmonary bypass
(CPB) surgery are now in routine practice in
many centers around the world with an aim to
reduce the rates of postoperative morbidity and
length of hospital stay. Despite achieving such
technical advances are referred, patients that a
significant proportion of CABG surgery now-
adays are relatively older and frailer with mul-
tiple cardiopulmonary and other comorbidities
as compared to patients operated on in the last
century. This is perhaps due to increased life
expectancy in the western world thanks to
improved medical care and advances reached
M. Khorsandi (*) • V. Zamvar in percutaneous coronary intervention success-
Department of Cardiothoracic Surgery, Royal Infirmary of fully managing less advanced coronary disease
Edinburgh, Edinburgh, UK in the younger, fitter patient groups whom in
e-mail: maziarkhorsandi@doctors.org.uk;
the past would have otherwise undergone sur-
vipin.zamvar@nhs.net
gery. Hence, the risk of significant postopera-
K. Shaikhrezai
tive morbidity and mortality still exists and is
Department of Cardiac Surgery, Golden Jubilee National
Hospital, Clydebank, Glasgow, UK even expected to increase in the coming years
e-mail: kasrash@gmail.com due to severity of coronary disease and
This chapter: # Her Majesty the Queen in Right of United Kingdom 2015 2359
Published by Springer-Verlag Berlin Heidelberg. All rights reserved.
P. Lanzer (ed.), PanVascular Medicine, DOI 10.1007/978-3-642-37078-6_233
2360
increasing general complexity of cases that
will be encountered (Nalysnyk et al. Heart
89:767–772, 2003). In this chapter we will be
discussing the complications of CABG
surgery.
Glossary of Terms
Cardioplegia A cold (4  C), high potassium
content solution administered at the time of
CABG bypass surgery to arrest the heart in
diastole. Diastolic cardiac arrest signifi-
cantly reduces leads to significant reduction
in myocardial cellular metabolism and
thereby reducing myocardial ischemia dur-
ing the operation. This solution also con-
tains nutrition necessary for the myocardial
cell survival during diastolic cardiac arrest
(Bojar 2011; Chikwe et al. 2006).
Cardiopulmonary bypass (CPB) This
machine is used to perfuse organs during
cardioplegic cardiac arrest during cardiac
surgery. It includes heparinized circuit
of a venous pipe and an arterial pipe,
a mechanical pump, a blood reservoir,
and an oxygenator. The venous pipe takes
deoxygenated blood from the venous
system. The blood is oxygenated and
pumped back into the arterial system via
the arterial pipe (Bojar 2011).
Deep hypothermic circulatory arrest In
cardiac surgery patients who undergo
major aortic procedures, e.g., aortic arch
surgery, and run the risk of cerebral
hypoperfusion/injury undergo so as to pre-
serve cellular function circulatory arrest.
The body is cooled to as low as 18 deep
hypothermic based on the Q10 temperature
coefficient principal every 10  C of temper-
ature reduction reduces cellular metabolism
by 50 %, thereby reducing the risk of ische-
mic injury to the brain (Bojar 2011).
Intra-aortic balloon pump (IABP) This is a
balloon device that is inserted percutane-
ously, most commonly through the femoral
artery into the the descending aorta. It
inflates in diastole thereby impedance/
M. Khorsandi et al.
reducing the work of the heart by reducing
afterload and improving the coronary circu-
lation (Bojar 2011; Chikwe et al. 2006).
Early Postoperative Graft Occlusion
and Myocardial Ischemia
Despite technical advances in CABG in the recent
years, the rate of perioperative graft occlusion and
myocardial infarction has been quoted as 5–10 %,
with in-hospital mortality rate reaching as high as
68 % in patients with graft occlusion (Rasmussen
et al. 1997). Ischemia post-CABG could be due to
graft spasm, incomplete revascularization, graft
failure, or complete occlusion of a native coronary
artery (Rasmussen et al. 1997; Bojar 2011).
