TIME SPECIFIC CONTENT TEACHING AV AIDS EVALUATION

OBJECTIVES AND
LEARNING
ACTIVITY
2 min Introduce the I. INTRODUCTION
topic Coronary artery bypass surgery, also known
as coronary artery bypass graft (CABG,
pronounced "cabbage") surgery, and
colloquially heart bypass or bypass surgery, is a
surgical procedure to restore normal blood
flow to an obstructed coronary artery. A normal
coronary artery transports blood to and from
the heart muscle itself, not through the
main circulatory system. There are two main
approaches. In one, the left internal thoracic
artery, LITA (also called left internal mammary
artery, LIMA) is diverted to the left anterior
descending branch of the left coronary artery. In
this method, the artery is "pedicled" which
means it is not detached from the origin. In the
other, a great saphenous vein is removed from a
leg; one end is attached to the aorta or one of its
major branches, and the other end is attached to
the obstructed artery immediately after the
obstruction to restore blood flow. CABG is
performed to relieve angina unsatisfactorily
controlled by maximum tolerated anti-ischemic
 medication, prevent or relieve left ventricular
dysfunction, and/or reduce the risk of death.
CABG does not prevent myocardial
infarction (heart attack). This surgery is usually
performed with the heart stopped, necessitating
the usage of cardiopulmonary bypass. However,
two alternative techniques are also available,
allowing CABG to be performed on a beating
heart either without using the cardiopulmonary
bypass, a procedure referred to as "off-pump"
surgery, or performing beating surgery using
partial assistance of the cardiopulmonary
bypass, a procedure referred to as "on-pump
beating" surgery. The latter procedure offers the
advantages of the on-pump stopped and off-
pump while minimizing their respective side-
3mt Define Coronary effects.
Artery Bypass II. DEFINITION OF CORONARY ARTERY Teacher defines OHP What is CABG
Graft BYPASS GRAFT Coronary Artery
Bypass Graft
Coronary Artery Bypass Graft surgery is a
surgical procedure consists of the construction
of new conduits (vessels to transport blood)
between the aorta, or other major arteries, and
the myocardium distal to the obstructed
coronary artery(or arteries).
: P Hariprasath
 Coronary artery bypass surgery, also known
List down the as coronary artery bypass graft surgery is a
5mt purposes of surgical procedure to restore normal blood
CABG flow to an obstructed coronary artery. Teacher list
downs the
III. PURPOSES OF CABG purposes of What are the
CABG and Chart purposes of
1. Restore blood flow to the heart. students note CABG
2. Relieves chest pain and ischemia. down the points.
3. Improves the patient’s quality of life.
4. Enable the patient to resume a normal life
style.
5. Lower the risk of a heart attack.

IV. INDICATIONS OF CABG

Indications for Coronary Artery Bypass
5mt Enumerate the Grafting (CABG) depend on various factors, Teacher What are the
indications of mainly on the individual's symptoms and enumerates the Chart indications of
CABG severity of disease. Some of these include, indications of CABG
1. Left main artery disease or CABG
equivalent: The left coronary
artery ( LCA) is an artery that
arises from the aorta above the left
cusp of the aortic valve and feeds
blood to the left side of the heart. It
is also known as the left main
 coronary artery ( LMCA) and
the left main stem coronary artery
( LMS).
2. Triple vessel disease: Triple vessel
disease refers to the presence of
narrowing or blockages in all three
of the major coronary arteries that
supply blood to the heart.
3. Abnormal Left Ventricular
function: Left ventricular diastolic
function plays an important role in
determining left ventricular filling
and stroke volume.
4. Failed PTCA: Percutaneous
transluminal coronary angioplasty
(PTCA) is a minimally invasive
procedure to open up blocked
coronary arteries, allowing blood
to circulate unobstructed to the
heart muscle. If a treatable
blockage is noted, the first catheter
is exchanged for a guiding
catheter. Once the guiding catheter
is in place, a guide wire is
advanced across the blockage, then
a balloon catheter is advanced to
the blockage site. The balloon is
 inflated for a few seconds to
compress the blockage against the
artery wall. Then the balloon is
deflated.
5. Immediately after Myocardial
3mt List down the Infarction (to help perfusion of the Teacher list What are the
contraindications viable myocardium). downs the Blackboard contraindication
of CABG 6. Life threatening arrhythmias contraindications s of CABG
caused by a previous myocardial of CABG.
infarction.
7. Occlusion of grafts from previous
CABGs.

