Practice Guidelines in Cardiothoracic Surgery

Transcription

1 REPORT Practice Guidelines in Cardiothoracic Surgery During the last 10 years, members of our specialty have been fielding, on an individual and on a collective basis, requests regarding standards of care as they relate to our patients. These requests have come mainly from third-party payors on a national level, as well as private carriers, and also from medicolegal committees within our specialty organizations. The Council of The Society of Thoracic Surgeons, after much deliberation involving many council meetings, ultimately decided that these requests were legitimate and that a carefully structured response from our specialty was indeed indicated. From the outset, it was decided that these documents should represent the opinions of our specialty as completely as possible and, therefore, the active participation and support of the other three major thoracic societies (the American Association for Thoracic Surge y, the Western Thoracic Surgical Association, and the Southern Thoracic Surgical Association) have been solicited. The committee and subcommittees formed as a result of this action of the Council of The Society of Thoracic Surgeons have met on many occasions and have had considerable deliberations concerning these matters. First of all, a title for these documents was thoroughly discussed; the use of the word "guidelines" seemed most appropriate and perhaps "minimal guidelines" would be even more appropriate. There was a clear understanding among the participants that this was not to be an effort to provide a textbook description of each procedure with a detailed analysis of evey facet of patient care and outcome analysis, but rather it was to be a simple description of those things that are tiormally anticipated in developing the indications for surgery, as well as simple statements regarding those things to be anticipated before, during, and after the operative procedure in the care of the patient. It also was agreed that an attempt would be made to provide some broad-range outcome statements. It was also understood that, even though this work product could be entitled "minimal guidelines," some of the items identified might not be included in the care of an individual patient. Further, it was clearly understood that many other items might logically and appropriately be included in patient care and not included in these minimal guidelines. Finally, and perhaps most importantly, it was agreed upon that this work product should be a "living document" and that frequent review and revision would be a part of the work intended. With the rapid advance of technology and patient care techniques, this final point is essential. Because of the volume of this effort, it will not be published in total form, but rather in the various elements of our specialty as the work product is completed and publication is appropriate. Because of the nature of the presentation of this material to thoracic and cardiovascular surgeons, it is clearly understood that revision of the first published portions of these documents may well be indicated prior to completion of the coverage of our specialty. Because of this, comments and suggestions regarding these guidelines are encouraged and solicited and should be addressed to the management of The Society of Thoracic Surgeons. It is our commitment to act upon these comments and suggestions and to revise and maintain this living document in a timely fashion. George G. Lindesmith, MD President, The Society of Thoracic Surgeons Background During his tenure as President of The Society of Thoracic Surgeons, George G. Lindesmith appointed the Ad Hoc Committee for Cardiothoracic Surgical Practice Guidelines. The current committee composition is as follows: GEORGE C. KAISER, MD, CHAIRMAN, St. Louis THOMAS D. BARTLEY, Pueblo, CO JOSEPH S. COSELLI, Houston JAMES A. DEWEESE, Rochester, NY T. BRUCE FERGUSON, JR, St. Louis THOMAS B. FERGUSON, St. Louis RICHARD G. FOSBURG, La Jolla ROBERT H. JONES, Durham GEORGE G. LINDESMITH, Los Angeles KEITH S. NAUNHEIM, St. Louis D. GLENN PENNINGTON, St. Louis MARVIN POMERANTZ, Denver W. GERALD RAINER, Denver ROBERT M. VANECKO, Chicago ANDREW S. WECHSLER, Richmond The organizational meeting of the Committee was held in Boston, Massachusetts, on May 8, During this and subsequent meetings, the guideline format and its degree of complexity were discussed extensively. It was recognized that practice guidelines were being constructed by many organizations, each with its own agenda and requirements. Therefore, guidelines varied in detail and complexity according to the perceived needs of the constituency. Furthermore, it was noted that there are no universally accepted guidelines for writing practice guidelines. However, to help the STS committee formulate its plan, guidelines already in existence or being developed were collected from other medical and peer review organizations, third-party payors, and both federal and state governments. This information was invaluable in assisting the Committee in arriving at its decisions regarding the structure and complexity of cardiothoracic surgical practice guidelines. After careful and extensive deliberation, it was decided to approach Practice Guidelines under the following rubrics: by The Society of Thoracic Surgeons Ann Thorac Surg 1992;53:93& /92/$5.00