Early graft occlusion following CABG is usu-
ally caused by technical failure, i.e., poor surgical
technique/difficult anastomosis due to calcifica-
tion, or compromised anatomic runoffs and is
almost always thrombotic in nature (Blessing
et al. 2003; Walts et al. 1982), as opposed to late
graft occlusion which is primarily due to fibrous or
fibromuscular proliferation with consecutive graft
degeneration (Walts et al. 1982). In this section we
will be focusing on early graft occlusion.
As always prevention is better than treatment.
Oral antiplatelet therapy with cyclooxygenase
(COX)-1 inhibitor agents such as aspirin is
known to have a preventative effect on early
graft occlusion. Hence, their institution in the
early (within the first 24 h) postoperative setting
is highly recommended. Their limited effect on
hemostasis renders them safe for early adminis-
tration in the postoperative setting (Storey 2011).
Early postoperative graft occlusion following
CABG surgery may manifest as low cardiac out-
put syndrome, signs of cardiac failure, e.g., pul-
monary edema, ventricular arrhythmias, or even
cardiac arrest (Bojar 2011).
In cases where postoperative ischemia is
suspected due to coronary spasm, institution of
nitrates/calcium channel blockers may be thera-
peutic as well as diagnostic. Whereas in cases
where there are severe ischemic ECG changes,
83 Complications of Coronary Artery Bypass Grafting Surgery
i.e., ST segment elevation, performing urgent cor-
onary angiography is paramount (Rasmussen
et al. 1997; Bojar 2011). It is imperative to deter-
mine the cause of ischemia in all cases, while
treatment is initiated.
Suspected post-CABG myocardial ischemia
should be managed aggressively. Medical therapy
should be intensified with the aid of beta-blockers.
Insertion of an intra-aortic balloon pump (IABP)
should be considered as a supportive measure in
order to reduce the load from an already ischemic
myocardium (Bojar 2011). These measures
should ideally be followed by coronary angiogra-
phy. There are two advantages to performing cor-
onary angiography; it allows for percutaneous
coronary intervention (PCI) where possible and
it helps identifying the site of graft occlusion
(Rasmussen et al. 1997; Zhao et al. 2008; Bojar
2011). However, it is important to appreciate the
risk of damage to the coronary anastomotic sites
by PCI due to greater vulnerability of such areas to
mechanical force. In cases where PCI is not fea-
sible or safe (e.g., risk of distal embolization in
saphenous vein grafts or proximity of the occlu-
sion to the coronary anastomosis), the patient has
not sustained a major myocardial infarction (MI),
and/or a large portion of the myocardium is at risk
of infarction, urgent reoperation should be con-
sidered by the surgical team (Rasmussen
et al. 1997; Zhao et al. 2008; Wijns et al. 2010;
Bojar 2011).
Low Cardiac Output Syndrome
Low cardiac output syndrome (LCOS) refers to
reduction in cardiac output due to transient myo-
cardial dysfunction (Kumar and Iyer 2010).
LCOS has been defined as the need for postoper-
ative IABP or inotropic support for longer than
30 min to maintain a systolic blood pressure of
90 mmHg or cardiac index of 2.2 L/min per
square meter (Rao et al. 1996; Maganti
et al. 2005). LCOS is a serious complication of
CABG surgery. Mortality rates from this condi-
tion can be as high as 38 %, and LCOS is
2361
considered the largest cause of mortality in
patients following CABG surgery (de Oliveira
Sá et al. 2012). The sequela of this syndrome is
that the blood flow is insufficient for the body to
maintain its metabolic needs resulting in
end-organ dysfunction, e.g., renal dysfunction
associated with low urine output, if untreated
leading to renal failure (Rosseel et al. 1997). The
factors responsible for low cardiac output include
hypovolemia, cardiac tamponade, electrolyte
abnormalities, arrhythmias, poor ventricular con-
tractility due to myocardial ischemia, and hypox-
emia (Rosseel et al. 1997).
The management of this condition includes
mild inotropy and reduction of afterload often by
means of IABP to reduce the workload of the
heart (Rosseel et al. 1997).
