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Coronary Artery Bypass Grafting (CABG) Brock Solomon PA-S November 25, 2008 The Patient 70 year old gentleman LORCATES? PMH: CVA this past July and received thrombolytic therapy… recovered fully – hyperlipidemia Past Surgical History: Right knee Replacement Family History: None Social History: Married, works at a Landscaping business, lives in Chambersburg, 60 pack year history, doesn’t drink alcohol, drink caffeine, and no recreational drug use The Patient Medications – – – – – Metoprolol 50 mg Lovastatin 40 mg Omeprazole 20 mg Plavix 75 mg ASA 325 mg Plavix and ASA were D/C 3 days prior to surgery Allergies – Percocet – Darvocet The Patient Found through Holter monitor that the patient had episodes of VT and A-Fib. Exercise stress test c/ perfusion study… poor exercise tolerance of 4 minutes and perfusion study showed inferior ischemia and reduced ejection fraction of 45% The Patient Catheterization: – 2 vessel disease – LAD 90% – Mid- Right Coronary Artery 80% Medical versus Surgical The Plan Undergo CABG… Harvest Conduits LAD by the Left Internal Mammary Artery (best) The Great Saphenous vein will be used to bypass the right coronary artery Benefits Improving blood flow to hypoperfused but viable myocardium Lessen chances from sudden cardiac death LV ejection fraction improvement 8-10% Risks Advanced Age Low pre-op red blood cell volume Pre-op anti-platelet/anti-thrombitic drugs Co-morbidities: – Renal Failure – Lung Disease (COPD) – DM/HTN/hyperlipidemia – CHF Pre-Op TEE to rule out cardiac enlargement, calcified LAD Antibiotics given 30 minutes before – Cefuroxime 1.5 g IV Foley Catheter Procedure General Anesthesia Sternotomy Harvesting Conduits Systemic Heparin Pericardium opened Cardiopulmonary Bypass in place and systemically cooled Saphenous Vein anastomosed to first obtuse marginal branch of Right Coronary Artery Procedure Saphenous vein anastomsed Diagonal Branch of Right Coronary Artery LIMA anastomsed to LAD Weaned off Cardiopulmonary machine Protamine Mediastinal Blake Drains placed Sternum closed by wires, incision closed Summary Amount of time spent on cardiopulmonary machine was 80 minutes Heart returned to NSR Patient was discharged 3 days after the procedure being asymptomatic and no post-op complications… besides being anxious to go HOME! ANY QUESTIONS? References Bainbridge, Daniel MD (2008). Hybrid Coronary Artery Bypass Grafting. Anesthesiology Clinics 26(3). Saunders Elsevier. Beauchamp, R Daniel MD, Evens, B. Mark, Mattlax, Kenneth MD. Townsend, Courtney MD (2008). Townsend: Sabiston Textbook of Surgery 18th Edition. Saunders Elsevier Bonow, Robert MD, Libby, Peter MD (2008). Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine. Saunders Elsevier Miller, Ronald MD (2005). Coronary Artery Bypass Grafting. Miller’s Anesthia, 6th edition. Churchill Livingstone, Elsevier.