2 Ann Thorac Surg 1992; REPORT The guidelines would be procedure-oriented. Appropriate CPT codes were to be indicated. This would allow appropriate identification of each procedure as it would be coded in the revised CPT-4 code book. The Society s CPT-4 Advisory Committee, under the Chairmanship of Sidney Levitsky, was assisting in the revision of the cardiothoracic surgical codes which in many instances were out of date or in which codes were entirely lacking for procedures such as thoracic organ transplantation and left ventricular assist device insertion. Furthermore, listing of the procedure and diagnostic codes would assist members in their practice and other bodies in identifying the exact procedure being performed. 2. The field of cardiothoracic surgery would be divided anatomically and associated pathologic processes in each area would be addressed. Although the guidelines were to be procedure oriented, the field of cardiothoracic surgery was organized along anatomic and pathologic lines. Organization of the guidelines in this manner was decided upon to allow ease of categorization and implementation. This apparent ambivalence was accepted to facilitate guideline development, yet encompass the entire field of cardiothoracic surgery. Although some organizations that developed practice guidelines had struggled with this apparent dichotomy between disease entities and procedures, the Committee felt its approach was practical and would expedite this complex process. 3. The criteria published by the American College of Obstetricians and Gynecologists* would be used as the model for the outline of the areas to be addressed for each Practice Guideline. Their outline is: Procedure Indication Confirmation of Indication Action Prior to Procedure Contraindications Additions were made to this outline to address aspects not included in that outline and to make it more compatible with our needs. The subsequent headings decided upon by the Committee were: Diagnosis Procedure Indication Confirmation of Indication Relative Contraindications Actions Prior to Procedure Actions During Procedure Actions Following Procedure Outcome References * Quality Assurance in Obstetrics and Gynecology, 1988 Edition, The American College of Obstetricians and Gynecologists, th St SW, Washington, DC It was decided that cardiothoracic surgical textbooks would be the references of choice. There were many reasons for this decision, not the least of which was that these would represent the generally accepted view in the cardiothoracic surgical community, and only a few references would be required, thereby avoiding extensive and cumbersome bibliographies. For newer procedures for which textbook references were incomplete or unavailable, it was agreed that appropriate references from the cardiothoracic surgical literature would be supplied. In view of the increasing emphasis by many upon outcome, it was agreed to include some estimate of expected outcome for each procedure. Subcommittees for each cardiothoracic surgical category were appointed with a member of the Ad Hoc Committee as chairman of the subcommittee. These subcommittees and their membership are as follows: 1. Ischemic Heart Disease ROBERT H. JONES, CHAIRMAN GERALD M. LAWRIE WEI-I LI BRUCE W. LYTLE 2. Valvular Heart Disease THOMAS D. BARTLEY, CHAIRMAN JOSEPH M. CRAVER ROBERT A. GUYTON 3. Thoracic Aortic Disease JOSEPH S. COSELLI, CHAIRMAN E. STANLEY CRAWFORD RANDALL B. GRIEPP NICHOLAS T. KOUCHOUKOS D. CRAIG MILLER 4. Chest Wall, Diaphragm, Mediastinum, Pericardium THOMAS B. FERGUSON, CHAIRMAN LARRY R. KAISER KEITH S. NAUNHEIM CHARLES L. ROPER WILLIAM F. SASSER 5. Esophageal Disease ROBERT M. VANECKO, CHAIRMAN ROBERT J. GINSBERG ALEX G. LITTLE MARK B. ORRINGER 6. Bronchopulmonary Disease RICHARD G. FOSBURG, CHAIRMAN JOHN R. BENFIELD RICHARD M. PETERS THOMAS W. SHIELDS