Mediastinal Bleeding
Mediastinal bleeding is a serious complication of
CABG surgery (Mehran et al. 2011). Acceptable
drain output after a standard CABG operation can
be 400+/ 200 ml in 24 h. In patients with preop-
erative dual antiplatelet therapy, this amount can
reach as much as 1,200 ml in 24 h (Mehran
et al. 2011). The amount of bleeding is usually
greatest in the first 6 h and starts to tail off in the
subsequent 6–12 h (Chikwe et al. 2006). Acute
severe bleeding may warrant the use of allogeneic
blood product transfusion and/or performing ster-
nal reopening and re-exploration, both of which
are independent risk factors for in-hospital mor-
tality (Mehran et al. 2011). Acute bleeding occurs
in 3–5 % of patients post-CABG surgery (Wil-
liams et al. 2010). In 1–3 % of patients sternal
reopening and exploration is warranted in the
operating theater/intensive therapy unit (Bojar
2011).
Postoperative bleeding can be categorized into
surgical or medical. However, etiology of bleed-
ing in the postoperative period is most often com-
plex and multifactorial (Bojar 2011). Significant
bleeding after an uneventful operation should be
assumed to be from a surgical cause (Bojar 2011).
2362
Common surgical sites of bleeding are from the
anastomotic suture lines, side branches of the
arterial or venous conduits, and substernal and
periosteal regions of the sternum (Bojar 2011).
However, medical causes of bleeding such as
excessive hemorrhage leading to coagulopathy,
the heparin effect, platelet dysfunction, and fibri-
nolysis associated with utilization of the cardio-
pulmonary bypass (CPB) are also common
etiologies of postoperative bleeding (Chikwe
et al. 2006; Klein et al. 2008; Bojar 2011).
Bleeding has been associated with the use of
the CPB machine during CABG, as the CPB
circuit is known to disrupt the factors constituent
to the coagulation cascade (Klein et al. 2008;
Bojar 2011). Hemodilution as a result of the crys-
talloid prime used in CPB reduces the concentra-
tion of the clotting factors and platelets leading to
increased propensity to bleeding. Furthermore,
platelet contact with the CPB circuit triggers fibri-
nolysis increasing the risks of bleeding (Klein
et al. 2008; Bojar 2011). Cell saving devices elim-
inate platelets hence significantly reducing coag-
ulability. Hypothermia as a result of heat loss due
to CPB and open chest and extremity wounds lead
to worsening coagulopathy, increasing the risks of
bleeding in patients undergoing CABG surgery.
Preoperative use of antiplatelet agents (e.g., high-
dose aspirin, clopidogrel, prasugrel) leads to
platelet dysfunction leading to increased bleeding
and increased need for blood product transfusion
(Klein et al. 2008; Bojar 2011).
It is also said that factors such as advanced age,
female gender, preoperative anemia, preexisting
poor left ventricular (LV) function, and
comorbidities such as hepatic, renal disease,
and/or peripheral vascular disease (PVD) are
patient-related risk factors for postoperative
bleeding (Chikwe et al. 2006; Bojar 2011).
Procedure-related causes of bleeding that
include complex operations (which require deep
hypothermic circulatory arrest), emergency oper-
ations, as well as reoperations are also associated
with increased risk of bleeding postoperatively
(Chikwe et al. 2006; Bojar 2011).
Mediastinal bleeding should be anticipated
preoperatively in any patient undergoing CABG
M. Khorsandi et al.
surgery. Coagulation markers such as prothrom-
bin time (PT), activated partial thromboplastin
time (APTT), and platelet count should be mea-
sured preoperatively, and any preexisting
derangements should be corrected (Chikwe
et al. 2006; Bojar 2011). In patients on oral
anticoagulation, warfarin should be withheld
4 days prior to surgery (Bojar 2011). Antiplatelet
therapy with aspirin and/or clopidogrel should
ideally be withheld 5–7 days prior to operation
to minimize the risk of bleeding (Bojar 2011).
