CABG

Coronary artery bypass(

)graft
Definition:- it is done to allow blood to flow around
blocked blood vessels in the heart‚ coronary arteries
are the blood vessels that supply the heart muscle with
oxygen and nutrients.
 INTRODUCTION:

 Arteriosclerosis is a common arterial disorder characterized

by thickening, loss of elasticity, and calcification of arterial
walls, resulting in a decreased blood supply.
 Atherosclerosis is a common arterial disorder characterized
by yellowish plaques of cholesterol, lipids, and cellular debris
in the inner layer of the walls of large and medium-sized
arteries.
 Most common cardiac
surgery

1- CABG:- (coronary artery bypass graft)

2- DVR:- (Double valve replacement):-
A- Aorta
B- Mitral
3- Tricuspid
4- ASD:- (atrioseptum place defect)
5- VSD:- (ventricoseptum place defect)
6- PAD:- (partial artery defect)
Heart attach
Pathophysiology
 Indications for CABG

 The 2004 ACC/AHA CABG guidelines state CABG is the

preferred treatment for:
 Disease of the left main coronary artery (LMCA).
 Disease of all three coronary vessels (LAD, LCX and RCA).
 Diffuse disease not amendable to treatment with a PCI.
 Diagnosis

 How is coronary artery disease diagnosed?

 The resting electrocardiogram (EKG) is a recording of the electrical
activity of the heart, and can demonstrate signs of oxygen starvation
of the heart (ischemia) or heart attack. Often, the resting EKG is
normal in patients with coronary artery disease and angina. Exercise
treadmill tests are useful screening tests for patients with a
moderate likelihood of significant coronary artery disease (CAD) and
a normal resting EKG. These stress tests are about 60 to 70%
accurate in diagnosing significant CAD.
 If the stress tests do not reveal the diagnosis, greater accuracy can
be achieved by adding a nuclear agent (thallium or Cardiolite)
intravenously during stress tests. Addition of thallium allows nuclear
imaging of the blood flow to different regions of the heart, using an
external camera. An area of the heart with reduced blood flow
during exercise, but normal blood flow at rest, signifies significant
artery narrowing in that region.
 Diagnosis

 Cardiac catheterization with angiography (coronary

arteriography) is the most accurate test to detect coronary
artery narrowing. Small hollow plastic tubes (catheters) are
advanced under x-ray guidance to the openings of the two
main heart arteries (left and right). Iodine contrast, "dye," is
then injected into the arteries while an x-ray video is
recorded. Sometimes, an exercise study is then done to
determine whether a moderate narrowing (40 - 60%) is
actually causing ischemia and, therefore, requires treatment.
 A newer modality, high speed CT scanning angiography has
recently become available. This procedure uses powerful x-
ray methods to visualize the arteries to the heart. Its role in
the evaluation of CAD is currently being evaluated. For more,
please read the CT Scanning Angiography article
 Diagnosis

 Combining echocardiography (ultrasound imaging of the

heart muscle) with exercise stress testing (stress
echocardiography) is also a very accurate technique to detect
CAD. When a significant blockage exists, the heart muscle
supplied by this artery does not contract as well as the rest of
the heart muscle. Stress echocardiography and thallium
stress tests are both at least 80% to 85% accurate in
detecting significant coronary artery disease.
 When a patient cannot undergo exercise stress test because
of nervous system or joint problems, medications can be
injected intravenously to simulate the stress on the heart due
to exercise and imaging can be performed with a nuclear
camera or ultrasound.
Procedure
 Number of bypasses

 The terms single bypass, double bypass, triple bypass,

quadruple bypass and quintuple bypass refer to the number
of coronary arteries bypassed in the procedure.
 Procedure (Simplified)

 The patient is brought to the operating room and moved onto

the operating table.
 An anesthetist places a variety of intravenous lines and
injects an induction agent (usually protocol) to render the
person unconscious.
 An endotracheal tube is inserted and secured by the
anesthetist or anathetia nurse) and mechanical ventilation is
started.
 Procedure

 The chest is opened via a median sternotomy and the heart is

examined by the surgeon.
 The bypass grafts are harvested - frequent conduits are the
internal thoracic arteries, radial arteries and saphenous veins.
When harvesting is done, the patient is given heparin to prevent
the blood from clotting.
 In the case of "off-pump" surgery, the surgeon places devices to
stabilize the heart.
 If the case is "on-pump", the surgeon sutures cannulaa into the
heart and instructs the perfusionist to start
cardiopulmonary bypass (CPB). Once CPB is established, the
surgeon places the aortic cross-clamp across the aorta and
instructs the perfusionist to deliver cardioplegia to stop the heart.
 One end of each graft is sewn onto the coronary arteries beyond
the blockages and the other end is attached to the aorta.
 Procedure