3 932 REPORT Ann Thorac Surg 1992;53: Transplantation (heart, lung, Assist Devices heart-lung) and Heart D. GLENN PENNINGTON, CHAIRMAN WILLIAM A. BAUMGARTNER A. MICHAEL BORKON JACK J. CURTIS VERDI J. DISESA J. KENT TRINKLE 8. Electrical Problems (pacemakers, arrhythmias, AICD) MARVIN POMERANTZ, CO-CHAIRMAN W. GERALD RAINER, CO-CHAIRMAN 9. Congenital Heart Disease GEORGE G. LINDESMITH, CHAIRMAN JEFFREY M. DUNN HILLEL LAKS WINFIELD J. WELLS James A. DeWeese, MD, serves as liaison between the cardiothoracic surgical organizations and the vascular surgical organizations, the North American Chapter of the International Cardiovascular Society, and the Society for Vascular Surgery. These vascular surgical organizations are developing practice guidelines for vascular surgery. This method of cooperation has been adopted to avoid reduplication of effort. Each subcommittee was charged with the development of guidelines for that category of cardiothoracic surgical practice. In rare instances a procedure might be potentially addressed by more than one subcommittee. Any possibility for overlap was resolved by the parent committee. As an initial effort, each subcommittee was requested to develop guidelines for three of the most commonly performed procedures in its area of expertise. These practice guidelines were then reviewed and critiqued by the entire Ad Hoc Committee and all subcommittees. After refinement, the final results were submitted to the Council of The Society of Thoracic Surgeons for approval. It was anticipated that this complex ratification process might develop snags. Therefore initially, the introductory, preoperative evaluation, and institutional requirement sections along with guidelines for nine procedures were submitted for approval. It was anticipated that any potential problems with this review process that arose could then be resolved making ratification of future guidelines easier. Because in any extensive and complex review process as outlined there might be some differences of opinion, it was proposed that the Council of The Society of Thoracic Surgeons would be the final arbiter. The goal of this review process is to achieve consensus, but at the same time recognize that practice guideline development is, and always will be, a dynamic process. It was decided that the first iteration of the guidelines be published every few months in The Annals of Thoracic Surgery. On the following pages are the first set of practice guidelines and the introductory, preoperative evaluation, and institution requirement sections. It is anticipated that eventually guidelines covering the entire specialty will be collated and published as a separate document. It should be emphasized that one of the most important aspects of this process is that these guidelines will require continual modification and revision as clinical cardiothoracic surgical practice changes. I would like to thank the members of the Ad Hoc Committee and of each subcommittee for their effort and excellent cooperation. George C. Kaiser, MD Chairman, Ad HOC Committee for Cardiothoracic Surgical Practice Guidelines Introduction The following sections provide basic practice guidelines for those individuals qualified in the specialty of cardiothoracic surgery. Although the practice of medicine requires a strong scientific foundation, medicine is also an art requiring both intuitive skills and good judgment. Occasionally, objective decisions concerning patient management must be modified depending upon such factors as individual patient characteristics or other associated factors. Such cognitive functions are an integral and essential part of the practice of cardiothoracic surgery with regard to preoperative patient evaluation, selection of operative procedures, and postoperative patient care until the patient has recovered. The ability to modify the process as needed for the greater benefit of the patient is vital if an optimal outcome is to be achieved for each patient. These intuitive and cognitive skills are essential to the successful practice of cardiothoracic surgery and must be applied in every phase, frequently requiring modification of the patient s care from preoperative preparation to discharge planning. These intellectual abilities are developed, sharpened, and maintained by constant exposure to patients in a clinical setting. In addition, the practitioner must update his or her fund of scientific information by journal review, attendance at scientific meetings and postgraduate seminars, as well as by consultation with colleagues both inside and outside of the specialty of cardiothoracic surgery. Because guidelines are but one aspect in the everevolving field of cardiothoracic surgery, it is anticipated that these guidelines must be modified frequently to keep pace with the advances. As a background upon which practice guidelines will be developed, it is pertinent to delineate the extent of expertise encompassed by the specialty of cardiothoracic surgery. This has already been done. Scope of Thoracic Surgery The thorax or chest extends from the neck to the abdomen and contains the principal organs of the circulatory and respiratory and upper gastrointestinal systems. The specialty of thoracic surgery consists of the diagnosis and Modified from Guidelines for Hospital Privileges for Thoracic Surgeons, developed by The Society of Thoracic Surgeons, endorsed by The American Association for Thoracic Surgery in 1986, and revised in 1991 and Copies may be obtained from: The American Association for Thoracic Surgery, Thirteen Elm St, Manchester, MA 01944; or The Society of Thoracic Surgeons, 401 N Michigan Ave, Chicago, IL

