Coronary artery

bypass grafting
CABG - OPCAB
Coronary artery disease

 Definisi:
 Penyempitan arteri koroner
 Disebabkan oleh penebalan dan hilangnya
elastisitas dinding arteri
 Membatasi aliran darah ke miokardium
 Usaha kembalinya aliran
 Saat istirahat
 Sumbatan
Coronary artery disease
 Morphology and processes:
 Akumulasi fokal intima dengan lemak, elemen
darah, jaringan fibrosa, kalsium dll.
 Dengan perubahan terkait media :
 Plaque
 Stenosis
 Regresi pembentukan plaque dan kolateral
 Plaque pecah dan trombosis
 Biasanya mempengaruhi berapa arteri koroner
secara bersamaan
Myocardial infarction

 Ketidakseimbangan antara supply dan demand

oksigen
 Myocardial necrosis terjadi setelah 20 minutes
 ZonaPembatasan
 Reperfusi dalam 3-4 jam akan membatasi
tingkat nekrosis miocard
 Disfungsi sistolik dan diastolik ventrikel kiri.
 Gagal Jantung kronis
Diagnosis

 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++)
Diagnosis

 Associated conditions
 Atherosclerosis: carotids, PAD

 Definitive diagnosis: extent, distribution

and severity of anatomic coronary artery
disease
 Coronary angiography
 New modalities: CT (MRI)
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
Coronary anatomy
Indications for surgery
 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 grafting
 Full sternotomy and CPB (HLM):
CABG

 Full sternotomy, no CPB:

OPCAB

 Small sternotomy, parasternal access,

thoracotomy, with or without CPB:
e.g. MIDCAB
Bypass grafting

 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
Conduits
LIMA / RIMA
Conduits
SVG
Conduits
Radial
Conduits
Gastro-epiploic
Conduit configurations
Endarter-
ectomy
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 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
Results
 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
Time-Related Survival
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
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