Coronary Artery Bypass Grafting (CABG) - MSD Manuals

Traditional CABG Procedure. Traditional coronary artery bypass grafting involves thoracotomy via a midline (median) sternotomy. A heart-lung machine is used ... MSDManual Pleaseconfirmthatyouareahealthcareprofessional Yes No LeavethisSite? Thelinkyouhaveselectedwilltakeyoutoathird-partywebsite.Wedonotcontrolorhaveresponsibilityforthecontentofanythird-partysite. 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Testyourknowledge CardiacCatherization Cardiaccatheterizationoftheleftortherightheartcanbeusedtodovarioustests,anditalsocanbeusedtodetermineappropriatetherapeuticinterventions.Rightheartcatheterizationismostcommonlyusedtoassesswhichofthefollowing?   Aorticbloodpressure  Coronaryarterydisease  Mitralvalvefunction  Pulmonaryarterypressure   MoreContent Videos 3DModels News SOCIALMEDIA CoronaryArteryBypassGrafting(CABG) By ThomasCascino ,MD,MSc,MichiganMedicine,UniversityofMichigan; MichaelJ.Shea ,MD,MichiganMedicineattheUniversityofMichigan Lastfullreview/revisionJul2021 ClickhereforPatientEducation TopicResources 3DModels(0) Audios(0) Calculators(1) Images(1) LabTest(0) Tables(0) Videos(0) EuroSCOREforCardiacSurgeryRiskAssessment(additiveversion) ChestX-RayofaPatientAfterCoronaryArteryBypassSurgery Coronaryarterybypassgrafting(CABG)involvesbypassingnativecoronaryarteriesthathavehigh-gradestenosisorocclusionnotamenabletoangioplastywithstentinsertion.IndicationsarechangingaspercutaneousinterventionsPercutaneousCoronaryInterventions(PCI)Percutaneouscoronaryinterventions(PCI)includepercutaneoustransluminalcoronaryangioplasty(PTCA)withorwithoutstentinsertion.PrimaryindicationsaretreatmentofAnginapectoris...readmorearebeingincreasinglyused.TraditionalCABGProcedureTraditionalcoronaryarterybypassgraftinginvolvesthoracotomyviaamidline(median)sternotomy.Aheart-lungmachineisusedtoestablishcardiopulmonarybypass(CPB),allowingthehearttobestoppedandemptiedofbloodtomaximizeoperativeexposureandfacilitatevesselanastomosis;stoppingtheheartalsomarkedlydecreasesmyocardialoxygendemand.BeforeinitiationofCPB,thepatientisgivenaveryhighdoseofheparintopreventclottinginthebypasscircuit.Thentheaortaiscross-clampedandtheheartisstoppedbyinjectionofacardioplegicsolution(crystalloidormorecommonlyblood-based)thatalsocontainssubstancesthathelpmyocardialcellstolerateischemiaandreperfusion.Thecardioplegicsolutionandtheheartaresometimescooledslightlytoenhancetoleranceofischemia;thepatient’sbodyiscooledviatheCPBmachineforsimilarreasons.Theleftinternalmammaryarteryistypicallyusedasapedicledgrafttotheleftanteriordescendingcoronaryartery.Othergraftsconsistofsegmentsofsaphenousveinremovedfromtheleg.Occasionally,therightinternalmammaryarteryorradialarteryfromthenondominantarmcanbeused.Oncompletionofthevascularanastomoses,theaortaisunclamped,allowingthecoronaryarteriestobeperfusedbyoxygenatedblood,whichtypicallyrestorescardiacactivity.Heparinanticoagulationisreversedbygivingprotamine.Despitecardioprotectivemeasures,stoppingtheheartisnotwithoutconsequences.Duringreperfusion,myocardialdysfunctioniscommonandcanleadtobradycardia,arrhythmias(eg,ventricularfibrillation),andlowcardiacoutput;theseeventsaretreatedbystandardmeasures,suchaspacing,defibrillation,andinotropicdrugs.Typically,hospitalstaysare4to5daysunlessprolongedbycomplicationsorconcomitantillnesses.ComplicationsofcoronaryarterybypassgraftingComplicationsanddisadvantagesoftraditionalCABGinvolvemainlySternotomyCardiopulmonarybypassMediansternotomyissurprisinglywelltolerated;however,healingtakes4to6weeks.Also,woundinfectionsoccasionallycausemediastinitisorsternalosteomyelitis,whichcanbevexingtotreat.CPBcausesseveralmajorcomplications,includingBleedingOrgandysfunction,includingneuropsychiatriceffectsStrokePost-CPBbleedingisacommonproblemcausedbyvariousfactors,includinghemodilution,heparinuse,plateletdysfunctionduetoexposuretothebypasspump,disseminatedintravascularcoagulation,andinducedhypothermia.OrgandysfunctionmayresultfromasystemicinflammatoryresponsecausedbytheCPBmachine(probablyduetoexposureofbloodcomponentstotheforeignmaterialofthebypasscircuit