Download Coronary Artery Bypass Graft

Coronary Artery
Bypass Graft
MODERATOR: Dr. HARISH NAIR
Dr. RAKESH M.G.
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Prior to 1930’s, heart surgery seen as impossible, with high morbidity and
mortality
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1937: Dr. John Gibbon designs heart-lung machine, which enables
cardiopulmonary bypass (CPB)
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1955: Vineburg and Buller implant internal mammary artery into
myocardium to treat cardiac ischemia and angina
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1958: Longmire, Cannon and Kattus at UCLA perform first open coronary
artery endarterectomy without CPB
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During 1960’s and 1970’s, CPB and cardioplegic arrest are adopted,
allowing Coronary Artery Bypass Graft (CABG) to emerge as a viable
surgical treatment
CABG
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Dr. Vasil Kolesov in 1964
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Pioneer Dr. Rene Favaloro
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Dr. Greene did the 1st LIMA
ANATOMY
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Chronic angina
Unstable angina
Acute myocardial infarction
Acute failure of percutaneous transluminal coronary
angioplasty (PTCA)
Severe coronary artery disease
Investigations
Routine Blood investigations
 RFT, LFT, Coagulation profile
 Serum electrolytes
 12 lead ECG
 Chest X ray
 Stress test
 Echocardiogram
 Angiogram
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CORONARY ANGIOGRAM
TYPES OF CABG
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Off pump CABG (OPCAB)
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On pump CABG –(1)Cardioplegia
(2)Fibrillating heart
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Mid CABG
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Robotic surgery
Anaesthesia preparation
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ECG leads
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Peripheral line
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Arterial line
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CVP and PA pressure line
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Intubation
Trans-esophageal endoscopy.
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Most common arteries
bypassed:
 Right
coronary artery
 Left anterior descending
coronary artery
 Circumflex coronary
artery
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Saphenous vein used for bypassing right coronary artery
and circumflex coronary artery
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Internal mammary artery (IMA) used for bypassing left
anterior descending coronary artery
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Patency rate over 90% after 10 years
If more veins are needed, alternative sites such as upper
extremity veins can be used
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Patency rate as low as 47% after 10 years
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Radial/ right gastro-epiploic artery. (also used)
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Conduit removed
Median sternotomy
 Sternum
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divided using electric saw
Cold potassium cardioplegia
Cardiopulmonary bypass
 Cannulation
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of:
Ascending aorta
Femoral artery
Right atrium
 Heparin
administered to minimize clotting
 Grafting
 Pacing
wire
 Closure
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Bypass of arteries:
 Incision
in target artery:
 Anastamosis
of graft with artery:
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Positive:
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Relief of angina in 90% of patients
80% angina free after 5 years
Survival about 95% after 1 year
Low chance of restenosis
Negative:
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2-3 days in ICU, 7-10 day total hospital stay
3-6 month full recovery time
5-10% have post-op complications
High cost
Long time on CPB
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Depression of the patient's immune system
Postoperative bleeding from inactivation of the blood clotting system
Hypotension
Minimally invasive surgery does not use
CPB
 Smaller incision
 Emerging as a replacement for
conventional CABG
 Starting in 1990’s, MIDCAB has gained
popularity
 Usually conducted for LIMA to LDA grafts
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Thoracotomy incision (~10 cm)
Small incisions for video-assisted
LIMA harvest
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LAD exposed
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Anastamosis
preformed with
assistance of
mechanical stabilizer
Completed graft
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Small portion of front of 4th rib removed
LIMA clipped and dissected
MIDCAB retractor and
LIMA stabilizer
facilitates grafting
Uses CPB
 Balloon catheter system for aortic
occlusion and cardioplegic arrest
 5-8 cm left anterior thoracotomy incision
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 No
sternotomy!!!
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LIMA harvested using
specialized retractor
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Aorta drawn into
operating field
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Aorta clamped, anastamosis performed
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Benefits:
 Bloodless
field
 Heart arrested
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allows more accurate anastomoses than MIDCAB
 Smaller
incision than CABG
 No sternotomy
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Drawbacks
 Uses
CPB
 Technically very difficult
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Currently, stenting is recommended over surgery
for one-vessel disease
 In
the future, drug-eluting stents will probably be used
 Minimally invasive surgeries could be used in place of
stents in diabetic, and other high-risk patients
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For more than one-vessel disease, surgery is
substantially better at preventing restenosis and
so will likely continue to be used in the future
 Minimally
invasive surgeries will expand and replace
most conventional CABG procedures
THANK YOU