4 Ann Thorac Surg 1992;53:93&9 REPORT 933 treatment of the major organs comprising the thorax, but is not totally confined to this area. More precisely, it includes the surgical treatment of congenital anomalies, malfunctions, diseases, and injuries of the thoracic cage, the heart and great vessels, the tracheobronchial system and lungs, esophagus, diaphragm, other mediastinal contents, and circulatory systems in all age groups. This specialty is recognized by certification by the American Board of Thoracic Surgery or fellowship in cardiovascular and thoracic surgery in the Royal College of Surgeons of Canada, or certification of special competence in general thoracic surgery by the Royal College of Surgeons of Canada. Certification requires specific training in an approved residency program which educates its students in both the diagnosis and treatment of diseases, malfunctions, and injuries of the thoracic cavity and its contents. This requires a detailed knowledge of normal and abnormal anatomy and physiology within the cardiorespiratory and gastrointestinal systems. Specific technical and cognitive skills must be learned both in the operating theater and in the post surgical setting which allow for excision, repair or replacement (via tissue transplant or prosthesis) of the contents of the thorax. These abilities must include detailed knowledge of and expertise with the operative techniques, the medications, and technological hardware required for the safe and expeditious performance of these procedures. Fields of expertise practiced by thoracic surgeons include: 1) Benign and malignant tumors of the lung, chest wall, esophagus and stomach and mediastinal contents; 2) Coronary artery disease and its complications; 3) Diseases of the great vessels; 4) Valvular heart disease; 5) Electrophysiological arrhythmia ablation and pacemakers; 6) hernias and other pathology of the diaphragm; 7) Malfunctions of the esophagus; 8) Congenital and developmental anomalies of the cardiovascular system, diaphragm, esophagus, trachea and all structures within the chest; 9) Gastrointestinal endoscopy; 10) Bronchoscopy, thoracoscopy, and mediastinoscopy; 11) Peripheral vascular surgery as associated with major vessel disease; and 12) Blunt and sharp injuries to the thorax (trauma) including preoperative diagnosis, surgical evaluation, operative management and postoperative care. An appropriately trained and credentialed thoracic surgeon should be expected to request privileges in those areas covered by his training. Training in Canadian programs is not in every case equivalent to that required by the ABTS. In those instances, the actual training received must be evaluated in the process of granting privileges. Those privileges may include, but not be limited to, the following list: Thoracic and cardiovascular surgical privileges (for adults and children) All operations involving resection, reconstruction, repair or biopsy of the lung and its parts (e.g. pneumonectomy, lobectomy, segmentectomy, localized resection, sleeve resection, in continuity with chest wall resection, including transplantation, etc., but not limited to these); and procedures incidental to the above. All operations involving resection of the chest wall or the pleura, such as resection of chest wall tumor, pleurectomy, decortication, thoracoplasty, resection of first (or other) rib($, empyema drainage, sternoplasty (for pectus excavatum or carinatum), etc., but not limited to these; and procedures incidental thereto. All operations involving resection, reconstruction or repair of the trachea and bronchi, such as tracheostomy, tracheal resection, bronchotomy, bronchoplasty, etc., but not limited to these; and procedures incidental thereto. All operations involving resection, reconstruction or repair of the esophagus and diaphragm, such as diverticulectomy, esophagectomy, esophagogastrectomy, colon interposition, jejunal interposition, hiatal herniorrhaphy, removal of diaphragmatic tumors, repair of the diaphragm, etc., but not limited to these; and procedures incidental thereto. All operations of the pericardium, involving resection, reconstruction, drainage, etc., such as pericardiectomy or pericardiotomy, but not limited to these; and procedures incidental thereto. All endoscopic procedures and instrumentations involving the esophagus and tracheobronchial tree, such as laryngoscopy, bronchoscopy, thoracoscopy, esophagoscopy, esophageal dilatation; etc., but not limited to these; and procedures incidental thereto. Lymph node and superficial biopsy procedures, such as scalene or axillary node biopsy, subcutaneous and muscular biopsy etc., and procedures incidental thereto. All procedures involving biopsy, excision of tumor, drainage, etc., of the mediastinum, such as mediastinoscopy or mediastinotomy, but not