V. CONTRAINDICATIONS OF CABG

1. Aneurysms
An aneurysm is an outward bulging, likened to
a bubble or balloon, caused by a localized,
abnormal, weak spot on a blood vessel wall.
Aneurysms are a result of a weakened blood
vessel wall, and may be a result of a hereditary
condition or an acquired disease.
2. Valvular disease
Valvular disease is any cardiovascular
disease process involving one or more of the
four valves of the heart (the aortic and bicuspid
valves on the left side of heart and
the pulmonary and tricuspid valves on the right
side of heart). These conditions occur largely as
a consequence of aging, but may also be the
result of congenital (inborn) abnormalities or
specific disease or physiologic processes
including rheumatic heart disease and
pregnancy.
3. Congenital disease
Congenital heart disease (CHD) is a problem
with the heart's structure and function that is
present at birth.

4. Unhealthy condition of sick person

Heavy state of the sick person, old age, when

the forecast is unfavorable to the surgery
because of the risk of aggravation of the
situation and the possibility of death.

5. Incurable disease history

Critical evaluation obtained neoplasm

oncological nature, abnormal growth of lung,
liver and kidney failure, uncontrolled
hypertension.
 6. Recent stroke

Recent stroke, which can cause a relapse

during the operation.

VI. PREOPERATIVE MANAGEMENT

Describe the
3mt preoperative Before coronary artery bypass
management of grafting ( CABG), the patient’s medical history Teacher What are the
CABG should be carefully examined for factors that describes the PPT preoperative
might predispose to complications. Such factors preoperative management of
include the following: management of CABG
 Previous cardiac surgery or chest CABG and
radiation students note
 Conditions predisposing to bleeding down the points.
 Renal dysfunction
 Cerebrovascular disease including carotid
bruits and transient ischemic attack (TIA)
 Electrolyte disturbances that might
predispose the patient to dysrhythmias
 Infection including urinary tract infection
and dental abscesses
 Respiratory function including the
presence of chronic obstructive
pulmonary disease or infection.
Routine Preoperative Investigations
 Complete blood count
 Clotting time, bleeding time
 Creatinine and electrolytes
 Liver Function Tests
 Screening for methicillin-resistant
Staphylococcus aureus
 Chest radiography
 Electrocardiography (ECG)
 Echocardiography or ventriculography (
to assess left ventricular function)
 Coronary angiography (to define the
extent and location of coronary artery
disease).

Patient preparation

Premedication

The aims of premedication are to minimize

myocardial oxygen demands by reducing heart
rate and systemic arterial pressure and to
improve myocardial blood flow with
vasodilators. Before the advent of CABG, the
majority of CAD patients were receiving beta-
adrenoceptor blocking drugs and calcium
channel antagonists or nitrates. These drugs
should be continued until the point of surgery
because sudden withdrawal of the medications
may cause tachycardia, rebound hypertension,
and a loss of coronary vasodilatation.
Administration of temazepam
immediately before CABG can decrease the risk
of tachycardia and hypertension resulting from
anxiety regarding the operation. In the operating
room, intravenous (IV) administration of a
small dose of midazolam before arterial line
insertion can also reduce anxiety, tachycardia,
and hypertension.
In patients referred for CABG, aspirin should be
continued up to the time of surgery, especially
in those who present with an acute coronary
syndrome. In patients receiving a thienopyridine
(e.g. clopidogrel or prasugrel) in whom elective
CABG is planned, the drug should be with-held
for either 5 days (for clopidogrel) or 7 days (for
prasugrel) before the procedure.

