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Op cab
- 1. OP CAB :- Techniquesand outcome -DR MANOJ P NAIR Lead Consultant(Cardio Thoracic Surgery) Aster Medcity,Cochin,South India.
- 2. • 1951 Vineburgimplanted the internal mammary artery into the myocardium • First successful OPCAB was performed in 1961 and Kolesov in 1964 performed the first successful anastomosis of left internal mammary • Outshone by the development of CPB
- 3. • Resurgence oftechnique in 1980s in isolated centers especially with limited resources • On pump CABG Vs OPCAB- controversial & focus of discussion in the field of cardiac surgery .
- 4. • OP CABis essentially coronary artery bypass grafting without the help of cardio pulmonary bypass
- 5. Placement of graftto more than one of the three major coronary arteries is safely possible with stabilization devices which keep the operating area of the heart still
- 6.
- 10. ON PUMP OFFPUMP Evolved methodology Evolving methodology Conduct of operation and preoperative selection “ well defined “ Still incompletely defined and still evolving
- 11. Anaesthetic Management “Close communicationbetween surgeon and Anaesthesiologist”
- 12. Surgeon to Anaesthesiologist •Positioning of heart • Displacement of Heart • Shunt placement • Coronary artery occlusion
- 14. Anesthesiologist to Surgeon •Ischemic changes in ECG • ECG amplitude may be severely decreased • ST segment changes may be underestimated • TEE to determine RWMA and right and left ventricular volumes
- 15. Surgical steps • Mediansternotomy • Conduits harvested:saphaneous vein, internal thoracic artery, radial artery.. • Heparinization done after the completion of mammary artery dissection • Pericardium opened,stay sutures placed • In older patients epicardial ultrasound of Ascending aorta
- 16. Heparin • Protocol variesfrom institution to institution • Minimum of 5000 U to full heparinization (3mg/kg)
- 17. Heparin Reversal With protamine •No administration • Partial • Full dose
- 18. Temperature management • Hypothermiashould be avoided • Normothermia with warm IV fluids and irrigation fluids • Warming blanket or mattress • Humidification of airway • Warm temperature in operating room
- 19. Surgical Technique To maintainhemodynamic stability • Positioning-Trendelenburg position – Increasing preload • Rotation of Operating table • Opening of Right pleura
- 20. Surgical technique continued.. •Opening right pericardium vertically • Minimize the manipulation of heart • Optimal exposure of lateral wall of heart • Ventricular pacing to prevent bradycardia while RCA grafting
- 21. Pre op insertionof IABP • Increase the tolerance of manipulation of heart in high risk patients
- 22. Exposure of LVsurfaces • Apex of heart towards ceiling • Lateral displacement • Apex to right or left
- 24. Use of staysutures • Stay sutures are placed in the posterior pericardium opposite the oblique sinus(most dependent part of the pericardial cavity)
- 25. Continued…. • Should avoidinjury to aorta and esophagus • Adjust orientation of the snares • Circumferential pressure on the heart should be avoided
- 26. Myocardial protection inOP CAB • Brief coronary occlusion to visualize vessels- Regional- Global dysfunction • Olden days-Intermittent pharmacologic arrest +profound bradycardia • Ischemic preconditioning
- 27. Myocardial protection.. • Fluidsand vasopressors • good exposure of target vessels • Selection of order of anastomosis • Intracoronary shunts • PADCAB
- 28. Exposure of RCAor PDA • Marked elevation of apex of the heart with minimal lateral displacement • Using Octopus and or starfish
- 29.
- 30. Exposure of distalRCA • Leftward traction • Table left and Trendelenburg position
- 31. Exposure of LAD Leftand upward towards the head
- 32. Exposure of OM •Elevation of the apex and lateral displacement to the right • Pericardial and right pleural openings • Table rightward and Trendelenburg position
- 33. Sequence of grafting •LIMA to LAD • Vein/radial to the OM • Proximal anastomosis • Vein/radial to PDA or RCA • Proximal anastomosis
- 34. General guideline • Graftthe artery that has the evidence of collateral blood supply to the distal arterial bed • Vessels without demonstrable collateral blood supply are grafted last
- 35. OP CAB VsON PUMP • Numerous studies and few conclusions • Meta analysis • Large retrospective studies • Randomized trials
- 36. Evolving trends • Lessblood loss and transfusion requirements • Less myocardial enzyme release in 24 hours • Less early Neurocognitive disorders. • Same length of hospital stay,mortality rate • Same long term neurological function • Cardiac outcome
- 37. • Quality oflife • In severely calcified Aorta where clamping can cause direct neurological complications • Large scale prospective studies are needed • Still “evolving”
- 38. Findings favoring OPCAB • Probably less bleeding • Probably less renal dysfunction • Probably less short term NCD,especially if aorta is calcified • Possibly shorter overall length of hospital stay
- 39. Findings favoring OnPump CABG • Less technically demanding • Shorter “learning curve” • Possibly better long term graft patency • Easier to graft posterior (Cx) Bypass targets • Probably more bypass grafts constructed ref: Circulation 2005
- 40. Current indications forOP CAB • Age 70 years • Low ejection fraction • Reoperative surgery • Patients with significant comorbidities • Cerebral vascular disease • Peripheral vascular disease
- 41. Current indications.. • Hepaticdisease • Bleeding disorders • COPD • Renal dysfunction • Atheromatous or calcified aorta • Patients who refuse blood products
- 42. • Duration –10 years • Total No – 2098 • Standard CABG - 1617 • OP CAB – 481 • Mortality in standard CABG - 6.8 • Mortality in OP CAB - 1.7 Selection of patients in OP biased SINGLE SURGEON EXPERIENCE
- 43. Conclusion : • BothOP CAB and standard CABG give excellent results • Neither should be judged,inferior to the other
- 44.
Editor's Notes
- #3 Basic life support (BLS) includes recognition of signs of sudden cardiac arrest (SCA), heart attack, stroke, and foreign-body airway obstruction (FBAO); cardiopulmonary resuscitation (CPR); and defibrillation with an automated external defibrillator (AED).