Antiplatelet therapy is continued in cases of
urgent CABG surgery in patients with acute cor-
onary syndrome (ACS) up to the day of surgery;
higher than average bleeding risk should be antic-
ipated in these cases (Bojar 2011; Mehran
et al. 2011). Alternatively glycoprotein IIb/IIIa
inhibitor agents such as Eptifibatide can be uti-
lized to bridge patients with ACS up to 2 h prior to
CABG surgery to minimize progression of dis-
ease prior to surgery and reduce the risk of bleed-
ing due to their shorter half-life (Dyke et al. 2000).
Meticulous surgical technique and surgical hemo-
stasis are perhaps the most important aspect in the
prevention of major postoperative hemorrhage
(Chikwe et al. 2006; Bojar 2011). Rewarming
the patient to normothermia prior to termination
of cardiopulmonary bypass would improve coag-
ulation system function and reduce the risk of
postoperative bleeding (Bojar 2011).
In postoperative patients, in whom bleeding is
suspected, any hemodynamic instability should
be addressed immediately. Chest drain output
should be meticulously measured, and drain
patency should be verified at all times (Chikwe
et al. 2006; Bojar 2011). Patients should be
warmed if hypothermic to improve the coagula-
tion system function. Coagulation studies should
urgently be performed, and any derangements
should be corrected with the use of appropriate
blood products. Transesophageal/thoracic echo-
cardiography (TEE/TTE) should be performed to
identify any signs of cardiac tamponade (Chikwe
et al. 2006; Bojar 2011). Sternal reopening should
be performed if life-threatening mediastinal
bleeding is suspected (Chikwe et al. 2006; Bojar
2011).
83 Complications of Coronary Artery Bypass Grafting Surgery
Deep Sternal Wound Infection
Superficial sternal wound infections affect 3–10 %
of median sternotomies (Chikwe et al. 2006). For-
tunately deep sternal wound infections (DSWI) are
less common (Mauerman and Sampathkumar
2008). DSWI affects 1–2 % of patients after
CABG surgery (Mauerman and Sampathkumar
2008). The criteria for DSWI, according to the
Centers for Disease Control and Prevention,
include isolation of microorganisms from culture
of mediastinal tissue or fluid, chest pain, fevers
(temperatures > 38.0, leukocytosis), sternal insta-
bility, purulent drainage from the wound, and iso-
lation of microorganisms from blood culture
specimen (Garner et al. 1988; Singh et al. 2011).
DSWIs can increase the median length of stay of
patients to 16 days as compared to 6 days in
patients without a wound infection
(Lu et al. 2003). Studies quote in-hospital mortality
of 6.9 % in patients developing DSWI compared to
2.8 % in patients without (Tang et al. 2004).
The most common microorganism associated
with DSWI is Staphylococcus aureus with
methicillin-resistant and methicillin-sensitive
Staphylococcus aureus having similar incidence of
 20 % each followed by coagulase-negative
staphylococcus (27 %) and gram-negative microor-
ganisms, e.g., Escherichia coli and Pseudomonas
aeruginosa (Friberg et al. 2007; Chaudhuri
et al. 2012).
Risk factors associated with DSWI according
to the modern literature are divided into patient-
related/preoperative risk factors, operative risk
factors, and postoperative risk factors. Patient-
related/preoperative risk factors include advanced
age (Borger et al. 1998; Tang et al. 2004), male
sex (Borger et al. 1998), insulin-dependent diabe-
tes mellitus (Lu et al. 2003), peripheral vascular
disease (Lu et al. 2003), previous stroke/TIA
(Borger et al. 1998; Tang et al. 2004), congestive
cardiac failure (Borger et al. 1998; Tang
et al. 2004), and preoperative renal failure
(on renal replacement therapy) (Toumpoulis
et al. 2005). Operative risk factors include
prolonged surgery and anesthesia (Tang
2363
et al. 2004), intraoperative complications, and
bilateral mammary artery usage for grafting
(Borger et al. 1998; Lu et al. 2003; Toumpoulis
et al. 2005). Postoperative risk factors include
re-exploration for bleeding, IABP support, and
prolonged ventilator support (Lu et al. 2003).
