Anda di halaman 1dari 48

Dr.

Luc Tambeur
Cor onar y ar t er y
bypass gr af t i ng
CABG - OPCAB
Cor onar y ar t er y di sease
Definition:
Narrowing of the coronary arteries
Caused by thickening and loss of elasticity
of the arterial walls
Limiting blood flow to the myocardium
Flow reserve (effort)
At rest
Occlusion
Cor onar y ar t er y di sease
Morphology and processes:
Focal intimal accumulation of lipids, blood elements,
fibrous tissue, calcium etc. with associated changes
in the media
Plaque
Stenosis
Regression of plaque and collateral formation
Plaque rupture and thrombosis
Usually affects multiple coronaries simultaneously,
proximally and at bifurcations
Myoc ar di al i nf ar c t i on
Imbalance between oxygen supply and
demand
Myocardial necrosis starts after 20 minutes
Border zone
Reperfusion within 3-4 hours can limit the
extent of myocardial necrosis
Scarring. LV systolic and diastolic dysfunction.
Chronic heart failure.
Di agnosi s
Symptoms: Angina pectoris, acute
myocardial infarction, chronic heart
failure, sudden death, incidental finding
on ECG
Noninvasive tests to identify and quantify
CAD and sequelae: ECG, CXR, Labs,
Exercise testing, Nuclear scans,
Echocardiography, CT (Ca
++
)
Di agnosi s
Associated conditions
Atherosclerosis: carotids, PAD
Definitive diagnosis: extent, distribution
and severity of anatomic coronary artery
disease
Coronary angiography
New modalities: CT (MRI)
Cor onar y angi ogr aphy
Grading of stenoses:
Moderate: 50% diameter = 75% cross-
sectional area loss
Severe: 67% diameter = 90% cross-
sectional area loss
Distribution:
Single system / two system / three system
Left main
Cor onar y anat omy
I ndi c at i ons f or sur ger y
Comparative benefit of surgery relative to no
treatment / medical treatment / PCI
Enormous variability in CAD, impacting on risk
calculation patient-specific predictions
General indications:
Left main or left main equivalent
3 system disease
2 system disease with severe prox. LAD and LVEF
< 50% or ischemia on non-invasive testing
1 or 2 system disease with large area of viable
myocardium and high-risk criteria
Bypass gr af t i ng
Full sternotomy and CPB (HLM):
CABG
Full sternotomy, no CPB:
OPCAB
Small sternotomy, parasternal access,
thoracotomy, with or without CPB:
e.g. MIDCAB
Bypass gr af t i ng
CABG = Golden standard and still most
widely used (STS database 80%)
Objective: complete revascularisation by
bypassing all severe stenoses in all
affected coronary branches with 1-1.5
mm diameter
Most widely used conduits: LIMA, RIMA,
SVG, radial artery, gastro-epiploic artery
Condui t s
LI MA / RI MA
Condui t s
SVG
Condui t s
Radi al
Condui t s
Gast r o-epi pl oi c
Condui t c onf i gur at i ons
Endar t er -
ec t omy
CABG
Median sternotomy
Conduit harvesting
Heparin, cannulation and CPB with mild to moderate
hypothermia
Cross-clamping of the aorta and cardioplegia
Distal anastomoses. Rewarming started.
Cross-clamp removed. Proximal anast. using a partially
occluding clamp. Clamp removed. De-airing.
CPB discontinued, cannulae removed, protamine.
Pacing wires, drainage tubes, hemostasis and closure.
CABG
OPCAB
Attempt to maintain normothermia
Median sternotomy
Conduit harvesting
Heparin. Pacing wires.
Maneuvers to maintain hemodynamic stability
(Trendelenburg, table, R pleura,.)
Pericardial sling
Luxation. Stabilisation. Distal anastomoses with or
without shunting.
Proximal anastomoses. Protamine.
Chest drains. Hemostasis. Closure.
Not di sc ussed
IABP and other support devices
Emergency surgery
Redo surgery
Other modalities of bypass grafting:
MIDCAB, robotic surgery,
Adjunctive surgical treatment: TMLR,
growth factors, cell transplantation
Combined surgery
Resul t s
Early mortality can be predicted, using risk
stratification models (Euroscore, STS)
Time-Related Survival, generally:
1 month: 98%
1 year: 97%
5 year: 92%
10 year: 81%
15 year: 66%
NB: 25% of early and late deaths are not
related to CAD or CABG
Ti me-Rel at ed Sur vi val
Resul t s
Freedom from angina: 60% at 10 years
Freedom from AMI: 86% at 10 years
Freedom from sudden death: 97% at 10 years
80% of patients are working 1 year postop.
Graft patency:
LIMA (to LAD) 90% at 10 and 20 years.
Radial artery 80% at 7 years
Gastro-epiploic artery 60% at 10 years
SVG 50-60% at 10 years, 80% to LAD