 The heart is restarted; or in "off-pump" surgery, the

stabilizing devices are removed. In some cases, the Aorta is
partially occluded by a C shaped clamp, the heart is restarted
and suturing of the grafts to the aorta is done in this partially
occluded section of the aorta while the heart is beating.
 Protamine is given to reverse the effects of heparin.
 The sternum is wired together and the incisions are sutured
closed.
 Complication

 Nonunion of the sternum; internal thoracic artery harvesting

devascularizes the sternum increasing risk.
 Myocardial infarction due to embolism, hypo perfusion, or
graft failure.
 Late graft stenosis, particularly of saphenous vein grafts due
to atherosclerosis causing recurrent angina or
myocardial infarction.
 Acute renal failure due to embolism or hypo-perfusion.
 Stroke, secondary to embolism or hypo- perfusion.
 1- CABG associated
 Post perfusion syndrome (pumphead), a transient
neurocognitive impairment associated with
cardiopulmonary bypass. Some research shows the incidence
is initially decreased by off-pump coronary artery bypass, but
with no difference beyond three months after surgery. A
neurocognitive decline over time has been demonstrated in
people with coronary artery disease regardless of treatment
(OPCAB, conventional CABG or medical management).
 2-General surgical

 Infection at incision sites or sepsis.

 Deep vein thrombosis (DVT)
 Anesthetic complications such as malignant hyperthermia.
 Keloid scarring
 Chronic pain at incision sites
 Chronic stress related illnesses
 Death.
 Instructions

 You will be asked to fast for eight hours before the

procedure, generally after midnight.

 If you are pregnant or suspect that you are pregnant, you

should notify your physician.

 Notify your physician if you are sensitive to or are allergic to

any medications, iodine, latex, tape, or anesthetic agents
(local and general).
 Instruction:

 The person is moved to the intensive care unit (ICU) to

recover. After awakening and stabilizing in the ICU
(approximately 1 day), the person is transferred to the
cardiac surgery ward until ready to go home (approximately
4 days).
 Instructions

 If you smoke, you should stop smoking as soon as possible

prior to the procedure. This may improve your chances for a
successful recovery from surgery and benefit your overall
health status.

 Based upon your medical condition, your physician may

request other specific preparation.
 Before the Procedure

 Your physician will explain the procedure to you and offer you
the opportunity to ask any questions that you might have
about the procedure.

 You will be asked to sign a consent form that gives your

permission to do the test. Read the form carefully and ask
questions if something is not clear.

 In addition to a complete medical history, your physician may

perform a complete physical examination to ensure you are in
good health before undergoing the procedure. You may
undergo blood tests or other diagnostic tests.
 Instructions before

 Your physician may request a blood test prior to the

procedure to determine how long it takes your blood to clot.

 Notify your physician if you have a pacemaker.

 During the Procedure

 The skin over the surgical site will be cleansed with an

antiseptic solution.

 Once all the tubes and monitors are in place, an incision may
be made in one of your legs to obtain a section of vein to be
used for grafts
 Instructions

 Notify your physician of all medications

(prescription and over-the-counter) and herbal
supplements that you are taking.

 Notify your physician if you have a history of

bleeding disorders or if you are taking any
anticoagulant (blood-thinning) medications, aspirin,
or other medications that affect blood clotting. It
may be necessary for you to stop some of these
medications prior to the procedure.
 During the Procedure

 Coronary artery bypass graft surgery requires a stay in a

hospital. Procedure may vary depending on your condition
and your physician’s practices.
 Generally, a coronary artery bypass surgery follows this
process:
 You will be asked to remove any jewelry or other objects that
may interfere with the procedure
 During the Procedure

 You will be asked to remove your clothing and will be given a

gown to wear.

 You will be asked to empty your bladder prior to the

procedure.
 During the Procedure

 An intravenous (IV) line will be started in your arm or hand.

Additional catheters will be inserted in your neck and wrist to
monitor the status of your heart and blood pressure, as well
as for obtaining blood samples. Alternate sites for the
additional catheters include the subclavian (under the
collarbone) area and the groin.

 You will be positioned on the operating table, lying on your

back.
 During the Procedure

 The anesthesiologist will continuously monitor your heart

rate, blood pressure, breathing, and blood oxygen level
during the surgery. Once you are sedated, a breathing tube
will be inserted through your throat into your lungs and you
will be connected to a ventilator, which will breathe for you
during the surgery.

 A catheter will be inserted into your bladder to drain urine.

 During the Procedure

 The physician will make an incision (cut) down the center of

the chest from just below the Adam's apple to just above the
navel.