Anesthesia

After standard monitoring equipment is

attached and peripheral venous access achieved
but before the arterial line is inserted, the
midazolam dose is administered. Before
placement of the arterial line, it should be
ensured that a radial artery graft will not be
used for CABG.
Cardiac surgery makes use of the
following 2 forms of neuroaxial blockade:
 Intrathecal opioid infusion
 Thoracic epidural anesthesia (generally a
low-dose local anesthetic/opioid
infusion].
During induction and tracheal intubation, it is
important to maintain a steady heart rate and
blood pressure. To this end, patients should be
preoxygenated. Induction of anesthesia is
accomplished by using high doses of opioid
(usually fentanyl or remifentanil) to minimize
the dose of propofol, etomidate,or thiopental
and there by maximize cardiovascular stability.
Although etomidate usually does not cause
changes in blood pressure, it may cause
hypotension in cardiac patients.
A number of agents may be used for
muscle relaxation. However, they each have
their own associated complications, as follows:

 Pancuronium increases myocardial

oxygen demand
  Vecuronium may cause bradycardia in
association with opioids
 Rocuronium can cause tachycardia
 Atracurium ( which is not considered
suitable for operations of long duration)
can cause hypotension secondary to
histamine release.
Trachea should be intubated orally because
nasal intubation may cause significant bleeding
once heparin is administered. A double-lumen
endotracheal tube is required if CABG is being
performed via a left thoracotomy. Central
venous access should be obtained. It is not
uncommon for the patient to become
hypotensive. To ensure that there is sufficient
diastolic pressure to maintain coronary
perfusion, hypotension should be treated with
IV fluids or with an alpha agonist if LV
function is depressed.
Typically, maintenance of anesthesia is
accomplished with an opioid infusion (fentanyl,
alfentanil, sufentanil, or remifentanil, combined
with either a propofol infusion ( total IV
anesthesia) or a volatile agent. Volatile agents
are generally carried in an air-oxygen mixture
because the use of nitrous oxide as a carrier is
controversial. Isoflurane may have a myocardial
protective effect and therefore is especially
useful in off-pump surgery.

Positioning

For a standard sternotomy, the anterior thorax is

exposed with the patient in a supine position. A
roll is placed in the interscapular region to
improve access to the sternum by extending the
neck and elevating the sterna notch.

Monitoring

In addition to the standard anesthetic

monitoring (electrocardiography, pulse
oximetry, nasopharyngeal temperature, urine
output, and gas analysis), there are a number of
specific monitoring requirements for cardiac
surgery, including the following:
 Arterial blood pressure monitoring
 Central venous pressure monitoring
 Transesophageal echocardiography
(TEE)
 Neurologic monitoring
 VII. Harvesting of Conduit

Saphenous Vein
5mt Enumerate the
procedure of The great (long) saphenous vein ( GSV) is
CABG located 2 cm anterior to the medial malleolus, Teacher PPT What is the
traverses the tibia, and ascends posteriorly up enumerates the procedure of
the tibial border before emptying into the procedure of CABG
femoral vein. It receives numerous tributaries, CABG and
notably at the knee, and contains 10 to 20 students listens
valves. Key associated structures are the carefully.
saphenous branch of the genicular artery. The
small (short) saphenous vein (SSV) is located
1cm posterior to the lateral malleolus, runs
centrally up the posterior calf, and drains into
the popliteal vein.
As CABG conduits, the saphenous veins have
an 80 to 90 percent early patency rate, which
decreases to 50% at 10 years. The saphenous
vein is generally acceptable as a conduit in the
absence of other vascular pathologies in the leg
(varicosities in the vein, venous insufficiency,
previous deep vein thrombosis (DVT) or small
lumen diameter or overlying infection.
The GSV can be procured either via
an open harvest technique, starting from either
the ankle or groin and using a vein stripper or
via an endoscopic technique. Likewise, the SSV
vein can be harvested either with an open
procedure or endoscopically.
The legs and groin should be shaved,
prepared, and draped in the operating room.
Care should be taken to avoid getting skin
preparation solution on the diathermy plate; this
can result in diathermy burns. Once the
anesthetist is ready for surgery to start and the
surgeon has confirmed the number of lengths
(25 cm) of vein required, the vein harvest can
begin.

