Download Off-pump coronary artery bypass graft

History
 In the late 1940s Dr.vineberg first reported on the
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implantation of the LIMA on the myocardiom
In 1950s Muray and coworkers reported on successful case of
coronary endarterectomy
In 1961, Goetz, anastemosed RIMA to the RCA and
demonstrated for the first time that direct myocardial
revascularization without CPB. In 1967, Kolessove, grafted
LIMA to the LAD through a left thoracotomy(MIDCAB)
During the years following, as a consequence of technical
difficulties related to the initial experience with off-pump
myocardial revascularization and refinements of techniques
of CPB, the off-pump approach was largely abandoned.
In 1980 two independent groups continued their work on
off-pump and reported favorable outcomes.
Surgical and Anesthetic Concerns
 Define basic anesthetic concerns
 Define Off-pump CABG Surgery
Anesthetic Management
 GETA with or without Thoracic Epidural
 Monitors – Arterial Line, CVC, PAC, TEE, Cerebral
Oximetry, 5Lead EKG
 IVF – Fluid warmers, Colloid vs Crystalloid, RBCs
 Drugs – Low dose Heparin, Antifibrinolytics, Narcotics
 CPB on Backup
There are three anesthetic approach in
OPCAB
GA with opioids and inhalation anesthesia or total
intravenous anesthesia(TIVA)
2. Combined GA with controlled ventilation and
neuraxial blockade using high thoracic epidural
analgesia(TEA)or combined GA/intrathecal
morphine(ITM)
3. Awake regional anesthesia with apontaneous
ventilation using TEA alone.
1.
High TEA combined with GA provides:
 better analgesia
 better pulmonary outcome
 reduction in perioperative morbidity &mortality
 reduction in extubation time
 shorter hospital stay
High TEA attenuates neuro-hormonal response, provides :
 thoracic sympatholysis(which improves coronary and
mammary artery perfusion)
 ensures hemodynamic stability
 decreases myocardial oxygen demand
 improves myocardial blood flow
 reduces the risk of arrhythmia
 myocardial ischemia
 improves renal function
 significantly decreases heart rate.
 A wake OPCAB :
combined femoral block/TEA or spinal anesthesia/TEA or
TEA alone
 Awake cardiac surgery might have some benefits, such as:
 Short ICU stay, maintenance of spontaneous respiration
avoids the disadvantages of mechanical ventilation and
GA in high-risk patients
 Awake cardiac surgery is feasible, but should be performed
only in selected patients by highly specialized and
experienced health care.
Hemodynamic changes during
OPCAB
 Heart positioning can lead to reduced SV and BP and increases
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CVP and RVEDP
During heart tilting compression free wall RV which is thin and
easily deformable lead to abstraction of RV outflow
The atria increase their size and become larger than ventricles,
contributing to the reduction cardiac output
Distortion of mitral and tricuspid annuli leads to MR and TR
Terendelenburg position (20 head down) inotropes, adequate
fluids, pleuropericardial position, IABP, is helpful
Management ischemia
 Good collaboration between anesthesiologist and
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surgeon
Maintaining MAP>70 mmHg allows an adequate
coronary perfusion
Changes in SvO2 and PaCO2 are associated with changes
in SjO2
Maintaining value of SvO2>70% maybe important to
prevent reduction in cerebral blood flow during OPCAB
Heart rate between 70 and 80 bpm, treat tachycardia and
prophylactic administration of anti-arrhythmic agents
To maintain to myocardial perfusion the surgeon can
insert a small shunt into the coronary artery
Benefits of OPCAB Surgery
 Avoidance of CPB
 Coagulopathy
 Neurologic Deficit
 Air/Plaque Embolism
 Aortic Manipulation/Clamping
 Avoidance of Ventricular Arrest, Defibrilation, Pacing
 Difficulty of separation from CPB
 Transfusion PRBC, FFP, PLT, Cryo
 Cannulation site trauma/bleeding
 Risk of full dose Heparin and Protamine
 Risk of deep hypothermia <34
 Risk of Hemodilution and Volume Shifts
 Potentially Faster Surgery
Benefits of OPCAB Surgery
 Decreased Cost to Patient
 Decreased ICU and Hospital stay
 Decreased duration of Intubation
 Decreased requirement for Inotropic, Chronotropic,
or Vasoconstrictive support
 Potentially decreased risk of infection and improved
wound healing
 Potentially Faster recovery
Technical aspects of Off-Pump
 Surgical approaches
 Exposure of the coronary targets
-Hemodynamic consequences of cardiac elevation and
displacement
-Preserving hemodynamics during cardiac elevation
 Mechanical stabilizers
 The use of the coronary snare
- Intracoronary shunts
 Improving visualization:the co2 blower/saline aeroslizer
CABG+ETC
Sequ
SVG
Sequ
LIMA
CABG
Total
OFF
ON
27
196
223
508
496
12
91
30
190
217
467
453
14
90
34
191
216
533
515
18
89
16
150
179
577
554
23
88
25
164
194
553
539
14
87
25
626
613
13
86
15
375
358
17
85
172
3639
3528
111
Total
Mean Number Grafts: 3.76
Year
Frequency of Sequences Grafts from
1385-1391
SVG Sequences
LIMA Sequences
34%
48%
Frequency percentage of CABG from 1385-1391
OFF_PUM CABG
97.9%
95.54%
4.53%
85 ‫سال‬
97.4%
2%
86‫سال‬
96%
96.62%
3.98%
2.53%
87‫سال‬
ON_PUMP CABG
88‫سال‬
2.99%
3.37%
89‫سال‬
97.7%
97%
90‫سال‬
2.3%
91‫سال‬
Conclusion
Historically,one of the main obstacles to complete
revascularization without CPB has been represented by
the inability to adequately:
 expose the coronary targets
 minimize their motion
 preserving cardiac function
 hemodynamic stability
The introduction:
 the stabilizers of the new generation
 refinements in techniques of coronary revascularization on
the beating heart
have improved the feasibility and reliability with which distal
anastomosis to all coronary arteries can now be constructed
Thank you for your attention