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Coronary Artery Bypass Grafting (CABG)
Coronary artery bypass grafting (CABG—see also Coronary Artery Disease:Revascularization) involves bypassing native coronary arteries with high-grade stenosis or occlusion not amenable to angioplasty with stent insertion. Indications are changing as percutaneous interventions (see Percutaneous Coronary Interventions (PCI)) are being increasingly used.
The procedure involves thoracotomy via a midline (median) sternotomy. A heart-lung machine is used to establish cardiopulmonary bypass (CPB), allowing the heart to be stopped and emptied of blood to maximize operative exposure and facilitate vessel anastomosis; stopping the heart also markedly decreases myocardial O2 demand. Before initiation of CPB, the patient is given a very high dose of heparin to prevent clotting in the bypass circuit. Then the aorta is cross-clamped and the heart is stopped by injection of a cardioplegic solution (crystalloid or more commonly blood-based) that also contains substances that help myocardial cells tolerate ischemia and reperfusion. The cardioplegic solution and the heart are sometimes cooled slightly to enhance tolerance of ischemia; the patient’s body is cooled via the CPB machine for similar reasons.
The left internal mammary artery is typically used as a pedicled graft to the left anterior descending coronary artery. Other grafts consist of segments of saphenous vein removed from the leg. Occasionally, the right internal mammary artery or radial artery from the nondominant arm can be used.
On completion of the vascular anastomoses, the aorta is unclamped, allowing the coronary arteries to be perfused by oxygenated blood, which typically restores cardiac activity. Heparin anticoagulation is reversed by giving protamine. Despite cardioprotective measures, stopping the heart is not without consequences. During reperfusion, myocardial dysfunction is common and can lead to bradycardia, arrhythmias (eg, ventricular fibrillation), and low cardiac output; these events are treated by standard measures, such as pacing, defibrillation, and inotropic drugs.
Typically, hospital stays are 4 to 5 days unless prolonged by complications.
Newer techniques seek to limit the complications of traditional CABG by
CPB can be avoided in select patients by using new techniques that allow the surgeon to revascularize the beating heart. Various devices and methods stabilize a portion of the myocardium, holding the operative site relatively motionless. Off-pump procedures are more commonly done through small parasternal or intercostal incisions (minimally invasive CABG), sometimes with endoscopy or even robotic assistance, but they may be done through a traditional median sternotomy, which provides better operative exposure.
Allowing the heart to beat means that the myocardium requires more O2 than when CPB is used. Thus, the heart is sensitive to the interruption of blood flow necessitated while the vascular anastomosis is done; this interruption can cause ischemia or infarction in the myocardium supplied by the affected vessel. Some surgeons place a temporary coronary artery shunt to provide distal perfusion.
The minimally invasive technique is somewhat more difficult to do and may not be suitable when multiple bypass grafts, particularly those involving vessels behind the heart, are required. Transfusion requirements, length of stay, and costs are typically less with off-pump CABG, but in some studies, the rate of the more serious complications of death, MI, and stroke are similar to that of CABG using CPB. Thus, the theoretic advantages of avoiding CPB do not seem to have been fully realized.
Minimally invasive CABG is usually done off-pump but may be done using CPB. In such cases, CPB is done endovascularly using special catheters inserted into the arterial and venous systems; the aorta is occluded by a balloon at the end of the aortic catheter rather than an external clamp. Although avoiding median sternotomy complications, this technique otherwise has similar rates of mortality and major perioperative complications as conventional techniques.
Drug NameSelect Brand Names
protamineNo US brand name
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