limited to these; and procedures incidental thereto. Closed heart operations, both congenital and acquired (including reconstruction with grafts) Open heart operations, both congenital and acquired (including valvuloplasty, replacement, reconstruction with grafts or transplantation) Surgery of tumors of the heart and pericardium Surgery of arrhythmias (arrhythmias ablation) Surgery for implantation of artificial heart and mechanical devices to support or replace the heart partially or totally. Correction or repair of all anomalies or injuries of great vessels and branches thereof, including aorta, pulmonary artery, pulmonary veins, venae cavae, but not limited to these; and procedures incidental thereto. All operations for myocardial revascularization (endarterectomy, bypass grafts or internal mammary artery or other grafts to coronary arteries). Operative procedures for correction or palliation of arteriosclerotic vessels, including the aorto-iliac-femoral system, but not limited to these; and procedures incidental thereto. All operations for placement or replacement of cardiac pacemaker systems, including multi-chamber sensory pacemakers, automatic implantable defibrillators, whether epicardial or pervenous approach, but not limited to these; and procedures incidental thereto. All operations involving transplantation of the heart, heart-lung block, and single or double lung transplants. These guidelines have been developed by the Ad Hoc Committee for Cardiothoracic Surgical Practice Guidelines of The Society of Thoracic Surgeons. Numerous professional organizations have been involved in the development of the practice guidelines, and there is a diversity of opinion concerning their format and content. Because there are no established standards for writing practice guidelines, they have tended to vary from organization to

5 934 REPORT Ann Thorac Surg 1992;5393&9 organization according to the perceived needs of the particular specialty. The Society of Thoracic Surgeons has elected to develop guidelines that are brief, broadly interpretable, helpful to practicing clinical cardiothoracic surgeons, and useful to those assessing quality of cardiothoracic surgical care. After considerable deliberation and discussion, the guideline format developed by the American College of Obstetricians and Gynecologists* was modified to fulfill the needs of practicing cardiothoracic surgeons and their patients. The guidelines were then developed and modified during an arduous review process. The general outline includes the following: Diagnosis, Procedure, Indication, Confirmation of Indication, Relative Contraindications, Actions Prior to Pryedure, Actions During Procedure, Actions Following Procedure, Outcome and References. To make these guidelines relevant to cardiothoracic surgical practice, coding diagnoses with their codes and the procedure codes are indicated in each guideline. Lack of appropriate codes for newer procedures made coding difficult, if not impossible, in some instances. From the inception of this task, it was acknowledged that practice guidelines could not and should not be all-inclusive. The development and application of guidelines must remain a dynamic process. Principles considered essential or important in a guideline at one time might become irrelevant or inappropriate at a later time. Extensively detailed and documented guidelines for the entire field of cardiothoracic surgery would approach the size of a textbook of cardiothoracic surgery, and would be obsolete before they were published. Cardiothoracic surgical textbooks are updated frequently. Many of the Committee members have been contributors to these texts. Their selection as textbook contributors and Committee members acknowledges their clinical expertise in the field of cardiothoracic surgery. These guidelines have been developed by subcommittees of selected experts and educators, knowledgeable in the field of cardiothoracic surgery and especially the specific area to which they were assigned. Their curricula vitae will be available for review at the business office of The Society of Thoracic Surgeons. As an initial entry into the field of practice guideline development, subcommittees in each of nine areas of the field of cardiothoracic surgery were charged with developing guidelines for three of the more commonly performed procedures in their designated area. These areas are: ischemic heart disease; valvular heart disease; thoracic aortic disease; transplantation and assist devices; arrythmias; bronchopulmonary disease; chest wall, diaphragmatic, mediastinal, and pericardial disorders; congenital heart disease, and esophageal disease. After thorough deliberation, it was decided to have these guidelines procedure oriented. The thrust for development of these guidelines was to assure the opportunity * Quality Assurance in Obstetrics and Gynecology, 1988 Edition, The American College of Obstetricians