Internal mammary artery

The LIMA (left internal mammary artery) and

the RIMA( right internal mammary artery) arise
from their respective subclavian arteries. The
internal mammary artery can be harvested either
by itself or as a pedicle.
LIMA is most commonly harvested
as a pedicle, the RIMA is generally skeletonized
because an RIMA pedicle may interfere with
sternal wound healing. The LIMA is useful in
left anterior descending artery anastomosis and
has a good patency rate in this seting. The
RIMA has a good patency rate when
anastomosed to the LAD but a reduced rate
when grafted to the circumflex or the right
coronary artery.

Coronary artery bypass

The usual incision for CABG is a midline

sternotomy although an anterior thoracotomy
for bypass of the LAD or lateral thoracotomy
for marginal vessels may be used when an off-
pump procedures is being performed.

Cardiopulmonary bypass

The first step in cardiopulmonary bypass is to

cannulate the aorta and right atrium. The aortic
area selected for cannulation must be soft and
non-atherosclerotic. To insert the aortic
cannula, unfractionated heparin is given and the
systolic blood pressure is lowered to less than
100mmHg. An aortotomy is performed with a
scalpel, the cannula is placed, and the purse-
string sutures are tightened around it.
The aortic cannula is then secured to a
rubber tourniquet with a heavy silk tie. Once in
place, the cannula is deaired and connected to
the arterial pump tubing, where its position in
the aorta can be confirmed by watching the
pattern of tube filling. The venous cannula is
inserted into the right atrial appendage in a
similar fashion, with the end of the cannula
positioned in the inferior venacava. Adequate
anticoagulation is confirmed by assessing the
activated clotting time; once this is done,
cardiopulmonary bypass can be commenced.
The aorta is cross-clamped distal to the cannula,
and cold cardioplegia solution is infused via the
aortic cannula. Retrograde cardioplegia may
also be administered via the coronary sinus,
especially in the patient who is undergoing
repeat CABGs and has few or no patent grafts
for adequate perfusion with antegrade
cardioplegia. Compared with crystalloid
cardioplegia, blood cardioplegia is associated
with a lower incidence of intraoperative
mortality, postoperative myocardial infarction,
shock and conduction defects.

Placement of Grafts

After the initiation of cardiopulmonary bypass,

the distal coronary bypass targets are identified.
As a rule, anastomosis to the right coronary
artery and the marginal branches of the
circumflex are completed first.
The circumflex is assessed by
retracting the heart cephalically. The LIMA is
usually anastomosed to the LAD. The
saphenous vein can be grafted to all coronary
arteries except LAD. In rare circumstances (eg.
CABG performed for acute anterior myocardial
infarction), a saphenous vein graft may be
placed to the LAD artery for expediency.
To accomplish the bypass, an
incision is made in the distal coronary artery
and the conduit ostium is sutured around the full
circumference of the anastomosis. The conduit
is then infused with cold cardioplegia solution
and the end is tied with a polypropylene suture.