Diagnosis of DSWI is made on clinical, radio-
logical, and microbiological grounds. Sternal
instability, fever, surgical site erythema, and puru-
lent wound discharge are clinical signs of DSWI.
On chest radiographs migration of sternal wires
and/or sternal fracture/s may be seen; computed
tomography (CT) scans may show, evidence of
osteomyelitis or nonunion of the sternum. Labo-
ratory studies of blood or wound cultures being
positive for bacteria would further reinforce the
diagnosis (Garner et al. 1988; Singh et al. 2011).
Management of DSWI includes preventative
measures with prophylactic antimicrobial therapy
preoperatively routinely in all patients (Lador
et al. 2012). Early medical management of any
suspected wound infections with broad-spectrum
antimicrobial agents followed by microbiologi-
cally guided antibiotic therapy targeting the iso-
lated microorganisms is of paramount importance.
Early surgical exploration and debridement, how-
ever, form the most important aspect of manage-
ment of a patient with a DSWI (Lu et al. 2003).
Arrhythmias
Arrhythmias are common phenomenon after CABG
surgery (Pires et al. 1995; Chikwe et al. 2006; Klein
et al. 2008; Bojar 2011). Atrial fibrillation (AF) is
usually of benign nature and is said to occur in about
25 % of patients postoperatively after CABG (Pires
et al. 1995; Chikwe et al. 2006; Klein et al. 2008;
Bojar 2011). Although the etiology of postoperative
AF is still unclear (Klein et al. 2008), it can lead to
devastating complications such as stroke (Pires
et al. 1995). Ventricular arrhythmias on the other
hand occur rarely after CABG surgery but are likely
to signify more sinister causes such as myocardial
injury and should trigger further investigations by
means of bedside TTE, CT angiography scan,
and/or coronary angiography (Bojar 2011).
2364
Conduction abnormalities occur commonly
post-CABG surgery (Chikwe et al. 2006; Klein
et al. 2008; Bojar 2011). 25 % of patients develop
transient conduction abnormalities (Bojar 2011),
which generally resolve in 24–48 h and are asso-
ciated with the use of cold cardioplegia solution.
Persistent conduction abnormalities do not influ-
ence the long-term outcome after CABG surgery
(Bojar 2011). The prevalence of more serious
conduction abnormalities such as atrioventricular
block (AV) (Mobitz type II) (Bojar 2011) and
complete AV block is very low after CABG sur-
gery (Bojar 2011; Khorsandi et al. 2012). The risk
of developing AV block post-CABG surgery
increases with the higher number of coronary
vessels bypassed, longer CPB time, and longer
cross-clamp times (Baerman et al. 1987).
Patient-related risk factors such as advanced
age, valvular heart disease, and previous arrhyth-
mias increase the risk of patients developing post-
CABG surgery arrhythmias (Chikwe et al. 2006).
Operative etiologies include inadequate
cardioplegia, ventricular distention, incomplete
revascularization, and inadequate de-airing of the
circulation prior to termination of surgery (Chikwe
et al. 2006; Bojar 2011).
Postoperative causes of arrhythmias include
ongoing myocardial ischemia, hypoxia, infections
(e.g., pneumonia, wound infection), pericardial
collections/tamponade, electrolyte disturbances,
coronary spasm, hypervolemia, pulmonary artery
catheter irritation, and drug withdrawal/toxicity
(e.g., beta-blockers, digoxin, and alcohol) (Chikwe
et al. 2006; Klein et al. 2008; Bojar 2011).
Management of arrhythmias is extremely
important in preventing complications. Prevention
is always better than treatment; hence, administra-
tion of magnesium sulfate after cardiopulmonary
bypass and/or beta-blockers is said to be a good
prophylactic measure in preventing postoperative
AF (Bojar 2011).
