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1 Guidelines for the Clinical Application of Bypass Grafts and the Surgical Techniques (JCS 2006) CCAB MIDCAB CCAB OPCAB LITA 3.2 RITA 3.3 GEA 3.4 IEA 3.5 RA 3.6 SVG Circulation Journal Vol. 70, Suppl. IV,

2 In-situ graft 4.2 Free graft Composite graft LAD 5.2 LAD Cx RCA Ca 6.3 PCI CABG Porcelain aorta AS MR Acute Coronary Syndromes CABG 9.1 CABG 9.2 CABG DPC CCABOPCAB Awake OPCAB TMLR TMLR CABG ACCAHA OPCAB CABG 60 % PCI CABG 8 ACCAHA CABG ACCAHA 1556 Circulation Journal Vol. 70, Suppl. IV, 2006

3 ACCAHA Class Class Class a b Class Class evidence level 3 evidence level A B1 C 2.1 CCAB OPCAB CCAB ACCAHA OPCAB OPCAB Class evidence level B Classaevidence level B Classb evidence level C Classevidence level B CCAB CABG CCAB OPCAB CABG Class Class OPCAB CCABG Classa Classbevidence level B skeletonization Classa OPCAB Classbevidence level C CABG Class Circulation Journal Vol. 70, Suppl. IV,

4 Classaevidence Classa OPCAB CCAB Class evidence level A OPCAB CCAB Classevidence level B OPCAB CCAB Classevidence level A OPCAB CCAB ICU Classevidence level A Classbevidence level C Classbevidence level C 2.3 OPCAB CCAB Classevidence level A stabilizer heart postioner OPCAB CCAB Classaevidence level A OPCAB CCAB Classaevidence level B MIDCAB Minimally Invasive Direct Coronary Artery Bypass in-situ LAD Class evidence level A Classa LAD LAD Classb Classevidence level C Classevidence level C MIDCAB MIDCAB Class OPCAB Classaevidence level C In-situ graft, Free graft, Composite graft 3.1 LAD LITA Class LITACx LITALAD Classa LITA skeletonization Classa 3.2 BITA mortality morbidity Classa In situ RITA 1558 Circulation Journal Vol. 70, Suppl. IV, 2006

5 Classa 3.3 GEA Classa GEA Class a Classb SVG Classevidence level A IEA composite graft free graft evidence 3.5 RA LAD ITA Classa RA in-situ ITA A-C Classa A-C RA SVG Classa RA Classa 3.6 SVG CABG emergency rescue CABG 1 SVG % LITA-LAD RA SVG Classb RCA SVG GEA In situ LITA LAD Class In situ RITA LAD LITA quality Class BITA single ITA mortality, morbidity Classaevidence In situ ITA SVG flow demand Class skeletonization In situ ITA skeletonization BITA Classaevidence level B In situ GEA Classa SVG % SVG LAD Classa A-C RA SVG Classa Circulation Journal Vol. 70, Suppl. IV,

6 A-C radial artery Classa atheromatous emboli Classaevidence level C OPCAB Class evidence level C LITA-RITA LITA-RA Y-composite graft LITA Classevidence level B LITA-RITA LITA-RA composite graft Class Composite graft Classa in-situ ITA Y-composite graft Classaevidence level C LAD 2 FAD LITARITARASVG Dx LITARITARASVG Composite RAFITA Cx LITARITARASVG Composite RAFITA RCA1-3 RITAGEARASVG Composite RAFITA RCA4 GEARASVG Composite RAFITA LADleft anterior descending arterydxdiagonal arteryco circumflex arteryrcaright coronary arterylitaleft internal thoracic arteryritaright internal thoracic arteryraradial arterysvgsaphenous vein graftgeagastro epiproic artery FITAfree internal thoracic artery 5.1 LAD Classa LAD ITA SVG Class LAD RITA LITA Class 5.2 LAD ITA LAD CxRCA LAD ITA RASVG LAD ITA ITA RCA Cx Classaevidence LAD ITA RA Classa LAD ITA SVG 10 Classa LAD RA SVG Classbevidence level C LAD ITA ITA RCA Cx Classaevidence 1560 Circulation Journal Vol. 70, Suppl. IV, 2006

7 5.2.2 RCA#1-3 RCA #1-3#4 Classa RCA GEA SVG Classbevidence 6.1 Classevidence level A 6.2 CABG RA Carpentier Ca RA Classaevidence CABG Classevidence level A 6.5 Ca 1 CABG 2 CABG CABG 6.6 CABG Class 6.7 CABG Class Class 6.8 CABG Classevidence level B Circulation Journal Vol. 70, Suppl. IV,