);thisresponsecancauseorgandysfunctioninanysystem(eg,pulmonary,renal,brain,gastrointestinal).Aorticcannulation,cross-clamping,andreleasecantriggerreleaseofemboli,causingstrokeinabout1.5%;microembolimaycontributetopost-CPBneuropsychiatriceffects,whichappearinabout5to10%.OthercommoncomplicationsofCABGincludeDysrhythmiasFocalmyocardialischemiaGlobalmyocardialischemiaPerioperativemyocardialinfarctionoccursinabout1%ofpatients.Atrialfibrillationoccursin15to40%ofpatients,typically2to4daysaftersurgery.Beta-blockers(includingsotalol)andamiodaroneappeartoreducethelikelihoodofthedevelopmentofatrialarrhythmiasaftercardiacsurgery.Nonsustainedventriculartachycardiamayoccurinupto50%ofpatients.Mortalitydependsmainlyonpatients’underlyinghealth;operatorandinstitutionalexperience(ie,numberofannualprocedures)alsoisimportant.Inanexperiencedprogram,periproceduralmortalityinotherwisehealthypatientsistypically<1to3%.AsimplecalculatorcancategorizeriskofCABGintothreegroups(low,intermediate,high).AmoreadvancedonlinecardiacsurgeryriskcalculatorispublishedbytheSocietyofThoracicSurgeons.AlternativeCABGProceduresNewertechniquesseektolimitthecomplicationsoftraditionalcoronaryarterybypassgraftingbyAvoidingcardiopulmonarybypass(off-pumpCABG)Avoidingmediansternotomy(minimallyinvasiveCABG)BothOff-pumpCABGCardiopulmonarybypasscanbeavoidedinselectpatientsbyusingtechniquesthatallowthesurgeontorevascularizethebeatingheart.Variousdevicesandmethodsstabilizeaportionofthemyocardium,holdingtheoperativesiterelativelymotionless.Off-pumpCABGproceduresaremorecommonlydonethroughsmallparasternalorintercostalincisions(minimallyinvasiveCABG),sometimeswithendoscopyorevenroboticassistance,buttheymaybedonethroughatraditionalmediansternotomy,whichprovidesbetteroperativeexposure.AllowingthehearttobeatmeansthatthemyocardiumrequiresmoreoxygenthanwhenCPBisused.Thus,theheartissensitivetotheinterruptionofbloodflownecessitatedwhilethevascularanastomosisisdone;thisinterruptioncancauseischemiaorinfarctioninthemyocardiumsuppliedbytheaffectedvessel.Somesurgeonsplaceatemporarycoronaryarteryshunttoprovidedistalperfusion.Off-pumpCABGistechnicallymorechallengingbutmaybeappropriateinpatientswhohavesignificantaorticcalcificationsthatcausesmanipulationoftheaortatobeofhigherrisk.Comparedtoon-pumpprocedures,off-pumpCABGisassociatedwithincreasedneedforrevascularizationatoneyear.MinimallyinvasiveCABGTheminimallyinvasiveCABGtechniqueissomewhatmoredifficulttodoandmaynotbesuitablewhenmultiplebypassgrafts,particularlythoseinvolvingvesselsbehindtheheart,arerequired.Transfusionrequirements,lengthofstay,andcostsaretypicallylesswithoff-pumpCABG,butinsomestudies,therateofthemoreseriouscomplicationsofdeath,myocardialinfarction,andstrokearesimilartothatofCABGusingCPB.Thus,thetheoreticadvantagesofavoidingCPBdonotseemtohavebeenfullyrealized.MinimallyinvasiveCABGisusuallydoneoff-pumpbutmaybedoneusingCPB.Insuchcases,CPBisdoneendovascularlyusingspecialcathetersinsertedintothearterialandvenoussystems;theaortaisoccludedbyaballoonattheendoftheaorticcatheterratherthananexternalclamp.Althoughavoidingmediansternotomycomplications,thistechniqueotherwisehassimilarratesofmortalityandmajorperioperativecomplicationsasconventionaltechniques. ClickhereforPatientEducation NOTE: ThisistheProfessionalVersion. CONSUMERS: ClickherefortheConsumerVersion ©2022Merck&Co.,Inc.,Rahway,NJ,USAanditsaffiliates.Allrightsreserved. CardiacImagingTests WasThisPageHelpful? Yes No Echocardiography Professionalsalsoread OverviewofCoronaryArteryDisease OverviewofAcuteCoronarySyndromes(ACS) RevascularizationforAcuteCoronarySyndromes MSDandtheMSDManuals Merck&Co.,Inc.,Rahway,NJ,USA (knownasMSDoutsideoftheUSandCanada)isaglobalhealthcareleaderworkingtohelptheworldbewell.Fromdevelopingnewtherapiesthattreatandpreventdiseasetohelpingpeopleinneed,wearecommittedtoimprovinghealthandwell-beingaroundtheworld. TheManualwasfirstpublishedin1899asaservicetothecommunity.ThelegacyofthisgreatresourcecontinuesastheMSDManualoutsideoftheUnitedStatesandCanada. LearnmoreaboutourcommitmenttoGlobalMedicalKnowledge. 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