FF PUMP- Çalışan kalpte

baypas: Teknik incelikler

Central Military Hospital

Baku, Azerbaijan
Cavid Ibrahimov
 Central Military Hospital

This technique has been successfully applied to around

453 of OPCAB patients from total 925 CABG patients.
Conversion rates are approximating 0.5%, mortality rate
0.5% during 3 years.
 Castroviejo APICAL
stabilization
Conversion Coronary
shunt
DPS No
LPS Perfusionist
in the
Mister Blower operating
room
OPCAB Central Military Hospital
 PERFUSION
• With greater
experience, and
conversion rates
0.5%, it was felt
acceptable to
maintain a
perfusionist
presence in the
hospital, but not
necessarily in the
actual operating
theater.
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Süni olmayan eməliyyat 
• B-bloker given to patients from preop period
• WARM ROOM
• The operating - 24°C (75°F) - until the draping
of the patient.
• After draping, the room temperature is
lowered to 20°C (68° F).

For ENUCLEATION A table that allows separate

elevation of the legs is preferable for OPCAB.

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 THE ANESTHESIA SET-UP AND MONITORING

• Multi-lead ST monitor - Ischemic activity

• Trans-esophageal echocardiography (TEE)-
Ischemic activity, calcific aort, mitral incompatence
• Pulmonary capillary wedge pressure (PCWP)-
A quadrangular change of the pulmonary wave
form is a warning signal similar to an
unexplainable increase of PCWP pressure.
• visual monitoring by anaesthetist and surgeon

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 Indication
• Patients with impaired left ventricular function,
• Left mainstem stenosis,
• Advanced age,
• Cerebrovascular accidents,
• Chronic renal failure,
• Chronic obstructive pulmonary disease,
• Sleep apnea syndrome,
• Atheromatous disease of the aorta,
• Acute myocardial infarction (MI), and reoperations are
all candidates for off-pump CABG
 CONTRAINDICATIONS
• Severe cardiogenic shock
• Intracavitary tromb
• Malignant ventricular arrhythmias
• A deep intramural or intraseptal coronary
pathway is no absolute contraindication.
• A very critical left main stenosis is no absolute
contraindication when combined with
hemodynamic and electrical instability.
• In this patients we prefer to anastomose first
LIMA-LAD.

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 (x3)
Risk factors of
conversion to
conventional CABG
MITRAL
INCOMPETENCE
intraop TEE

• Country: Japan
• 616 patient
• Middle age: 68
• In 14 patient were
conversion from
OPCAB to CABG.
• During OM
anastomosis
 ANESTHESIA MANAGEMENT
• General anesthesia
• Thoracic epidural anesthesia
• High dose opioid technique-great
hemodynamic stability/prolonged
postoperative respiratory depression.

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 MANAGING ANTI-COAGULATION
• We still operate for full heparin doses to
obtain an ACT of 400 seconds, demanding 3-
mg/kg or more if needed. In consequence the
ACT is measured every 15 minutes and top-up
doses of heparin are administered when ACT
is below 400 seconds.
• Protamine is used at a 1 to 1 ratio (or 0.8 to 1)
for reversal of the heparin effect at the end of
the anastomotic time.
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 Country: Italy
Year: 2014 TheTotal Calculated Dose dose of protamine
OPCAB equal to 1 mg for each 100 units of heparin.
Salvator et all.

The first after the administration of 2/3 of The second after the administration of the
the Total Calculated Dose of protamine. Total Calculated Dose of protamine.

The commonly applied ratio equal to 1:1 (ratio of protamine

to heparin) could be higher than needed with potential and hazardous
impacts on the efficacy of the coagulation system.

