Coronary artery

bypass grafting
CABG - OPCAB

Dr. Luc Tambeur

Coronary artery disease

Definition:
Narrowing of the coronary arteries
Caused by thickening and loss of elasticity
of the arterial walls
Limiting blood flow to the myocardium
Flow reserve (effort)
At rest
Occlusion

Coronary artery disease

Morphology and processes:
Focal intimal accumulation of lipids, blood elements,
fibrous tissue, calcium etc. with associated changes
in the media
Plaque
Stenosis
Regression of plaque and collateral formation
Plaque rupture and thrombosis
Usually affects multiple coronaries simultaneously,
proximally and at bifurcations

Myocardial infarction
Imbalance between oxygen supply and
demand
Myocardial necrosis starts after 20 minutes
Border zone
Reperfusion within 3-4 hours can limit the
extent of myocardial necrosis
Scarring. LV systolic and diastolic dysfunction.
Chronic heart failure.

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% crosssectional area loss
Severe: 67% diameter = 90% crosssectional 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

Endarterectomy

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