Coronary Artery

Bypass Grafting
CABG
Cardio Pulmonary Bypass Machine
CPBM

 Also known as a heart-lung machine

 It is a device that does the work of the heart & lung when the heart is stopped for
surgical procedure, or for other reasons
 Most pastient are on the pump only as long as it takes to complete open heart
surgery
Component of CPBM

 2 main function unit

• Pump
• Oxygenator
 Tubing (silicone rubber of PVC)
 Pumps (roller, centrifugal)
 Oxugenator (membrane oxygenators, oxygenation)
 Cannulae (venous, arterial)
Working schema of CPBM
Special tubing connected to large blood Allows oxygen-depleted blood to leave the
vessels body

Machine oxygenates Travels to CPBM

Return blood to the body through a second

set of tubing Constant pumping of the machine

Pushes the oxygenated blood through the

body
 Tubes placed away from the surgical site do not interfere with the
surgeons work
 Placed in a blood vessel large enough to accommodate tubing &
pressure of pump
 2 tubes insure blood leaves the body before reaching the heart &
returns to the body after the heart, giving a still & mostly bloodless
area to operate
 Third tube inserted very near or directly into the heart, but not
connected to the CPBM. Used to flush heart with cardioplegic, a
potassium solution which stops the heart
 Once the cardioplegic takes effect, the CPBM is initiated and takes
over the heart and lung function
Purpose of CPBM

 To stop the heart without harming the patient (oxygenated blood must continue to
circulate through the body surgery)
 The pump does the work of heart (pumping blood through body) and fulfils the
function of lungs (oxygenates the blood while pumping)
 The CPBM is used for 2 primary reasons:
• many cardiac surgeries would be impossible to perform with the heart
beating. “moving target” significant blood loss
• The pump is used not for surgical need, but to help out if patients has heart
failure. In some cases, a heart failure patient may be placed on the pump to
support the patient until a heart transplant become available
Risk CPBM

 Formation of small blood clots in blood prcessed by mmachine- can probably

cause stroke, MI or renal failure on returning to body’s bloodstream
 The machine can also trigger an inflammatory process that candamage many of
the body’s system and organs, called “psot-pericardiotomy syndrome”.
 Post operative bleeding may be a serious complication, occasionally requiring a
return to the operating room
 Problems with temporary confusion or memory loss.
CORONARY ARTERY BYPASS
GRAFTING (CABG)
 History
 Definition & introduction
 Procedure
 Recent advances in CABG
 Indications
 Contraindication
 complication
History of CABG

 John Gibbon- clinically useful cardiopulmonary bypass (CPBM)- 1953

 William Mustard- first direct surgical approach to coronary circulation – 1953
 Dr. Robert Goetz & Dr. Michael Rohman- first successful surgeons to perform
CABG with donor vessel anastomosed to the RCA. The actual anastomosis with
the Rosenbach ring developed an atheromatous plaque-occluded the origin of the
IMA used.
 Russian cardiac surgeon, Dr. Vasilii Kolesov- first successful IMA- Coronary
artery anastomosis in 1964
 1970’s- first full decade of CABG (relived angna & improved (QoL)
Alternative terminology

 Heart bypass
 Bypass surgery
 Aorto coronary bypass (ACB)
 “Cabbage”
 Single bypass, double bypass, triple bypass, quadriple bypass, and quintuple
bypass
Definition
 CABG is a surgical procedure in which one or more blocked
coronary arteries are bypassed by a blood vessel graft to
restore normal blood flow to the heart, with an intent to
relieve angina & prevent death
 Arteries or veins from elsewhere in the patient’s bode are
grafted to the coronary arteries to bypass atherosclerotic
narrowing’s and improve the blood supply to the coronary
circulation supplying the myocardium
Introduction
Pembuluh Utama Jantung dan
penempitannya
Procedure

 2 stages to bypass surgery:

• Stage 1: healthy blood vessel (the graft) is removed from leg or chest wall
• Stage 2: connecting graft to coronary artery, “bypassing” diseased segment,
improving the blood supply to the heart
 1 of the folloeing technique is used:
• Heart-lung machine is used to circulate blood around the body, allowing the surgeon
to operate on the heart )”on-pump” surgery)
• The “beating heart” technique, where the surgery is performed while the heart is still
beating and working. This is called “off pump” surgery.
The operation usually takes between 3-6 hours
Pengambilan sepotong pembuluh darah
(graft)
 Vena saphena magna dari tungkai bawah
 Arteri radialis dari lengan bawah
 Arteri mamria interna dari balik tulang dada
 Cardioplegic solution avoids tissue damage, lowers the temperature of heart
 Most patients who undergo CABG, have at least 3 graft done
 CABG builds a detour around one or more blocked coronary arteries with graft
from healthy veis or artery
 The graft goes around the clogged artery (or arteries) to create new pathways for
oxyen-rich blood to flow to the heart
 Electric shccks start the heart pumping again after grafting
 The heart –lung machine is turned off & after the normal bloodflow is resumed,
the chest cavity is closed
Penjahitan pembuluh darah (graft) ke
pembuluh darah jantung (coroner)
Recent advances in CABG

 Totally endoscopic, minimally invasive CABG with use of a surgical robot,

doesn’t require an incision and patient can often return to normal activities in few
weeks
 Keyhole surgery: requires 2-3 inch incision instead of splitting chest open
 Hybrid procedures (minimally invasive bypass surgery and stented angioplasty in
one operation)
 Off- pump or “beating heart” bypass
Difference-”off-pump CABG”

 The bypass is sewed onto heart , while heart continues beating. Various types of
heart stabilizers are used to restrain the heart one section at a time so the surgeon
can operate on it
 The chest is opened through a midline sternotomy incision. After the targer
coronary vessel is exposed & stabilized, it is occluded & opened
 A bridging plastic tube- which allows blood flow during suturing– may be placed.
The bypass graft is then sutured to the coronary artery
Advantages off-pump over on-pump
CABG
 Reduced need for blood transfussions
 Reduced risk of bleeding, stroke and kidney failure
 Potential for reduced psychomotor and cognitive problems
 High-risk patients with additional disease like lung disease, kidney failure and
peripheral vascular disease may benefit from thos kind of operation
indications

 The 2004 ACC/AHA CABG guidelines state CABG is prefferd treatment for
• Disease of the left main coronary artery (LMCA)
• Disease of all three coronary artery vessels (LAD, LCX, RCA)
• Diffuse disease not amenable to treatment with a PCI
 The 2005 ACC/AHA guidelines further state:
CABG is preferred treatment with other high-risk patients such as those with
severe ventricular dysfunction (i.e low ejection fraction), or diabetes mellitus
Indications….. Contd….

 Significant (>50%) left main stenosis

 Disabling angina despite maximal medical therapy ( surgery can be performed
with acceptable risk)
 3 vessels disease ( survival benefit greater when LVEF <50%)
 2 vessel disease with significant proximal LAD stenosis & either EF<50% or
demonstrable ischemia on non-invasive testing
Contraindications

 Absence of an opem major artery 1 mm or more in diameter beyond the

obstruction lesion
 Absence of viable myocardium in the area supplied by stenosed artery
 Co-existing severe non cardiac confition with poor prognosis