Overdose of protamine has anticoagulant effects which might lead to bleeding

complications. It causes platelet dysfunction, inhibits glycoprotein Ib-vWF activity
and serine proteases involved in coagulation and enhances fibrinolysis .
 HEART RATE BETWEEN 55 TO
HEMODYNAMIC CONDITIONS » 70- BPM SINUS RHYTHM

SYSTOLIC ARTERIAL BLOOD

PRESSURE > 85-MMHG AND
DIASTOLIC ARTERIAL BLOOD
PRESSURE > 50-MMHG
CVP > 5-MMHG AND PCWP 10 >
< 18-MMHG

CARDIAC INDEX > 2 L/MIN / M²

NORMOXIA, NORMOCARBIA
AND NORMOTHERMIA

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 SURGERY
 Median sternotomy
 Conduits harvested: saphaneous vein, internal
thoracic artery, radial artery.
 Full heparinization done after the completion
of mammary artery dissection
 Pericardium opened, stay sutures placed
 Holding stabilizers

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 Country: Turkey
Year: 2015 Effect of LIMA Harvesting Technique on Postoperative
Patient: 160 Drainage in Off-Pump CABG
OPCAB
Mehmet Özülkü et all

Group (1) consisted of patients in whom Less sternum pain

LIMA was harvested with surrounding Semi
Wound site complications
tissues using the pedicled technique. skeletonized
Better pulmonary function
Group (2) consisted of patients in whom technique
considered in diabetics
LIMA was harvested using the
semiskeletonized technique, with the
veins separated from surrounding
connective tissues.

It was observed that semiskeletonized LIMA

presents reduced amount of postoperative drainage in the first
and second 24-hour periods and total amount of drainage than
pedicled LIMA, independent of pleural integrity.
 We make
four
pericardial
incision lines.
 Major challenge during OPCAB surgery
… exists in managing the
cardiovascular volume changes
that occur with dislocation of the
heart during exposition of the
latero-posterior wall. This may
possibly be associated with
kinking of systemic and
pulmonary veins or an increase
of mitral valve incompetence.
Preload decreases acutely and
cardiac performance drops
suddenly.
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 Preload increasing ways
* Opening of the right pleura may reduce
haemodynamic compromise.
* The systemic and pulmonary venous return is primarily
preserved by elevating the legs.
* Trendelenburg is avoided due to its compromise on
superior vena caval return with possible cerebral
consequences.
* Colloids are administered to maintain a central venous
pressure > 8-mmHg or PCWP above 12-mmHg.
* Higher filling pressures are accepted in the presence
of COPD, atrial fibrillation or severe left ventricular
hypertrophy.
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 Afterload
Vasodilatation in the presence of a
normo-thermic body can also
induce a decrease in afterload.
Pharmacological increase of
afterload may improve collateral
coronary perfusion. The decision
to increase afterload depends on
the preexisting ventricular
function.
In severely depressed ventricles,
low doses of inotropic support
are administered in combination
with vasopressors. In all other
patients we absolutely avoid
inotropic support and administer
alpha 1 agonists because they
decrease venous capacitance
(improve preload).
ELECTRICAL INSTABILITY

INSTABILITY

• Electrical instability in OPCAB surgery has

surgical and electrolytic causes.
• This instability has major hemodynamic
consequences, therefore our approach is
absolute avoidance, even of a single PVC.
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 ELECTRICAL INSTABILITY

Sinus bradycardia below 55-bpm - placing atrial pacing leads.

Sinus tachycardia above 70-bpm

 an insufficient level of anesthesia,
 an insufficient beta-blocking agents
 an insufficient level of oxygen-ishcemia- nitroglycerin infusion

Left Bundle Branch Block, placing AV

Right Bundle Branch Block sequential pacing

Left Anterior Hemiblock (LBBB, RBBB or LAHB) -

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 Country: Iran Magnesium sulfate, due to its pivotal role in cardiac
Patient: 600 excitability, neuromuscular transmission and vasomotor tone is
Year: 2015 given in a preventive manner in almost all patients at a dose of 25-
OPCAB mg/kg.
Feridoun Sabzi et all Group A received 50
Group B or control
mg/kg of magnesium
group received only 100
sulfate (MS) in 100 ml
ml 0.9% NaCl solution
0.9% NaCl solution over 20
Bleeding at the same time points.
min before the anesthesia
OPCAB (n=450)
induction. (n=150)

Preoperative MS use may be associated with the

postoperative platelet dysfunction and increased
tendency to bleeding.

