CABG_Dr. Luc Tambeur

8/11/2019 CABG_Dr. Luc Tambeur

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Dr. Luc Tambeur

Coronary artery

bypass graftingCABG - OPCAB


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Coronary artery disease

Definition:

Narrowing of the coronary arteries

Caused by thickening and loss of elasticityof the arterial walls

Limiting blood flow to the myocardium

Flow reserve (effort)At rest

Occlusion


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Coronary artery disease

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


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Myocardial infarction

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.


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Diagnosis

Symptoms: Angina pectoris, acute

myocardial infarction, chronic heart

failure, sudden death, incidental findingon ECG

Noninvasive tests to identify and quantify

CAD and sequelae: ECG, CXR, Labs,Exercise testing, Nuclear scans,

Echocardiography, CT (Ca++)


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Diagnosis

Associated conditions

Atherosclerosis: carotids, PAD

Definitive diagnosis: extent, distributionand severity of anatomic coronary artery

disease Coronary angiography

New modalities: CT (MRI)


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Coronary angiography

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


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Coronary anatomy


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Indications for surgery

Comparative benefit of surgery relative to notreatment / 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 viablemyocardium and high-risk criteria


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Bypass grafting

Full sternotomy and CPB (HLM):

CABG

Full sternotomy, no CPB:

OPCAB

Small sternotomy, parasternal access,thoracotomy, with or without CPB:

e.g. MIDCAB


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Bypass grafting

CABG = Golden standard and still most

widely used (STS database 80%)

Objective: complete revascularisation bybypassing 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


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Conduits

LIMA / RIMA


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Conduits

SVG


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Conduits

Radial


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Conduits

Gastro-epiploic


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Conduit configurations


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Endarter-

ectomy


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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.


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CABG


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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.


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Not discussed

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


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Results

Early mortality can be predicted, using riskstratification 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 notrelated to CAD or CABG


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Time-Related Survival


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Results

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

CABG_Dr. Luc Tambeur

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