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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e65 CLINICAL STATEMENTS AND GUIDELINES Synopsis The decision to add CABG to another planned cardiac surgery in patients with significant CAD is multifactorial. Considerations include but are not limited to comorbidities, technical feasibility of CABG, extent of the jeopardized myocardium, availability of conduit, left ventricular ejection fraction, and the additional time needed to construct the coronary bypass while on cardiopulmonary bypass. A multidisciplinary discussion with a Heart Team can help weigh the risks and benefits of adding CABG to the index cardiac operation. Age does not appear to be a prohibitive risk factor for the addition of CABG to other cardiac surgery in patients between the ages of 75 and 84 years,1,2,4 but risk increases in patients ≥85 years of age.12 The available evidence supporting CABG at the time of cardiac surgery performed for another primary indication (ie, valve, aortic, or other cardiac surgery) is limited and complicated because many studies include patients with CAD defined as at least 1 vessel with stenosis ≥50%, thus including both intermediate and significant CAD. The knowledge that incomplete revascularization is associated with reduced long-term survival rates after surgery compared with patients who receive complete revascularization may inform decisions about adding CABG to other cardiac surgery.5,10 Additionally, it has become standard practice to bypass significant coronary artery stenoses in patients undergoing other cardiac surgery. Recommendation-Specific Supporting Text 1. Several observational studies and meta-analyses compared clinical outcomes in patients undergoing aortic valve replacement (AVR) with and without significant CAD (≥70% stenosis of any major epicardial coronary vessel, including side branches, or ≥50% stenosis of the left main).6-9,12 Patients who underwent AVR with concomitant CABG demonstrated long-term survival and health-related quality of life similar to that of patients without CAD. Concomitant CABG may increase the risk of perioperative morbidity and mortality compared with isolated AVR.2-4 In patients with significant CAD who underwent isolated AVR or AVR plus CABG, concomitant CABG was associated with a reduced late all-cause mortality rate (hazard ratio, 0.62; 95% CI, 0.49–0.79; P<0.001).10 A large study of 6151 patients found that patients with extensive CAD (>50% left main stenosis or ≥3 diseased vessels) undergoing AVR with CABG had more comorbidities and had more perioperative morbidity, but not mortality, than did patients with less extensive CAD undergoing AVR with CABG.12 A large study that propensity-matched patients undergoing AVR to patients undergoing AVR with CABG demonstrated no differences in morbidity or mortality between groups, which suggests that survival is dominated largely by patient comorbidities.7 Studies focusing on CABG as a secondary procedure during other cardiac operations, including mitral valve, tricuspid valve, aortic, and pericardial surgery, are limited. 2. Limited data are available comparing CABG for intermediate CAD (stenosis, 40%–69%) in patients undergoing other cardiac surgery. Observational studies comparing patients undergoing AVR with and without CABG for intermediate CAD suggest that the addition of CABG may reduce ischemic events.5,7,10,12 Patients with intermediate CAD may benefit from physiological testing with iFR or FFR to guide decision-making. 12.4 Use of Epiaortic Ultrasound in Patients Undergoing CABG Recommendation for Use of Epiaortic Ultrasound in Patients Undergoing CABG Referenced studies that support the recommendation are summarized in Online Data Supplement 39. COR LOE Recommendation 2a B-NR 1. In patients undergoing CABG, the routine use of epiaortic ultrasound scanning can be useful to evaluate the presence, location, and severity of plaque in the ascending aorta to reduce the incidence of atheroembolic complications.1-10 Synopsis Atherosclerotic disease of the aorta is common in patients who undergo CABG surgery, with a reported prevalence that varies between 19% and 90%, depending on the patient population and modality of examination.2,11-16 There has been a clear association between aortic atherosclerosis and stroke,17 especially in patients undergoing CABG.11,12,18-21 Epiaortic ultrasound has been demonstrated to be far superior to either surgical digital palpation or transesophageal echocardiography for defining the presence and extent of disease and has come to be recognized as the “gold standard” for the detection of aortic atherosclerosis.13-15,22-24 There has been considerable variability in the extent to which epiaortic ultrasound has changed operative strategy, varying from 4% to 22%.1,2,6,9,16 Recommendation-Specific Supporting Text 1. The ability of routine epiaortic ultrasound to decrease stroke risk in patients undergoing CABG is unclear. One small prospective trial failed to meet a prespecified 50% difference in neurocognitive testing.4 Although it is not uniformly reported,3 Downloaded from http://ahajournals.org by on October 7, 2026