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 THE ANTERIOR WALL

• The LAD - this area is frequently vascularized

before other areas of the heart.
• Usually the diagonal vessels are vascularized
before the LAD.

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 RETRACTORS-The first original
anastomotic stabilizers were
compression and friction stabilizers.

Compression stabilizers deform the

natural shape of the cardiac surface,
which is potentially deleterious.

The optimal stabilizer is a suction

stabilizer, respecting very much the
natural shape of the heart.

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left anterior descending coronary artery

right coronary artery

circumflex coronary artery

 There are two possible exceptions to this.
Bleeding vessel
 The first is when the coronary vessel has an intraseptal or
intramural pathway with unknown depth.
 The second situation is with an occluded vessel, often with an
inverted or retrograde coronary flow. Bleeding is controlled through
pushing on the proximal part of the vessel with a small sponge.

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 THE SHUNTING
Continued perfusion
Not shunting a coronary vessel during the
anastomotic phase dramatically increases the risk of
a sudden appearance of ischemia and possible
conversion.
practiced in a stress-free low-fidelity simulation
(hundreds of times )
In addition there is a risk of total AV block if a
proximal right coronary artery is occluded and
grafted without shunting; even more in the
presence of LBBB, RBBB or total AV block.

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 Causes of ischemia during shunt use
 Dysfunctioning of the Shunt: In the presence of shunts
reinforced with a metal spring, the surgeon can pinch
the spring and thereby obstruct the internal channel.
 First proximal When putting an intracoronary shunt
we prefer to see first proximal side flow and then put
the distal side.
 Insufficient Flow Through Shunt: The first and most
efficient approach is for the surgeon to consider the
placement of a larger shunt. This can double the
delivered flow for the same perfusion pressure if a 0.5-
mm larger shunt can be used.

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 The unstable or moving target surface forces the
surgeon to work with an open needle holder
(without or with open hatches) during the
needle passage of the vessel walls.

Castroviejo- at least 23-cm in length.

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 THE ANASTOMOSIS

 7-0 suture makes a 250-micron

 8-0 needle makes on average 150-micron
 We strongly advise therefore to use an 8-0
suture with a 6-mm needle to facilitate the
anastomotic process.

 Open/unlocked needle holder

 The anterior wall airspace allows a parachuted or non-parachuted
technique
 But the other surfaces with potentially reduced airspace often require
a non-parachuted technique.
 In addition the parachuted technique may induce a possible sawing
effect on the vessel wall creating penetration trauma, most certainly
in a moving coronary artery.
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ENUCLEATION
 CONCEPTS OF ENUCLEATION
MEASUREABLE OBJECTIVES VISIBILITY
STABILIZATION OF THE VENTRICLE
STABILIZATION OF THE ANASTOMOTIC AREA
ELONGATION OF MYOFIBRILS
CHANGES IN MITRAL VALVE PLATEAU
PULMONARY PRESSURES AND WAVE FORM
PVC, HEART RATE, CARDIAC
OUTPUT, ISCHEMIA
APICAL POSITIONER
The atrial size can increase
by 50% and become larger
than ventricle.

Compression on the anterior and lateral

walls has therefore more serious
hemodynamic consequences than
compression on the posterior wall.
 THE APICAL POSITIONER

This comes in two shapes:

Suction cup (SC). Apex is the only place where
the cup comfortably fits.
Suction surface (SS) with a three-appendage.
The suction force : (-250) to (-400)-mmHg.
A negative force : creates a risk of hematoma,
even rupture, in older patients or in patients
with reduced connective tissue (steroid therapy).

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Practice this maneuver having the aorta cannulated.

