CORONARY ARTERY

BYPASS GRAFT
 INTRODUCTION
Coronary artery bypass grafting (CABG) is a major surgical
operation where atheromatous blockages in a patient’s coronary
arteries are bypassed with harvested venous or arterial conduits. The
bypass restores blood flow to the ischemic myocardium which, in
turn, restores function, viability, and relieves anginal symptoms.
Almost 400,000 CABG surgeries are performed each year
making it the most commonly performed major surgical procedure,
but surgical trends have decreased as the use of alternative options
such as medical treatment and percutaneous coronary intervention
(PCI) have increased.
History of Heart Surgery
• Prior to 1930’s, heart surgery seen as impossible, with
high morbidity and mortality
• 1937: Dr. John Gibbon designs heart-lung machine,
which enables cardiopulmonary bypass (CPB)
• 1955: Vineburg and Buller implant internal mammary
artery into myocardium to treat cardiac ischemia and
angina
• 1958: Longmire, Cannon and Kattus at UCLA perform
first open coronary artery endarterectomy without CPB
• During 1960’s and 1970’s, CPB and cardioplegic arrest
are adopted, allowing Coronary Artery Bypass Graft
(CABG) to emerge as a viable surgical treatment
• According to the American Heart Association 427,000 coronary
artery bypass graft (CABG) surgeries were performed in the
United States in 2004, making it one of the most commonly
performed major operations.

• Today over 500,000 CABGs are done every year in United

States alone. In India where there is a rising incidence of heart
disease the number of CABG surgeries is showing an increasing
trend.
DEFINITION
It is a surgical procedure performed to relieve angina and
reduce the risk of death from coronary artery disease. Arteries or
veins from elsewhere in the patient's body are grafted (internal
thoracic arteries, radial arteries and saphenous) to the coronary
arteries to bypass atherosclerotic narrowings and improve the
blood supply to the coronary circulation supplying the
myocardium (heart muscle.
PURPOSE
Restore blood flow to the heart.
Relieve chest pain & ischemia.
Improves the patient’s quality of life.
Enables the patient to resume a normal life cycle.
Lower the risk of a heart attack.
GOALS OF CABG
• Improving your quality of life and reducing angina and other
CHD symptoms
• Allowing you to resume a more active lifestyle
• Improving the pumping action of your heart if it has been
damaged by a heart attack
• Lowering the risk of a heart attack (in some patients, such as
those who have diabetes)
• Improving your chance of survival
 Number Of Bypass
• The terms single bypass, double bypass, triple bypass, quadruple
bypass and quintuple bypass refer to the number of coronary arteries
bypassed in the procedure. In other words :
• Double bypass means two coronary arteries are bypassed (e.g. the
left anterior descending (LAD) coronary artery and right coronary
artery (RCA)
• Triple bypass means three arteries are bypassed (e.g. LAD, RCA,
left circumflex artery (LCX)
• Quadruple bypass means four vessels are bypassed (e.g. LAD, RCA,
LCX, first diagonal artery of the LAD)
• Bypass of more than four coronary arteries is uncommon
INDICATION
According to American Heart Association
• Left main artery stenosis or equivalent
• Triple vessel disease
• Stable or unstable angina
• Abnormal Left Ventricular function.
• Failed PTCA.
• Hemodynamic instability
• Immediately after Myocardial Infarction (to help perfusion of the
viable myocardium).
• Life threatening arrhythmias caused by a previous myocardial
infarction.
• Occlusion of grafts from previous CABG.
CONTRAINDICATION
• Left main artery disease or aortic valve insufficiency
• Abdominal aortic aneurysm
• Haemorrhage diseases
• Valve diseases, congenital heart diseases, cardiomyopathy
• Lower extremities edema
• Severe hypertension, blood pressure higher than 70/110
• Uncontrolled arrhythmias
• Pregnancy
SELECTION OF CONDUIT
VENOUS GRAFT ARTERIAL GRAFT

