Early in a coronary artery bypass surgery during vein harvesting from the legs (left of image) and the establishment of bypass (placement of the aortic cannula) (bottom of image). The perfusionist and heart-lung machine (HLM) are on the upper right. The patient's head (not seen) is at the bottom.

Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.

Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery 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 from the aorta to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, recent researches also shown that this surgery can be done with the heart still beating, by putting stabilizing devices on the heart. Image File history File links Download high resolution version (6010x4586, 2218 KB) http://fmp. ... Image File history File links Download high resolution version (6010x4586, 2218 KB) http://fmp. ... The aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ... A cannula (pl. ... A perfusionist in front of a heart-lung machine (upper right) early in a coronary artery bypass surgery. ... A heart-lung machine (upper right) in a coronary artery bypass surgery. ... Image File history File links Download high resolution version (6066x4067, 1748 KB) http://fmp. ... Image File history File links Download high resolution version (6066x4067, 1748 KB) http://fmp. ... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ... It has been suggested that Subcutaneous fat be merged into this article or section. ... A heart-lung machine (upper right) in a coronary artery bypass surgery. ... Cardiac Surgeon is a surgeon who performs operative procedure on the Heart and also on Great vessels of the body. ... The heart and lungs, from an older edition of Grays Anatomy. ... The aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ... “Surgeon” redirects here. ... angina tonsillaris see tonsillitis. ... This article does not cite any references or sources. ... Section of an artery For other uses, see Artery (disambiguation). ... In the circulatory system, a vein is a blood vessel that carries blood toward the heart. ... In medicine, grafting is a surgical procedure to transplant tissue without a blood supply. ... The aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ... Atherosclerosis is a disease affecting arterial blood vessels. ... A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure. ... Human blood smear: a - erythrocytes; b - neutrophil; c - eosinophil; d - lymphocyte. ... The coronary circulation consists of the blood vessels that supply blood to and from the heart muscle itself. ... Myocardium is the muscular tissue of the heart. ... A Heart-Lung Machine (upper right) in a Coronary Artery Bypass surgery (CABG) Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery. ...

The technique was pioneered by Argentine cardiac surgeon René Favaloro at the Cleveland Clinic in the late 1960s.^[1] Cardiac Surgeon is a surgeon who performs operative procedure on the Heart and also on Great vessels of the body. ... René Favaloro Dr. René Gerónimo Favaloro (July 12, 1923 - July 29, 2000) was a famous Argentinian cardiologist who created the technique for coronary bypass surgery. ... Cleveland Clinic is a multispecialty academic medical center located in Cleveland, Ohio. ...

Currently, about 500,000 CABGs are performed in the United States each year.

Terminology

There are many variations on terminology, in which one or more of 'artery', 'bypass' or 'graft' is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'),^[2] pluralized as CABGs (pronounced 'cabbages'). More recently the term aortocoronary bypass (ACB) has come into popular use. CAGS (Coronary Artery Graft Surgery, pronounced phonetically) has been used (primarily outside the United States) and should not be confused with Coronary Angiography (CAG). A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter. ...

Number of bypasses

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, a double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagnonal artery of the LAD) while quintuple means five. Less commonly more than four coronary arteries may be bypassed. The LAD, or left anterior descending artery (or anterior interventricular branch of the left coronary artery, or anterior descending branch) passes at first behind the pulmonary artery and then comes forward between that vessel and the left auricula to reach the anterior interventricular sulcus, along which it descends to the... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ... The LCX, or left circumflex artery (or circumflex artery, or circumflex branch of the left coronary artery) follows the left part of the coronary sulcus, running first to the left and then to the right, reaching nearly as far as the posterior longitudinal sulcus. ...

A greater number of bypasses does not imply a person is "sicker," nor does a lesser number imply a person is "healthier."^[3] A person with a large amount of coronary artery disease (CAD) may receive fewer bypass grafts due to the lack of suitable "target" vessels. A coronary artery may be unsuitable for bypass grafting it if it is small (< 1 mm or < 1.5 mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart). Similarly, a person with a single stenosis ("narrowing") of the left main coronary artery requires only two bypasses (to the LAD and the LCX). However, a left main lesion places a person at the highest risk for death from a cardiac cause.^{[citation needed]} Coronary heart disease (CHD), also called coronary artery disease (CAD) and atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the muscle of the heart). ... A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure. ... The left coronary artery, also abbreviated LCA, arises from the aorta above the left cusp of the aortic valve. ...