When postoperative AF is encountered, any
possible precipitating etiology should be
addressed, e.g., correction of electrolyte abnor-
malities and prompt institution of antimicrobial
therapy for any suspected infections. Rate and
rhythm control can be instituted when postopera-
tive AF is encountered. In unstable patients rapid
M. Khorsandi et al.
rhythm control by means of synchronised electri-
cal cardioversion (50–100 J) is indicated. Potas-
sium channel blockers (e.g., amiodarone) are used
very commonly for rhythm control in patients
with postoperative AF. In refractory AF rate con-
trol can be achieved with digoxin, nondihydro-
pyridine calcium channel blockers (e.g.,
diltiazem), or beta-blockers (e.g., metoprolol)
(Bojar 2011). Anticoagulation with heparin and
warfarin should be considered if arrhythmias per-
sist for >48 h (Klein et al. 2008; Bojar 2011).
Bradyarrhythmias are often encountered after
CABG surgery. Epicardial pacing by means of
epicardial pacing wires should be commenced to
maintain hemodynamic stability. In cases where no
epicardial pacing wires have been inserted at the
time of surgery, transcutaneous/transvenous car-
diac pacing is an alternative. As per management
of tachyarrhythmias, electrolyte disturbances
should also be addressed in bradyarrhythmias
(Klein et al. 2008; Bojar 2011). In patients with
unresolved bradyarrhythmias, insertion of a perma-
nent pacemaker should be considered.
Stroke
Stroke is defined as any focal or global neurolog-
ical deficit lasting for >24 h, which cannot be
explained by any other etiology but that of cere-
bral ischemia or hemorrhage (Tarakji et al. 2011).
Clinical presentation of stroke depends on the
territory involved and the severity of the insult, i.
e., presence of preformed collaterals, and varies in
severity from focal deficit (e.g., hemiplegia/
hemiparesis, dysarthria, or aphasia) to coma and
death (Bojar 2011). Perioperative stroke is rare
and affects 1–2 % of patients undergoing CABG
surgery (Chikwe et al. 2006). Although rare the
effects of stroke can have a devastating effect for
the patients after this major surgery (Ricotta
et al. 1994; Tarakji et al. 2011; Selnes
et al. 2012). Perioperative stroke can be embolic
(2/3 of all strokes), or it can be due to cerebral
hemorrhage or generalized cerebral
hypoperfusion (e.g., during cardiopulmonary
bypass). In embolic stroke the sources of emboli
include the extracorporeal bypass circuit (air), left
83 Complications of Coronary Artery Bypass Grafting Surgery
side of the heart, the ascending aorta, and carotid
bifurcation (thrombi, debris, calcifications)
(Tarakji et al. 2011; Selnes et al. 2012). The risk
of postoperative stoke is related to the constant
background risk of stroke after any major cardio-
vascular surgery due to the presence of diffuse
vasculopathy in high-risk patients, or related to
systemic inflammatory response and hypercoa-
gulability states the severity of which peaks
around day 2 after surgery (Tarakji et al. 2011).
Presence of cardiovascular risk factors also
magnifies the risk of stroke in patients (Ricotta
et al. 1994). The Relative risk of stroke is signif-
icantly higher in smokers and in patients with
advanced age, diabetes mellitus, carotid artery
atherosclerosis, hypertension, perioperative hypo-
tension, calcified ascending aorta, calcified aortic
valve, left-sided mural thrombus, prolonged car-
diopulmonary bypass time, postoperative AF and
in patients undergoing emergency CABG surgery.
Failure to administer antiplatelet therapy postop-
eratively is also a risk factor for postoperative
stroke (Chikwe et al. 2006; Bojar 2011; Tarakji
et al. 2011; Selnes et al. 2012).
The diagnosis of stroke is primarily clinical
and is subsequently aided by means of imaging.