and Gynecologists, th St SW, Washington, DC for the best and most complete cardiothoracic surgical care for each patient. Issues of appropriateness and quality must be defined before cost can be assessed. The Committee is aware of its responsibility to each patient and to society to deliver this care in the most cost-efficient manner. General recommendations that are applicable to the delivery of care to all cardiothoracic patients are presented separately. Basic preoperative evaluation and the necessary supporting services are identified in the following sections. The Preoperative Evaluation To be certain that the contemplated operation will not propose an undue risk to the patients, those who are candidates for a major thoracic or cardiac procedure should undergo a thorough preoperative evaluation. This evaluation is designed to detect concomitant medical diseases that might prove to contraindicate operation or that may require further treatment in preparation for the proposed surgical procedure. The following represents the minimum required preoperative evaluation and should be performed within one week of the date of opera tion. 1. Thorough history and physical examination 2. Chest roentgenogram 3. Urinalysis 4. Electrocardiogram 5. Blood sample for typing in all patients and a type and crossmatch for blood products in cases having a risk of significant blood loss. Patients who have previously provided blood via autologous donation may be excused from this requirement. 6. Blood analysis to include complete blood count, platelet count, PT, PTT and SMA Room air blood gas determination including pco,, PO,, and ph in patients with suspected pulmonary compromise. 8. Appropriate medical consultation where indicated. 9. Assessment of nutritional status. Institutional Requirements There are certain institutional requirements that must be met if cardiothoracic surgery is to be safely performed within a health care center. These include: 1. Blood Bank-The performance of cardiac surgery necessitates an active and competently managed blood bank. At times, a blood bank may be called upon to provide large quantities of many different types of blood components with little or no notice. The presence of such a facility within the hospital is mandatory if major cardiothoracic surgery is to be performed safely. 2. Intensive Care Units-Adequate postoperative care often mandates complex equipment for treatment and the monitoring of many hemodynamic indices and

6 Ann Thorac Surg 1992;53:93&9 REPORT 935 other clinical parameters simultaneously. A hospital should have both the equipment for and medical, nursing, and ancillary personnel experienced in postsurgical critical care delivery if patient needs are to be met satisfactorily. Due to the needs for emergency intervention which occasionally arise in the postoperative period, there should be a physician on call within the hospital, preferably one with experience in the care of critically ill patients. 3. Anesthesiology-The safe performance of cardiothoracic surgical procedures requires a cooperative effort between surgeon and anesthesiologist. The critical nature of these patients and the multiple cardiopulmonary manipulations that inevitably occur require anesthesiologists who are expert in the delivery of care to patients with complex cardiac and thoracic problems. These anesthesiologists must be familiar with all types of ventilators, monitoring equipment, and other supportive equipment. Anesthesiologists with special interest in cardiothoracic surgical problems are preferable. 4. Operating Rooms-Both postoperative complications and primary cardiothoracic emergencies frequently re- quire urgent operative intervention. An institution must therefore have the capability to rapidly mobilize surgical and support teams for emergency procedures 24 hours a day, seven days a week. 5. Medical Consultation Services-Supportive expertise must be available 24 hours a day, seven days a week in medical subspecialty fields such as cardiology, pulmonology, neurology, hematology, nephrology, and infectious disease. 6. Respiratory Therapy-The modern delivery of critical care requires around the clock availability of respiratory care personnel familiar with the operation, function, and maintenance of a wide variety of modern life support equipment. 7. Radiology-Around the clock radiologic services must be available in the fields of diagnostic radiology and nuclear medicine. 8. Laboratory and Pathology Services-Around the clock laboratory services must be available for immediate blood gas analysis and determination of serum biochemical and hematologic including coagulation values. EDITOR S NOTE: This is the second set of guidelines to be published. The first set, on three procedures in the areas of chest wall, diaphragm, mediastinum, and pericardium, appeared in the April issue of The Annals of Thoracic Surgery (Ann Thorac Surg 1992;53:729-37).