Techniques of Anastomosis

1. Distal anastomosis technique

It is anastomosis of vein or artery graft to the
diseases coronary artery.
2. Proximal anastomosis technique
It is anastomosis of vein or artery graft to the
aorta.
WEANING FROM CARDIOPULMONARY
BYPASS

The patient is fully rewarmed, mechanical

ventilation is initiated with the resumption of a
normal sinus rhythm. If bradycardia or
temporary heart block develops, then pacing
wires are placed in the right atrium and right
ventricular outflow tract for temporary pacing.
In addition, electrolyte abnormalities such as
hypomagnesemia and hypokalemia are treated.
The transesophageal echo can be of great help
in identifying regional or global myocardial
dysfunction as the perfusionist leaves blood in
heart to allow ejection. By using the
transesophageal echo, the patient is then
weaned from cardiopulmonary bypass as a
greater percentage of the overall hemodynamic
support is provided by the native ventricular
function. Gradual reduction of venous return
and incremental volume loading of the heart
assist in this process until cardiopulmonary
bypass is discontinued. After successful
cessation of cardiopulmonary bypass,
anticoagulation is reversed by administration of
protamine.
 VIII. COMPLICATIONS OF CABG

EARLY COMPLICATION Teacher

specifies the Chart What are the
Specify the  Cardiovascular dysfunction or low output complications of complications
5mt complications of syndrome can occur as a result of CABG and of CABG
CABG decreased preload, increased afterload, students note
arrhythmias, cardiac tamponade or down the points.
myocardial depression with or without
myocardial necrosis.
 Postoperative bleeding can occur
secondary to coagulopathy, uncontrolled
hypertension or inadequate hemostasis.
 Cardiac tamponade results from bleeding
into the pericardial sac or accumulation
of fluids in the sac, which compresses the
heart and prevents adequate filling of the
ventricles. Cardiac tamponade should be
suspected when there is low CO
postoperatively.
 Myocardial depression (impaired
myocardial contractility), which can be
reversible, occurs secondary as a result of
myocardial necrosis in 15% of all CABG
surgeries.
 Perioperative MI continues to be a
serious problem that can occur in 5% of
 patients with stable angina and up to 10%
of patients with UA postoperatively as a
result of the surgical procedure.
 Cardiac dysrhythmias commonly occur
after heart surgery. Ischemia, hypoxia,
electrolyte imbalances, alterations in
autonomic nervous system, hypertension,
increased catecholamine levels, among
others, may attribute to dysrhythmia
development.
Atrial arrhythmias may occur any time
during the first 2-3 weeks
postoperatively, but peak incidence is 3-5
days.
PVCs occur in 8.9 to 24 of patients, most
frequently after CABG.
 Hypotension may be caused by
inadequate cardiac contractility and
reduction in blood volume or by
mechanical ventilation all of which can
produce a reduction in CO.
 Pulmonary complications occurs as a
result of intubation and cardiopulmonary
bypass.
Continuous pulse oximetry, arterial blood
gas studies, and chest X-ray are done
frequently in order to monitor pulmonary
 function of a patient after heart surgery.
Noncardiac pulmonary edema can occur
immediately after surgery and can occur
the first several days after surgery as a
result of increased pulmonary capillary
permeability.
Pneumothorax can occur anytime
postoperatively, especially when chest
tubes are removed.
Phrenic nerve damage can occur,
resulting in diaphragmatic paralysis.
Pulmonary emboli, although uncommon,
can result from atrial fibrillation, heart
failure, obesity, hypercoagulability and
immobilization.
Elderly patients are at risk of developing
pneumonia, atelectasis and pulmonary
effusions.
 Renal insufficiency or failure can occur
as a result of deficient perfusion,
hemolysis, low CO before and after open
heart surgery and by use of vasopressor
agents to increase blood pressure.
 GI postoperative complications can
include abdominal distention, ileus,
gastroduodenal bleeding, cholecystitis,
hepatic dysfunction shock liver
 syndrome, pancreatitis, mesenteric
ischemia, diarrhea or constipation.
 Neuropsychological complications
postoperatively include
neuropsychological dysfunction,
postcardiotomy delirium, and peripheral
neurologic deficits.