• Saphenous vein • Internal mammary artery

• Radial artery
• Gastro epiploic artery
• Inferior epigastric artery
OTHERS
• Cryopreserved Allograft
veins
• Prosthetic and xenograft
conduits
SELECTION OF CONDUIT
• Internal mammary artery ---- It is the most common artery used for
bypass graft. It is left attached to its origin (the subclavian artery)
but then dissected from the chest wall. Next, it is anastomosed
(connected with sutures) to the coronary artery distal to the
blockage. The long-term patency rate for IMA grafts is greater than
90% after 10 years.
• Saphenous Vein---- Saphenous veins are also used for bypass grafts.
The surgeon removes the saphenous vein from one or both legs
endoscopi cally. Sections are attached to the ascending aorta and
then to a coronary artery distal to the blockage. Saphenous vein
grafts do develop diffuse intimal hyperplasia. This contributes to
future stenosis and graft occlusions. The use of antiplatelet therapy
and statins after surgery improves vein graft patency. Patency rates
of these grafts are 50% to 60% at 10 years.
Radial artery---- The radial artery is another conduit that can be used. It
is a thick muscular artery that is prone to spasm. Perioperative calcium
channel blockers and long-acting nitrates can control the spasms.
Patency rates at 5 years are as high as 84%. There have been no reports
of extremity complications (e.g., hand ischemia, wound infection) after
removal of this artery.
Gastroepiploic Artery--- Other potential conduits include the
gastroepiploic or infe rior epigastric artery. However, they are rarely
used, since the dissection of these arteries is extensive. This increases the
length of surgery and the risk for wound complications at the harvest
site, especially in an obese or diabetic patient .Like the radial artery,
these are also prone to spasms. One-year patency rate for the epigastric
artery is 90%, and 10-year patency rate for the gastroepiploic artery is
62%.
• Cryopreserved Allograft Veins------Cadaver saphenous veins that have
been cryopreserved can be used when there are few autologous conduits.
Their long-term patency is not as good as that of auto graft veins, but
cadaver saphenous veins can serve as a conduit in patients who have
undergone multiple reoperations for CAD. After removal from the
cadaver, the veins are tested for disease, treated with antibiotic solutions,
and frozen. When needed, the vein is thawed and implanted in a manner
similar to that for an autologous vein.
• Prosthetic and Xenograft Conduits--- Polytetrafluoroethylene (PTFE),
and polyglycolic acid have been used as prosthetic conduits. The greatest
challenge for prosthetic grafts is that the size of the graft (2 to 4 mm) that
would be useful in bypass surgery makes them prone to occlusion.
• Bovine IMAS are available as a xenograft. Like crys preserved
saphenous veins, these conduits are useful in situations in which
autologous grafts are largely unavail able. Other biological allografts,
such as human umb cal vein, are available but they also tend to
thrombose within the first year.
TYPES OF CABG
Traditional Coronary ArteryBypass Graft
• CABG procedures are performed with the patient under general
anesthesia. In the traditional CABG procedure, the surgeon
performs a median sternotomy and connects the patient to the
cardiopulmonary bypass (CPB) machine.
• Next, a blood vessel from another part of the patient’s body (eg,
saphenous vein, left internal mammary artery) is grafted distal
to the coronary artery lesion, bypassing the obstruction .
• CPB is then discontinued, chest tubes and epicardial pacing
wires are placed, and the incision is closed. The patient is then
admitted to a critical care unit.
OFF-PUMP CABG
A number of alternative CABG techniques have been
developed that may have fewer complications for some groups of
patients. Off-pump CABG (OPCAB) surgery has been used
successfully in many patients since the 1990s.
Off-Pump Coronary Artery Bypass. The off-pump
coronary artery bypass (OPCAB) procedure uses full or partial
sternotomy to access all coronary vessels. OPCAB is performed
on a beating heart using mechanical stabilizers and without CPB.
It is usually reserved for patients who have limited
disease but are at high risk for traditional surgery secondary to
multiple co morbidities. Patients who are typically candidates for
OPCAB have a very low EF, severe lung disease, acute or
chronic kidney disease, a high risk for stroke, or a calcified aorta.
Minimally invasive direct coronary artery grafting
Minimally invasive direct coronary artery grafting
(MIDCAB) is performed through a strategically placed minimal
access incision and so avoids all invasive aspects of conventional
CABG.
Through an anterior MIDCAB, a submammary incision
over the fourth intercostal space, the left internal mammary artery
can be dissected down with the aid of a thoracoscope and grafted
to the mid-left anterior interventricular artery.
More lateral MIDCAB incisions allow access to other
coronary vessels including branches of the circumflex artery.
Patient selection remains, at least at present a restriction to the
ever increasing minimally invasive methods being developed.
Minimally invasive direct coronary artery grafting
Robot-Assisted Cardiothoracic Surgery.
This technique incorporates the use of a robot in
performing CABG or mitral valve replacement. The benefits of
robotic surgery include increased precision, smaller incisions,
decreased blood loss, less pain, and shorter recovery time.
Advantages of MIDCAB Over CABG