7 936 REPORT Ann Thorac Surg 1992;53:93&9 Practice Guidelines Ischemic Heart Disease: I Diagnosis: 410 Acute myocardial infarction Acute myocardial infarction of septum alone Acquired cardiac septal defect Repair of postinfarction ventricular septal defect Indication: Demonstration of left-to-right shunting at the ventricular level in a patient after myocardial infarction Confirmation of Indication: 1) Oxygen step-up on right heart catheter Relative Contraindications: 2) Indicator-dilution curve or cardiac imaging shunt study showing left-to-right shunt at the ventricular level 3) Echocardiograp hy 4) Cardiac catheterization sometimes appropriate Risk judged greater than benefit Actions Prior to 1) Confirm presence of VSD Actions During 2) Coronary arteriography sometimes appropriate Repeat shunt study to document closure Actions Following 1) Cardiorespiratory support References 2) Treat arrhythmias Outcome: 1) Mortality of 10% to 60% determined by preoperative status 2) 3) Discharge 7 to 21 days determined by preoperative status and postoperative complications Elimination or diminution of left-to-right shunt 1. Hill JD, Stiles QR. Acute ischemic ventricular septal defect. Circulation 1989;79(Suppl 1): Kirklin JW, Barratt-Boyes BG. Postinfarction ventricular septal defect. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. New York: Wiley, 1986:

8 Ann Thorac Surg 1992;5393&9 REPORT 937 Practice Guidelines Ischemic Heart Disease: I1 Diagnosis: Indication: Coronary atherosclerosis Chronic ischemic heart disease, unspecified Coronary artery bypass grafting (autologous vein or arterial graft) 1-V CABG 2-V CABG 3-V CABG 4-V CABG 5-V CABG 6 + -V CABG Stable angina pectoris Unstable angina pectoris Angina equivalent syndromes Acute myocardial infarction Exercise-induced congestive heart failure Acute coronary occlusion or dissection after catheterization or angioplasty Ischemic cardiomyopathy prior to other major surgical procedures Resting ischemic electrocardiographic change Positive exercise treadmill test Radionuclide perfusion defect Exercise ejection fraction less than 0.50 Ischemic ventricular arrhythmias Left main stenosis of 50% or greater vessel diameter Stenosis of three major coronary arteries Stenosis of two major coronary arteries, including proximal LAD stenosis Stenosis of 50% or greater in any coronary vessel in a patient undergoing cardiac operation for another cause (valve replacement, left ventricular aneurysm resection, electrophysiologic procedure, post-myocardial infarction VSD) Atherosclerotic vein graft to coronary vessels Failure of previously placed conduit Coronary artery aneurysm Intraoperative coronary occlusion or embolization Acute aortic dissection involving or occluding coronary ostia Ventricular septa1 defect or cardiac rupture Left ventricular aneurysm with angina Refractory ventricular tachycardia or congestive heart failure

9 938 REPORT Ann Thorac Surg 1992;53: ) Ischemia-induced mitral regurgitation 26) Ventricular tachycardia or ventricular fibrillation not associated with left ventricular aneurysm Confirmation of Indication: Relative Contraindications: Actions Prior to Actions During Actions Following Outcome: Coronary arteriography and/or noninvasive testing as indicated Risk judged greater than benefit Examine for potential conduit to be used for bypass 1) Confirm suitability of conduit 2) Confirm adequate size and quality of arterial sites for graft insertion 1) Cardiorespiratory support 2) Treat arrhythmias 1) 1% to 20% mortality determined by patient age and condition, associated disease, coronary anatomy, and left ventricular function 2) Discharge in less than ten days in uncomplicated cases 3) Relief of ischemic symptoms References 1. Spencer FC. Bypass grafting for coronary artery disease. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest. Philadelphia: W.B. Saunders, 1990:182& Kirklin JW. Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/ American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol 1991;17:

10 Ann Thorac Surg 1992;53:93&9 REPORT 939 Practice Guidelines Ischemic Heart Disease: I11 Diagnosis: Indication: Confirmation of Indication: Relative Contraindications: Actions Prior to Procedure : Actions During Actions Following Outcome: ) 2) 3) 4) Left ventricular aneurysm Resection or plication of left ventricular aneurysm Congestive heart failure Systemic emboli Angina pectoris Ventricular arrhythmias Cardiac imaging study with contrast, echocardiography, or radionuclide technique showing dyskinesia Asymptomatic true aneurysm 1) Coronary arteriography 2) Left ventriculography often indicated 1) Remove mural thrombus 2) In presence of ventricular tachycardia, map endocardium and ablate sites of early repolarization 1) Cardiorespiratory support 2) Treat arrhythmias 1) Mortality of 3% to 30% determined by patient age, general status, associated disease, and extent of myocardium involved 2) 3) Discharge in 7 to 21 days depending on preoperative status Diminution or relief of symptoms References 1. Harken AH. Left ventricular aneurysm. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest. Philadelphia: W.B. Saunders, 1990: Magovern GJ, Sakert T, Simpson K, et al. Surgical therapy for left ventricular aneurysm. A ten-year experience. Circulation 1989;79(Suppl 1):102-7.