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Title: Coronary%20artery%20bypass%20grafting


1
Coronary artery bypass grafting
  • CABG - OPCAB

2
Coronary artery disease
  • Definition
  • Narrowing of the coronary arteries
  • Caused by thickening and loss of elasticity of
    the arterial walls
  • Limiting blood flow to the myocardium
  • Flow reserve (effort)
  • At rest
  • Occlusion

3
Coronary artery disease
  • Morphology and processes
  • Focal intimal accumulation of lipids, blood
    elements, fibrous tissue, calcium etc. with
    associated changes in the media
  • ? Plaque
  • ? Stenosis
  • Regression of plaque and collateral formation
  • Plaque rupture and thrombosis
  • Usually affects multiple coronaries
    simultaneously, proximally and at bifurcations

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Myocardial infarction
  • Imbalance between oxygen supply and demand
  • Myocardial necrosis starts after 20 minutes
  • Border zone
  • Reperfusion within 3-4 hours can limit the extent
    of myocardial necrosis
  • Scarring. LV systolic and diastolic dysfunction.
    Chronic heart failure.

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Diagnosis
  • Symptoms Angina pectoris, acute myocardial
    infarction, chronic heart failure, sudden death,
    incidental finding on ECG
  • Noninvasive tests to identify and quantify CAD
    and sequelae ECG, CXR, Labs, Exercise testing,
    Nuclear scans, Echocardiography, CT (Ca)

12
Diagnosis
  • Associated conditions
  • Atherosclerosis carotids, PAD
  • Definitive diagnosis extent, distribution and
    severity of anatomic coronary artery disease
  • Coronary angiography
  • New modalities CT (MRI)

13
Coronary angiography
  • Grading of stenoses
  • Moderate 50 diameter 75 cross-sectional area
    loss
  • Severe 67 diameter 90 cross-sectional area
    loss
  • Distribution
  • Single system / two system / three system
  • Left main

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Coronary anatomy
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Indications for surgery
  • Comparative benefit of surgery relative to no
    treatment / medical treatment / PCI
  • Enormous variability in CAD, impacting on risk
    calculation ? patient-specific predictions
  • General indications
  • Left main or left main equivalent
  • 3 system disease
  • 2 system disease with severe prox. LAD and LVEF lt
    50 or ischemia on non-invasive testing
  • 1 or 2 system disease with large area of viable
    myocardium and high-risk criteria

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Bypass grafting
  • Full sternotomy and CPB (HLM)
  • CABG
  • Full sternotomy, no CPB
  • OPCAB
  • Small sternotomy, parasternal access,
    thoracotomy, with or without CPB
  • e.g. MIDCAB

25
Bypass grafting
  • CABG Golden standard and still most widely used
    (STS database 80)
  • Objective complete revascularisation by
    bypassing all severe stenoses in all affected
    coronary branches with 1-1.5 mm diameter
  • Most widely used conduits LIMA, RIMA, SVG,
    radial artery, gastro-epiploic artery

26
ConduitsLIMA / RIMA
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ConduitsSVG
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ConduitsRadial
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ConduitsGastro-epiploic
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Conduit configurations
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Endarter-ectomy
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CABG
  • Median sternotomy
  • Conduit harvesting
  • Heparin, cannulation and CPB with mild to
    moderate hypothermia
  • Cross-clamping of the aorta and cardioplegia
  • Distal anastomoses. Rewarming started.
  • Cross-clamp removed. Proximal anast. using a
    partially occluding clamp. Clamp removed.
    De-airing.
  • CPB discontinued, cannulae removed, protamine.
  • Pacing wires, drainage tubes, hemostasis and
    closure.

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CABG
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OPCAB
  • Attempt to maintain normothermia
  • Median sternotomy
  • Conduit harvesting
  • Heparin. Pacing wires.
  • Maneuvers to maintain hemodynamic stability
    (Trendelenburg, table, R pleura,.)
  • Pericardial sling
  • Luxation. Stabilisation. Distal anastomoses with
    or without shunting.
  • Proximal anastomoses. Protamine.
  • Chest drains. Hemostasis. Closure.

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Not discussed
  • IABP and other support devices
  • Emergency surgery
  • Redo surgery
  • Other modalities of bypass grafting MIDCAB,
    robotic surgery,
  • Adjunctive surgical treatment TMLR, growth
    factors, cell transplantation
  • Combined surgery

45
Results
  • Early mortality can be predicted, using risk
    stratification models (Euroscore, STS)
  • Time-Related Survival, generally
  • 1 month 98
  • 1 year 97
  • 5 year 92
  • 10 year 81
  • 15 year 66
  • NB 25 of early and late deaths are not
    related to CAD or CABG

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Time-Related Survival
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Results
  • Freedom from angina 60 at 10 years
  • Freedom from AMI 86 at 10 years
  • Freedom from sudden death 97 at 10 years
  • 80 of patients are working 1 year postop.
  • Graft patency
  • LIMA (to LAD) 90 at 10 and 20 years.
  • Radial artery 80 at 7 years
  • Gastro-epiploic artery 60 at 10 years
  • SVG 50-60 at 10 years, 80 to LAD
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