MIDCAB CABG
Full sternotomy No Yes
CPB No Yes
Operating time 2-3 hrs 3-6 hrs
Recovery time 1-2 weeks 3-6 months
Effectiveness 90% 90%
Incision length 10 cm 30 cm
NURSING MANAGEMENT
• Pre operative nursing care
• Intra operative nursing care
• Post operative care
PRE OPERATIVE NURSING CARE
Assessment

• Patient history ---Patient history of major illness, previous

surgery, medications, and usage of drugs and smoking and
drug history
• Physical Examination (head to toe )
• Diagnostic procedure
Physical Examination
• General appearance and behavior.
• Vital signs
• Nutritional and fluid status ,weight, height
• Inspection and palpation of the heart ,noting the point of
maximal impulses ,abnormal pulsation ,and thrills
• Auscultation of the heart ,noting pulse rate ,rhythm, and quality;
S4 and S3 , murmur, and friction rib
• Jugular venous pressure
• Peripheral pulses
• Peripheral edema
Physical Examination
A systematic assessment of all systems performed ,with
emphasis on cardiovascular functioning
Functional status of the cardiovascular system determined
by reviewing the patient symptoms , including past and present
experience with chest pain ,hypertension, palpation ,cyanosis,
breathing difficulty ,leg pain that occur with walking ,Orthopnea,
peripheral edema. Because alteration in cardiac function (cardiac
out put can affect renal, respiratory, gastrointestinal ,
integumentary, hematological, and neurological functioning )
Diagnostic Evaluation
• Undergo several pre-operative imaging tests, in which the
arteries that deliver blood to your heart are evaluated. Eg. 2D
Echo &CAG.
• Chest x – ray
• ECG
• Hemodynamic studies
• Blood coagulation factors
Pre operative teaching about intensive care unit
experience for the patient
Equipment to point out
 Cardiac monitor
 Arterial line
 Thermo dilution catheter
 IV lines and IV infusion pump
 Endotracheal tube and ventilator
 Suctioning
 Explain when extubation can be anticipated
 Foley’s catheter
 Chest tubes
 Pacing wires
 Nasogastric tubes
 Respiratory preparation & post operative exercises will be taught to patient.
 Incentive spirometry
 Deep breathing excercises
INTRAOPERATIVE CARE
Before the chest incision is closed, chest tubes are inserted to
evacuate air and drainage from the mediastinum and the thorax.
Temporary epicardial pacemaker electrodes may be implanted on
the surface of the right atrium and the right ventricle.
These epicardial electrodes can be connected to an external
pacemaker if the patient has persistent brady cardia
perioperatively.
Possible intraoperative complications include low cardiac output,
dysrhythmias, hemorrhage, MI, stroke, embolization, and organ
failure from shock, embolus, or adverse drug reactions.
Astute intraoperative nursing assessment is critical to prevent,
detect, and initiate prompt intervention for these complications.
 POST OPERATIVE CARE
Post operative care in intensive care unit
• Connect an intubated patient to the ventilator or an extubated patient
to oxygen.
• Connect the patient to a pulse oximeter..
• Connect the patient to a cardiac monitor, and obtain candacoutput
and index..
• Transduce and zero hemodynamic monitoring lines
• Set up cardiac output equipment. .
• Connect chest tubes to 20 cm H₂O suction.
• Assess for bleeding and urine production.
• Verify pacemaker connection and function. .
• Check intravenous infusions.
• Record first set of vital signs.
• Send blood specimens for chemistry, hematology, coagulation and
arterial blood gas analysis.
• Obtain portable chest x-ray film.
• Obtain 12-lead electrocardiogram.
• Obtain detailed report from the anesthesia team
• Height and weight
• Drugs administered, including current infusions and antibiotics
• Colloid and crystalloid solutions administered
• Maintain intake output chart.
 Postoperative Management of
Hemodynamics
• BP – low
• – administer fluids – preferably colloids
• Positioning – supine - leg elevated
• If blood loss – replace
• BP – high
• Nitroproside
• Hypothermia
• Rewarm the patient
• Warm blanket
• Warm humidified oxygen
• Air mattress
 Assess pulmonary artery pressure and cardiac output
Postoperative Management of Bleeding
• The nurse should monitor the patient for signs of bleeding from the
chest tubes and the surgical sites as well as clinical signs of
hypovolemia related to blood loss
• Hemoglobin and hematocrit should be monitored at regular intervals
• Drugs such as protamine sulfate (to reverse the effects of heparin) or
antifibrinolytic agents such as aminocaproic acid or desmopressin
(DDAVP)
• Blood products such as fresh frozen plasma and platelets may also be
ordered.
Postoperative Renal Management

