Coronary Artery Bypass Grafting - thaiheart.org

1 1 Coronary Artery Bypass Grafting ( cabg ) .. ( Coronary Artery Bypass surgery, cabg ) medical treatment, medical intervention (percutaneous Coronary intervention, PCI) non-surgical treatment angina sudden cardiac death invasive treatment morbidity mortality cabg cabg 25 2000.

2 1935 Cluade Beck pectoralis muscle ..1951 Vineberg internal mammary Artery (IMA) 1954 Murray (IMA) Coronary Artery ..1956 Bailey Longmire Coronary endarterectomy ..1961 Senning Coronary patch angioplasty ..1962 Sones Shirey ( Coronary angiography, CAG) anatomy pathology cabg 40 ..1964 Kolessov IMA left anterior descending Artery (LAD).

3 1967 Favaloro Effler saphenous vein graft (SVG) Coronary Artery cabg 1 sequential Grafting (graft Coronary Artery 2 ) IMA .. cabg 19 ..1974 cabg ( 1 ) cabg on-pump cabg conventional cabg standard cabg ..1978 Bennetti off-pump cabg (OPCAB) OPCAB 700.

4 1991 morbidity 4% mortality 1% 2 ..1996 Minimally Invasive Direct Coronary Artery Bypass (MID-CAB)3,4 left anterior mini-thoracotomy ( full median sternotomy) LAD diagonal Artery right Coronary Artery circumflex Artery cabg median sternotomy (OPCAB) 2 conventional cabg OPCAB catheters Port-Access (Heart port ) Surgery Robotic Surgery cabg I.

5 Conventional cabg on-pump cabg II. Less invasive cabg - Off-pump cabg - On-pump beating-heart cabg - Minimally Invasive Direct Coronary Artery Bypass (MID-CAB) - Port-Access Coronary Surgery - Totally Endoscopic Coronary Artery Bypass (TECAB) - Robotic Surgery cabg conventional cabg off-pump cabg off-pump cabg 23% cabg .. 2546, 2547 2548 ( 2) off-pump cabg cabg oxygen supply oxygen demand cabg Bypass benefit cabg 1.

6 Relief of symptoms: cabg angina ischemia-induced heart failure 2. improve longevity: cabg medical treatment left main Coronary Artery stenosis cabg symptoms, Coronary anatomical pathology left ventricular function American College of Cardiology and American Heart Association 2004 Guideline Update for CABG10 Indications for cabg in asymptomatic or mild angina Significant left main Coronary Artery stenosis Left main equivalent (proximal LAD and proximal circumflex arteries) Three vessel disease Proximal LAD stenosis with one or two vessel disease and either ejection fraction (EF)

7 < 50% or extensive ischemia by noninvasive study 3 Indications for cabg in stable angina As for cabg in asymptomatic or mild angina One or two vessel disease without significant LAD stenosis but with a large area of viable myocardium Disabling angina despite medical therapy Indications for cabg in unstable angina/Non-ST segment elevation MI Significant left main Coronary Artery stenosis Left main equivalent Proximal LAD stenosis with one or two vessel disease Ongoing ischemia not responsive to maximal non-surgical therapy Indications for cabg in ST-segment elevation MI Ongoing ischemia not responsive to maximal non-surgical therapy Mechanical complications of acute MI: infarct ventricular septal defect, mitral valve insufficiency Cardiogenic shock Life threatening ventricular arrhythmias Indications for cabg in poor left ventricular function Significant left main Coronary Artery stenosis Left main equivalent Proximal LAD stenosis with 2 or 3 vessel disease Indications for cabg in life threatening ventricular arrhythmias Caused by left main Coronary Artery stenosis Caused by three vessel disease Indications for cabg after failed percutaneous Coronary angioplasty (PTCA)

8 Ongoing ischemia or threatened occlusion with significant myocardium at risk Hemodynamic compromise Indications for cabg with previous cabg Disabling angina despite optimal non-surgical therapy Prior cabg without patent Bypass grafts but with class I indications for surgery for native vessel Coronary Artery disease Coronary blood flow distal Coronary pressure cross-sectional area 75% 50% cabg 4 ( 1) cabg long-term graft patency long-term survival cabg complete revascularization Bypass one Bypass territory LAD, intermediate Artery , circumflex Artery right Coronary Artery 1.

9 1 . graft CAG left ventricle (ventriculography) left ventricle ejection fraction (LVEF) echocardiography LVEF (LVEF 40 50% mild impairment, LVEF 30 40% moderate impairment, LVEF <30% severe impairment poor LVEF LVEF < 20%) LVEF poor LVEF reversible ischemia viable myocardium poor LVEF generalized left ventricular hypokinesia Arterial inflow to the conduit cabg conduit (graft) arterial inflow conduit Coronary Artery pedicled graft (no proximal anastomosis) pedicled graft left right IMA (LIMA, RIMA)

10 Gastro-epiploic Artery pedicled graft Coronary Artery free grafts saphenous vein, radial Artery , cephalic vein free graft anterior aspect ascending aorta ascending aorta extensive atheroma (plague) brachiocephalic (innominate) Artery , pedicled internal mammary Artery , vein graft synthetic aortic graft Bypass conduit 11 Conduit arterial conduit venous conduit long-term patency Left internal mammary Artery (LIMA) pedicled arterial conduit long-term patency LAD, diagonal Artery Right internal mammary Artery (RIMA)