8 Class b evidence level C LAD 80 Classa OPCAB 80 Classaevidence level C 7.2 Class OPCAB Class a 7.3 PCI CABG Class skeletonization Classa OPCAB Classb 7.4 Classa MIDCAB Classbevidence level C 1 2 Classa TEE OPCAB Classevidence level C CABG 24 4 Classbevidence level C CABG 36 Classaevidence level C Classbevidence level C % CABG Classa evidence level C Circulation Journal Vol. 70, Suppl. IV, 2006

9 Classaevidence level C CABG ICU 7.7 OPCAB Classa Classaevidence level C Classbevidence level C Class high risk OPCAB Child-Pugh B C Classbevidence level C CABG MR Classb evidence level C 7.10 CABG Classevidence Classa Classb % 1530 % % 25 % CABG PTCA CABG AS AVRClassevidence CABG AS AVR AVR Classaevidence level C CABG AS AVR AVR Classbevidence level C CABG MR Classa CABG PCI Class CABG 3 Class CABG Classa LAD Circulation Journal Vol. 70, Suppl. IV,

10 % Classa % 78 % CABG Classa 7.14 CABGClassevidence level B CABG Classa CABG Classbevidence level C 7.15 CABG 7.16 PCI CABG CABG PCI Classaevidence level A 7.17 CABGClass CABGClassaevidence Classbevidence level C STS database Euro SCORE 8.3 STS risk algorithm Euro SCORE 8.4 CABG CABG 1564 Circulation Journal Vol. 70, Suppl. IV, 2006

11 Parsonnet score Higgins score French score OPR score Pons score Euro SCORE STS risk algorithm single center single center Multi center 42 Multi center 9 Multi center 7 Multi center 128 Multi center USA USA France Canada Spein 8 USA Heart Surgery for CABG Heart Surgery Heart Surgery Heart Surgery Heart Surgery Heart Surgery Mortality Mortality Mortality Mortality Mortality Mortality Mortality Morbidity Morbidity Morbidity Morbidity Morbidity Univariated and Univariated and Univariated and Univariated and Univariated and Univariated and Univariated and logistic regression logistic regression logistic regression logistic regression logistic regression logistic regression logistic regression analysis analysis analysis analysis analysis analysis analysis Score Score Score Score Score Inter net Inter net data data data data data mortality mortality morbidity morbidity , STS Euro SCORE morbidity CABG CABG 1 CABG evidence level A CABG PCI doctor's feesurgeon s fee DPC DPC PCI CABG PCI 16 OPCAB 60 % Circulation Journal Vol. 70, Suppl. IV,

12 CCAB OPCAB 4 PCI CABG Drug eluting stent ,494,9001,592,000 3,310, vs p vs NS vs p0.001 OPCAB 3,100,0001,140,000 vs 4,100,0001,960,000 p0.001 OPCAB 100 OPCAB OPCAB 30 % on pump CABG On pump CABG 1 487, ,000 OPCAB 30 % 1 146, ,900 OPCAB on pump CABG 255, % OPCAB DPC incentive OPCAB CCAB OPCAB single use 10.1 Classb evidence level C SVG MVP systemst Jude Medical ATG coronary connector system St Jude Medical Inc, St Paul, Minn Circulation Journal Vol. 70, Suppl. IV, 2006

13 10.2 Classevidence level C 2 AESOPIntuitive Surgical, Inc. Sunnyvale, CA da Vinci Surgical System OPCAB TEA Awake CABG 10.4 Classaevidence level A CO2 Transmyocardial surgical laser revascularizationtmlr Classevidence level C High Thoracic epidural anesthesia: TEA awake off-pump CABGAwake OPCAB 1999 Awake OPCAB TEA Awake OPCAB LAD 1 RCA 2 Awake OPCAB TMLR PCI CABG TMLR CO2 Heart Laser TM PLC Medical Systems, Milford, MAHolmiumYAG Eclipse TM Cardio Genesis Corp, Sunnyvale, CA 2 CO2 HolmiumYAG 1 1 HolmiumYAG CO2 photoacoustic TMLR 1 23 TMLR OPCAB Circulation Journal Vol. 70, Suppl. IV,

CABG: coronary artery bypass grafting, ITA: internal thoracic artery, GEA: gastroepiploic artery, IEA: inferior epigastic artery, LV: left ventricle,

CABG: coronary artery bypass grafting, ITA: internal thoracic artery, GEA: gastroepiploic artery, IEA: inferior epigastic artery, LV: left ventricle, Coronary Artery Bypass Grafting in the Presence of Atherosclerotic Lesions in the Ascending Aorta Tadashi Isomura, Toru Satoh, Nobuhiko Hayashida, Hiroshi Maruyama, Kouichi Hisatomi*, Tatsuya Higashi,