• urinary output of at least 0.5 mL/kg/h

• The nurse must monitor the urinary output at least hourly
• potassium level should be monitored at least every 4 to 6
hours for the first 24 hours
• monitored for cardiac dysarrhythmias if the serum
potassium level is abnormal
• Blood urea nitrogen and serum creatinine.
Postoperative Gastrointestinal Management
• . Anesthetic agents, analgesics, and hypo perfusion of the
gut during surgery can also contribute to gastrointestinal
dysfunction
• The nurse should monitor the patient for bowel sounds,
abdominal distention, and nausea and vomiting.
• N.G tube should be kept for intubated patient
Additional Postoperative Management
• Pain management
• Prevention of infection
• Psychological issues
IMMEDIATE COMPLICATIONS
• Cardiac complications Pulmonary complications
Hypovolemia Hemothorax and
pneumothorax
Persistent bleeding
Atelectasis
Cardiac tamponate Pneumonia
Fluid overload Pulmonary embolism
Hypothermia Failure to wean
Hypertension
Tachydysrhythmias Renal complications
Renal insufficiency
Bradycardias
Cardiac failure
Myocardial infarction
CONT…
Gastrointestinal complications
Splanchi ischemia
Illeus
GI bleeding
Neurological and psychological complication
Stroke
Hypotension
Neurocognitive dysfunction
Post cardiotomy delirium
 LATE COMPLICATIONS
Respiratory complications
Psychological complications
Atelectasis
Anxiety
Pleural effusion Fear
Pneumonia depression
Post pericardiotomy syndrome
Wound infection
Gastro intestinal complications
constipation
gastrointestinal bleeding
paralytic illeus
intestinal ischemia
HOME CARE INSTRUCTION
• Wear comfortable clothes at all times.
• Take periodic walks and slowly increase the
duration of exercise.
• Follow the diet prescribed by your dietician.
• Do not fail to take all your medications on
time.
• Quit smoking.
• Participate in a cardiac rehabilitation
program if possible.
• Maintain caution to avoid any bump or direct injury to
your chest. Your scar might take one to two months to
heal completely.
• Control your anger and stress.
• Follow up with your doctor(s) as instructed.
Life style changes
• Walk at least 30 minutes a day.

Join a regular exercise program

Quit smoking, avoid secondary smoke

whenever possible.

Reduce your stress level.

Continue your medications as prescribed.

Follow up with your doctor on a regular basis or

immediately when symptoms recur.
DO NOT CONSUME

• Deep fried foods

• Bakery products
• Dry fruits , coconut , groundnut.
• Red meat, shellfish, egg yolk, organ meat
Sugar, jaggery, honey, jam, sweets,
fruit juices, Wine, Whisky & Beer
• Sodium and fluids are restricted as per
the disease
HEALTH EDUCATION
• DIET (SALT RESTRICTED)
• PERIODIC MONITORING OF BLOOD SUGAR
• DRUGS
• EXERCISES
• PERSONAL HYGIENE ( STRICT ASEPTIC
PRECAUTIONS TO PREVENT INFECTION)
• FOLLOW UP
• Return to work usually occurs after the six week recovery.
• Exercise stress testing is routinely done four to six weeks
after CABG surgery.
• Rehabilitation consists of a 12 week program of gradually
increasing monitored exercise lasting one hour three
times a week.
PROGNOSIS
• Prognosis following CABG depends on a variety of
factors, but successful grafts typically last around 10-
15 years.

• Statistically there is 5 years of difference in survival rate

between those who have had surgery and those treated
by drug therapy.

• Age at the time of CABG is critical to the prognosis,

younger patients with no complicating diseases have a
high probability of greater longevity.

• The older patient can usually be expected to suffer further

blockage of the coronary arteries.
 Nursing diagnosis
• Acute pain related to surgical trauma and pleural irritation caused by
chest tubes
• Hyperthermia related to infection or post pericardiotomy syndrome
• Decreased cardiac output related to blood loss and compromised
myocardial function.
• Impaired gas exchange related to chest surgery
• Ineffective renal tissue perfusion related to decreased cardiac
output, hemolysis, or vasopressor drug therapy
• Risk for imbalanced fluid volume and electrolyte imbalance related
to alterations in blood volume
• Disturbed sensory perception related to excessive environmental
stimulation, sleep deprivation , physiological imbalance
THANK YOU