 The sternum (breastbone) will be divided in half with a

special operating instrument. The physician will separate the
two halves of the breastbone and spread them apart to
expose the heart.
 Coronary artery bypass graft surgery - on-pump
procedure:

 In order to sew the grafts onto the very small coronary

arteries, the heart must be stopped to allow the physician to
perform the very delicate procedure. Tubes will be inserted
into the heart so that the blood can be pumped through your
body by a cardiopulmonary bypass machine.

 Once the blood has been diverted into the bypass machine for
pumping, the heart will be stopped by injecting it with a cold
solution.
 Coronary artery bypass graft surgery - on-pump
procedure

 When the heart has been stopped, the physician will perform
the bypass graft procedure by sewing one end of a section of
vein over a tiny opening made in the coronary artery just
above the blockage, and the other end over a tiny opening
made in the coronary artery just below the blockage. If the
internal mammary artery inside your chest is being used as a
bypass graft, the lower end of the artery will be cut from
inside the chest and sewn over an opening made in the
coronary artery below the blockage.
 Coronary artery bypass graft surgery - on-pump
procedure

 You may have more than one bypass graft performed,

depending on how many blockages you have and where they
are located. After all the grafts have been completed, the
physician will examine them to make sure they are working.

 Once the bypass grafts have been completed, the blood

circulating through the bypass machine will be allowed back
into your heart and the tubes to the machine will be removed.
Your heart will be restarted.
 Coronary artery bypass graft surgery - on-pump
procedure

 Temporary wires for pacing may be inserted into the heart.

These wires can be attached to a pacemaker and your heart
can be paced, if needed, during the initial recovery period.
 Coronary artery bypass graft surgery - on-pump
procedure :

 Once the chest has been opened, the area around the artery
to be bypassed will be stabilized with a special type of
instrument.

 The rest of the heart will continue to function and pump

blood through the body.

 The cardiopulmonary bypass machine and the perfusionist

who runs it may be kept on stand-by should the procedure
need to be completed on bypass
 Coronary artery bypass graft surgery - on-pump
procedure

 The physician will perform the bypass graft procedure by

sewing one end of a section of vein over a tiny opening made
in the coronary artery just above the blockage, and the other
end over a tiny opening made in the coronary artery just
below the blockage.

 You may have more than one bypass graft performed,

depending on how many blockages you have and where they
are located.

 Before the chest is closed, the physician will examine the

grafts to make sure they are working.
 Procedure completion, both methods:

 The sternum will be pushed back together and sewn together

with small wires.

 The skin over the sternum will be sewn back together.

 Tubes will be inserted into your chest to drain blood and

other fluids from around the heart. These tubes will be
connected to a suction device to keep fluids pulled away from
the heart.
 Procedure completion, both
methods:

 A tube will be inserted through your mouth or nose into your

stomach to drain stomach fluids.

 A sterile bandage/dressing will be applied.

 After the Procedure
In the hospital:

 After the surgery you may be taken to the recovery room

before being taken to the intensive care unit (ICU) to be
closely monitored. Alternatively, you may be taken directly to
the ICU from the operating room. You will be connected to
monitors that will constantly display your electrocardiogram
(ECG or EKG) tracing, blood pressure, other pressure
readings, breathing rate, and your oxygen level. Coronary
artery bypass surgery requires an in-hospital stay of several
days or longer.
 After the procedure, in the hospital

 You will most likely have a tube in your throat so that

breathing can be assisted with a ventilator (breathing
machine) until you are stable enough to breathe on your own.
As you continue to wake up from the anesthesia and start to
breathe on your own, the breathing machine will be adjusted
to allow you to take over more of the breathing. When you
are awake enough to breathe completely on your own and
you are able to cough, the breathing tube will be removed.
The stomach tube will also be removed at this time.
 After the procedure, in the hospital

 After the breathing tube is out, your nurse will assist you to
cough and take deep breaths every two hours. This will be
uncomfortable due to soreness, but it is extremely important
that you do this in order to keep mucus from collecting in
your lungs and possibly causing pneumonia. Your nurse will
show you how to hug a pillow tightly against your chest while
coughing to help ease the discomfort.
 After the procedure, in the hospital

 The surgical incision may be tender or sore for several days

after a CABG procedure. Take a pain reliever for soreness as
recommended by your physician. Aspirin or certain other
pain medications may increase the chance of bleeding. Be
sure to take only recommended medications.
 You may be on special IV drips to help your blood pressure
and your heart, and to control any problems with bleeding. As
your condition stabilizes, these drips will be gradually
decreased and turned off as your condition allows.
 After the procedure, in the hospital

 Once the breathing and stomach tubes have been removed

and your condition has stabilized, you may start liquids to
drink. Your diet may be gradually advanced to more solid
foods as you are able to tolerate them.
 When your physician determines that you are ready, you will
be moved from the ICU to a post-surgical nursing unit. Your
recovery will continue to progress. Your activity will be
gradually increased as you get out of bed and walk around
for longer periods of time. Your diet will be advanced to solid
foods as you tolerate them.
 Arrangements will be made for a follow-up visit with your
physician.
 At home:

 Once you are home, it will be important to keep the surgical

area clean and dry. Your physician will give you specific
bathing instructions. The sutures or surgical staples will be
removed during a follow-up office visit, in the even they were
not removed before leaving the hospital.
 You should not drive until your physician tells you to. Other
activity restrictions may apply
 At home

 Notify your physician to report any of the following:

 fever and/or chills

 redness, swelling, or bleeding or other drainage from the

incision site

 increase in pain around the incision site

 At home

 Preoperative Information
 In the time leading up to surgery, there are a few simple steps you can
take to enhance your successful and speedy recovery. These suggestions
can help you feel better and heal faster.
 Smoking
If you smoke, quit. Smoking makes you more prone to developing
pneumonia and pulmonary complications after surgery. It also makes your
heart work harder, and accelerates the atherosclerotic process. You must
quit smoking at least 3 weeks prior to surgery.
 Medications
Consult your physician if you are unsure about the continuation of any
medications you may be taking. It is advisable to discontinue blood-
thinning medications—such as aspirin,5-7 days prior to surgery.
 If you take medications in the morning, you may do so with a minimal

amount of water the day of your surgery.

 Please bring a list of all medications you are currently taking, and the

dosage, on the day of admission.

 At home

 Aspirin
Please check with your cardiologist regarding continuing aspirin
usage prior to surgery. Aspirin should also not be used as an over-
the-counter medication in the week prior to surgery. Many over-the-
counter medicines, such as Anacin, Bufferin, NSAID'S (non-steroidal
anti-inflammatory drugs) and products containing salicylates also
contain aspirin. Tylenol® is okay.
 Diet
Do not eat or drink past midnight the night before your surgery.
 Nutrition
Nutrition is essential to good health and is especially important prior
to your hospitalization for surgery. Maintaining healthy nutritional
habits may help with a quick recovery. A balanced diet, adequate in
calories, proteins, vitamins and minerals, should be consumed. A
balanced diet is one that contains a wide variety of foods from the
Four Food Groups—grains, fruits and vegetables, dairy products,
and meat. If you have been following a therapeutic diet as part of
your medical treatment, continue to do so and inform your
physician.
 At home

 Rest
Arrive at the hospital as rested and relaxed as possible.
 Alcohol
Stop drinking alcohol–liquor, beer and wine–2 days prior to surgery.
 Fever or cold
If you develop a fever or cold, contact your physician prior to coming to the
hospital.
 Contact Person
Plan to have someone accompany you to the hospital the morning of your
surgery.

It is beneficial to designate one family member or friend to maintain

communication with your surgeon and the healthcare team. This will enhance
the flow of information and decrease the chance for miscommunication.
 Rooms
All patients are scheduled for a semi-private room. Private rooms are subject to
availability, and by request, and are not covered by insurance. For patients
seeking deluxe accommodations, the Milstein's McKeen Pavilion offers attractive,
modern rooms, a concierge and room service for patients and visitors.
 Recovering at Home

 Within 3 to 5 days, most patients are eager to leave the hospital

despite some apprehension about giving up the security of an
expert medical team. It is important to be patient with the pace
of recovery, even after discharge from the hospital.
 Remember, fatigue is normal after a major operation like heart
surgery. You shouldn't be surprised to find that one day you feel
strong, while the next day you feel tired and weak. Don't get
discouraged; your recuperation period will allow the body to
heal, replenish its blood content, and increase its strength and
endurance.
 CUMC has both in-patient and out-patient cardiac rehabilitation
programs. In addition, we can refer patients to a variety of home
health care agencies if necessary for post-discharge home care
and cardiac rehabilitation. Please speak with your physician and
social worker about these options.
 Recovery

 Temperature
 If you feel warm or chilled, take your temperature 3 times a
day (morning, afternoon and evening).
 Call your cardiologist if your temperature exceeds 101
degrees.
 Recovery

 Medications
 Take all medications prescribed by your doctor as directed.
 Do not change the dosage of your medication without your
doctor's approval.
 If you are on iron pills, please note that they may cause
constipation and black stools
 Recovery

 Remember to Move Carefully!

 Rapid change of position (sitting to standing or vice versa)
may be accompanied by dizziness if done to quickly.
 Rest whenever you get tired.
 Rest between activities. If you need to rest for more than one
hour after an activity, you may be pushing yourself too hard.
Do a little less the next day.
 Avoid placing undue strain on your chest region by sitting in
one position for long periods of time.
 When sitting or standing, use your leg muscles—do not use
your arms to lower or raise yourself from your chair.
 Do not cross your legs—it interferes with blood flow.
 Pace yourself.
Thank you