Transcript Coronary Artery Bypass Grafting (CABG)

Coronary Artery Bypass
Grafting
(CABG)
Brock Solomon PA-S
November 25, 2008
The Patient
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70 year old gentleman
LORCATES?
PMH: CVA this past July and received
thrombolytic therapy… recovered fully
– hyperlipidemia
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Past Surgical History: Right knee Replacement
Family History: None
Social History: Married, works at a Landscaping
business, lives in Chambersburg, 60 pack year
history, doesn’t drink alcohol, drink caffeine, and
no recreational drug use
The Patient
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Medications
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Metoprolol 50 mg
Lovastatin 40 mg
Omeprazole 20 mg
Plavix 75 mg
ASA 325 mg
Plavix and ASA were D/C 3 days
prior to surgery
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Allergies
– Percocet
– Darvocet
The Patient
Found through Holter monitor that the
patient had episodes of VT and A-Fib.
 Exercise stress test c/ perfusion study…
poor exercise tolerance of 4 minutes and
perfusion study showed inferior ischemia
and reduced ejection fraction of 45%
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The Patient
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Catheterization:
– 2 vessel disease
– LAD 90%
– Mid- Right Coronary Artery 80%
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Medical versus Surgical
The Plan
Undergo CABG… Harvest Conduits
 LAD by the Left Internal Mammary Artery
(best)
 The Great Saphenous vein will be used to
bypass the right coronary artery
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Benefits
Improving blood flow to hypoperfused but
viable myocardium
 Lessen chances from sudden cardiac
death
 LV ejection fraction improvement 8-10%
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Risks
Advanced Age
 Low pre-op red blood cell volume
 Pre-op anti-platelet/anti-thrombitic drugs
 Co-morbidities:
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– Renal Failure
– Lung Disease (COPD)
– DM/HTN/hyperlipidemia
– CHF
Pre-Op
TEE to rule out cardiac enlargement,
calcified LAD
 Antibiotics given 30 minutes before
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– Cefuroxime 1.5 g IV
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Foley Catheter
Procedure
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General Anesthesia
Sternotomy
Harvesting Conduits
Systemic Heparin
Pericardium opened
Cardiopulmonary Bypass in place and
systemically cooled
Saphenous Vein anastomosed to first obtuse
marginal branch of Right Coronary Artery
Procedure
Saphenous vein anastomsed Diagonal
Branch of Right Coronary Artery
 LIMA anastomsed to LAD
 Weaned off Cardiopulmonary machine
 Protamine
 Mediastinal Blake Drains placed
 Sternum closed by wires, incision closed
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Summary
Amount of time spent on cardiopulmonary
machine was 80 minutes
 Heart returned to NSR
 Patient was discharged 3 days after the
procedure being asymptomatic and no
post-op complications… besides being
anxious to go HOME!
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ANY QUESTIONS?
References
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Bainbridge, Daniel MD (2008). Hybrid Coronary Artery
Bypass Grafting. Anesthesiology Clinics 26(3). Saunders
Elsevier.
Beauchamp, R Daniel MD, Evens, B. Mark, Mattlax,
Kenneth MD. Townsend, Courtney MD (2008).
Townsend: Sabiston Textbook of Surgery 18th Edition.
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Saunders Elsevier
Bonow, Robert MD, Libby, Peter MD (2008). Braunwald’s
Heart Disease: A textbook of Cardiovascular Medicine.
Saunders Elsevier
Miller, Ronald MD (2005). Coronary Artery Bypass
Grafting. Miller’s Anesthia, 6th edition. Churchill
Livingstone, Elsevier.