LATE COMPLICATIONS

 Postpericardiotomy syndrome (Dressler’s

syndrome) is a group of symptoms
occurring several weeks to months after
cardiac and pericardial trauma and MI.
The cause of postpericardiotomy
syndrome is not certain, but it may result
from anticardiac antibodies, viral etiology
or other cause.
Postpericardiotomy syndrome occurs as
the result of tissue trauma, which triggers
an autoimmune response and
inflammation of the pericardial cavity
resulting in pericardial and severe pleural
pain.
Manifestations fever, malaise, arthralgias,
dyspnea, pericardial effusion and pleural
effusion and friction rub.
  Cardiac tamponade that occurs as a late
complication of cardiac surgery, 1.3 of
patients and is commonly associated with
administration of anticoagulants or
antiplatelet therapy, usually occur within
2 weeks of surgery.
 Wound infections, including sternal
wound infections and mediastinitis, occur
in 0.4 to 5 of all patients having cardiac
surgery.
Wounds infections usually appear 4 to 14
days postoperatively with symptoms of
fever, leukocytosis, inflammation and
purulent drainage.
Staphylococci organisms are the most
common causative organism.

IX. POSTOPERATIVE MANAGEMENT

Teacher PPT What are the
Describe the  Adequate oxygenation is ensured, describes the postoperative
5mt postoperative respiratory insufficiency is common after management of management of
management of open heart surgery. CABG CABG
CABG Assisted or controlled ventilation is
employed. Respiratory support is used
during first 24 hours to provide airway in
the event of cardiac arrest, to decrease the
work of the heart and to maintain
 effective ventilation.
Chest X-ray taken immediately after
surgery and daily thereafter to evaluate
state of lung expansion and to detect
atelectasis; and to demonstrate heart size
and contour and confirm placement of
central line, ET tube, and chest drains.
 Hemodynamic monitoring during the
immediate postoperative period for
cardiovascular and respiratory status and
fluid and electrolyte balance to prevent or
recognize complications.
 Drainage of mediastinal and pleural chest
tubes is monitored.
 Fluid and electrolyte balance is closely
monitored.
 Administer postoperative medications.
 Monitoring for complications.
 Cardiac pacing, if indicated, by way of
temporary pacing wires from the incision.
X. CONCLUSION
Coronary artery bypass grafting, or CABG , is a
type of operation that improves blood flow to
the heart. This surgery is used to treat coronary
artery disease (CAD). CABG also is known as
bypass surgery, coronary artery bypass surgery,
and open heart surgery.
CABG is used to treat people who have
severe CAD. CAD is the narrowing of the
coronary arteries—the blood vessels that supply
oxygen and nutrients to the heart muscle. This
condition is caused by a buildup of fatty
material called plaque within the walls of the
arteries. Over time, that plaque made up of fat,
cholesterol, calcium, and other substances
found in the blood will become very hard.
When this happens, the coronary arteries are
narrowed or blocked, limiting the supply of
oxygen-rich blood to the heart muscle.
ASSIGNMENT
Write an assignment on nurses responsibility of a
patient undergoing with CABG.

BIBLIOGRAPHY
 Joyce.M.Black, Esther Matassari Jacob. Medical
Surgical Nursing, 5th edition 1997, page no:843-
850
 Brunner and Suddharth’s, Textbook of Medical
Surgical Nursing. 12th edition 2010, Wolters
kluwer publications. Page no:755-756.
 Lewis, Medical Surgical Nursing, chinthamani
ELSEVIER publishers, page no, 764-765 .
 Hariprasath P.(2016).Textbook of
Cardiovascular and Thoracic Nursing. Ist
edition.Jaypee publishers,page no:314-320.
 https://en.wikipedia.org/wiki/Coronary_artery_bypass_
surgery
 https://www.medicinenet.com/coronary_artery_bypass
_graft/article.htm
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