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 THE DEEP PERICARDIAL STITCH/TAPE

The leverage effect with the suture is obtained by elevating the posterior
mediastinum
Two-hand maneuver
Three-hand maneuver
Under the left atrium and between the two superior pulmonary veins, the
higher the better the leverage.
Leverage the left atrium and the left ventricle in one block and maintain
the atrial-ventricular axis.
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LV stroke volume: 12-23% decline
RV end-diastolic pressure: is elevated
Left atrial filling pressure: 10-50% increase

The two prongs should be separated

around 4-cm from one another.
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 EFFECTS OF ENUCLEATION

METHOD LEVERAGE HEMODYNAMICS VISIBILITY

RETRO-CARDIAC SPONGE/ + + + ANTERIOR
PROSTHESIS - - - POSTERIOR
CROSS-YOUR HEART TAPES +++ --- + + + ANTERIOR
+ + POSTERIOR
ANASTOMOTIC STABILIZER AS + + +
ENUCLEATOR
APICAL POSITIONER, ++ + ++
SUCTION CUP (SC)
APICAL POSITIONER, SUCTION ++ ++ ++
SURFACE (SS)
DEEP STITCH, OUTSIDE 4 + -- +
PULMONARY VEINS QUADRANT
DEEP TAPE, INSIDE 4 PULMONARY +++ +++ ++
VEINS QUADRANT
DEEP TAPE IN COMBINATION WITH +++ +++ +++
APICAL POSITIONER (SS)
Anestezi Cərrah
 OM anastomosis
 The most extensive changes in CFX anastomosis

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OM
 ANASTOMOSES TO THE PROXIMAL RIGHT
CORONARY ARTERY

• Temporary occlusion of the right coronary vessel can lead to

complete atrioventricular block. For this reason a number of
additional precautions and strict monitoring protocols are taken
when the OPCAB approach requires a proximal right coronary
anastomosis. We normally perform the proximal right anastomosis
after grafting all other regions.
• The anastomosis is often easier and with more visibility when
performed from the left side of the patient.
• The conduction safety : the placement before the start of this
anastomosis of atrioventricular pacing wires.
• (even in an occluded RCA) and therefore all theShunting is strongly
recommended shunt sizes up to the largest caliber should be
available in the operating theatre, including the 3-mm shunt.

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 How to train young surgeons?
Within a space of 1 to 2-cm it becomes very
difficult to perform this parachuted
technique, therefore train also non-
parachuted technique.
You need superior training in small space
needle manipulation and rotation.
Use 8-0 suture and needles of 6-mm length.
Country: UK
Year : 2016 OPCAB is a safe and reproducible surgical technique that can be
Period: 14 years taught successfully to cardiothoracic trainees. Clinical outcomes
Patient: 5566 are unrelated to level of supervision or seniority of trainees. (J
Michele Murzi et all Thorac Cardiovasc Surg 2012;143:1247-53)
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MULTIFACTORAL STEPS TO AVOIDING
STROKE
1) Reduce the combined CABG-carotid surgery to
the patients with real neurological instability ;
2) Increase the mean pressure of the patient in
the patients with occluded or severely
stenosed internal carotid arteries ;
3) Protect the patient during his complete period
of hyper-coagulopathy (the first 5 to 7 days)
with therapeutic levels of anti-aggregation.

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 APPROACH
TO AVOID STROKE
 Stroke as pathology is strongly associated with coronary
artery disease. Therefore the coronary artery bypass
patient is at risk for stroke during his complete further
life.
 Strict avoidance of partial and total clamping during
preoperative TEE (routine observations in all patients).
Aortic “no-touch” technique was associated with nearly 60% lower
risk of postoperative cerebrovascular events as compared to
conventional side-clamp OPCAB with effect consistent across patients
at different risk. ( J Am Heart Assoc. 2016;5: e002802 doi:
10.1161/JAHA.115.002802)
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 This risk increases gradually with the increase of the interval after
surgery.
However, the highest risk of stroke in the life of a patient with
coronary artery disease is around surgery, more precisely the first 15
days after time 0, the start of surgery.

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Kənardan görünən 
Central Military Hospital
Thank you for attention

Central Military Hospital

Baku Azerbaijan