CT scans and/or MRI are mandatory to confirm
the diagnosis. Once diagnosis has been con-
firmed, it is also important to identify the source
of emboli by means of echocardiography and
carotid color Doppler studies (Chikwe
et al. 2006; Bojar 2011; Selnes et al. 2012).
Preventative measures are recommended prior
to embarking on CABG surgery (Selnes
et al. 2012). Any history of previous stroke or
transient ischemic attacks should prompt further
investigations such as carotid Doppler and/or
MRI angiography (Bojar 2011). Studies have
suggested that patients who have considerable
carotid artery stenosis (>60 %) are at significant
risk of postoperative stroke (Li et al. 2009).
Patients with >75 % stenosis of the internal
carotid arteries should be considered for carotid
endarterectomy or carotid stent angioplasty prior
to CABG surgery (Chikwe et al. 2006). There is
evidence that preoperative statin and beta-blocker
administration reduces the risk of perioperative
stroke (Bouchard et al. 2010; Bojar 2011; Selnes
2365
et al. 2012). At the time of CABG surgery, the use
of epiaortic ultrasound in order to identify signif-
icant calcification or aortic atherosclerotic plaque
(Selnes et al. 2012) and careful positioning of the
aortic cannula (e.g., by using ultrasound) to avoid
diseased plaques can reduce the risk of stroke
(Chikwe et al. 2006; Bojar 2011).
In patients who have sustained a stroke, imme-
diate management includes maintaining airway,
oxygenation, and ventilation. Avoiding hypoten-
sion would ensure perfusion of ischemic but sal-
vageable regions of the brain. Electrocardiogram
(ECG), transthorakal echocardiography (TTE),
and computed tomography (CT) of the brain are
the essential investigations. Aspirin has a negligi-
ble negative effect in the outcome of hemorrhagic
stroke but a very positive effect in the outcome of
ischemic stroke; hence, unless there is a strong
suspicion of hemorrhagic stroke, aspirin should
be administered. CABG patients are not candi-
dates for thrombolysis postoperatively (Chikwe
et al. 2006).
Speech and language therapy is important in
reducing the risk of aspiration pneumonia postop-
eratively in patients who have sustained a stroke.
Until swallowing has been fully assessed in these
patients, feeding should be instituted via nasogas-
tric or total parenteral nutrition routes. Other ther-
apies such as neurophysiotherapy and stroke
rehabilitation can greatly aid patient recovery, e.
g., by helping to minimize the risk of developing
pressure sores in stroke patients and can play very
important part in the long-term functional out-
come of stroke patients (Chikwe et al. 2006;
Bojar 2011).
Evidence suggests that aspirin, dipyridamole,
and clopidogrel reduce the risk of stroke recur-
rence by 13 % (Chikwe et al. 2006).
Postoperative Mortality
According to the European Association for Cardio-
Thoracic Surgery (EACTS) (Wijns et al. 2010),
3-month mortality rate following elective CABG
surgery is 1–2 %, (Wijns et al. 2010). In the UK
between 2004 and 2008, the risk of mortality fol-
lowing CABG surgery for the elective patient
2366
group (n = 78,367) was 1.1 % versus 2.6 % for
emergency cases (n = 32,990) (Wijns et al. 2010).
Patients with Left main stem (LMS) stenosis had
higher rate of mortality 2.5 % versus 1.5 % for
patients without LMS stenosis (Wijns et al. 2010).
Diabetes mellitus has increased risk of mortality
compared to patients without (2.6 % vs. 1.6 %)
(Wijns et al. 2010). Off-CPB CABG in experi-
enced hands has showed significantly reduced
rates of many serious complications as the cause
of postoperative mortality such as stroke, deep
sternal wound infection, and respiratory complica-
tions (Wijns et al. 2010).
Summary
CABG surgery has become increasingly safe and
the risk of major complications are low. Although
major complications occur rarely they pose a great
challenge to the patient and the surgeon and sig-
nificantly increase the rate of postoperative mor-
bidity and mortality in patient. Early recognition
and management of major complications are par-
amount to long term outcome.
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