The surgeon reviews the coronary angiogram prior to surgery and identifies the lesions (or "blockages") in the coronary arteries. The surgeon will estimate of the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart. Angiography or arteriography is a medical imaging technique in which an X-ray picture is taken to visualize the inner opening of blood filled structures, including arteries, veins and the heart chambers. ...

Indications for CABG

Several alternative treatments for coronary artery disease exist. They include:

• Medical management (statins, antihypertensives, smoking cessation, tight blood sugar control in diabetics)
• Percutaneous coronary intervention (PCI)

Both PCI and CABG are more effective than medical management at relieving symptoms,^[4] (e.g. angina, dyspnea, fatigue), but repeat procedures are required more frequently after PCI.^[4] Lovastatin, the first statin to be marketed The statins form a class of hypolipidemic agents. ... Antihypertensives are a class of drugs that are used in medicine and pharmacology to treat hypertension (high blood pressure). ... A No Smoking sign Smoking cessation (commonly known as quitting, or kicking the habit) is the effort to stop smoking tobacco products. ... In medicine, blood sugar is a term used to refer to levels of glucose in the blood. ... For the disease characterized by excretion of large amounts of very dilute urine, see diabetes insipidus. ... Percutaneous coronary intervention is an invasive cardiologic therapeutic procedure to treat narrowed coronary arteries (artery stenosis). ... angina tonsillaris see tonsillitis. ... Dyspnea (R06. ... “Fatigue (physical)” redirects here. ...

CABG is the preferred treatment with:^[4]

• Disease of the left main coronary artery (LMCA). LMCA disease is associated with sudden death; therefore, lesions of the LMCA are sometimes referred to as widow makers.
• Disease of all three coronary vessels (LAD, LCX and RCA).
• Diffuse disease not amendable to treatment with a PCI.

CABG is the likely the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.^[4] The left coronary artery, abbreviated LCA and also known as the left main coronary artery (often abbreviated LMCA), arises from the aorta above the left cusp of the aortic valve. ... Sudden death is a way of providing a winner for a sports contest which would otherwise end in a tie. ... The LAD, or left anterior descending artery (or anterior interventricular branch of the left coronary artery, or anterior descending branch) passes at first behind the pulmonary artery and then comes forward between that vessel and the left auricula to reach the anterior interventricular sulcus, along which it descends to the... The circumflex artery, also known as the circumflex branch, is an artery that comes off of the left coronary artery. ... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ... In cardiovascular physiology, ejection fraction (Ef) is the fraction of blood pumped out of a ventricle with each heart beat. ... For the disease characterized by excretion of large amounts of very dilute urine, see diabetes insipidus. ...

Prognosis

Prognosis following CABG depends on a variety of factors, but successful grafts typically last around 10-15 years. In general, CABG improves the chances of survival of patients who are at high risk (meaning those presenting with angina pain shown to be due to ischemic heart disease), but statistically after about 5 years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. 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.

Complications

People undergoing coronary artery bypass are at risk for the same complications as any surgery, plus some risks more common with or unique to CABG.

CABG associated

• Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by Off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management).
• Nonunion of the sternum; internal thoracic artery harvesting devascularizes the sternum increasing risk.
• Myocardial infarction due to hypoperfusion, early graft occlusion, or graft failure.
• Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction.
• Acute renal failure due to hypoperfusion.
• Stroke, secondary to aortic manipulation or hypoperfusion.

Postperfusion syndrome, also known as pumphead, is a controversial condition that describes a constellation of neurocognitive impairments attributed to cardiopulmonary bypass (CPB) during cardiac surgery. ... A Heart-Lung Machine (upper right) in a Coronary Artery Bypass surgery (CABG) Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery. ... Off-pump coronary artery bypass (OPCAB) is very similar to the conventional coronary artery bypass grafting (CABG) procedure. ... Nonunion is permanent failure of healing following a broken bone. ... The sternum (from Greek στέρνον, sternon, chest) or breastbone is a long, flat bone located in the center of the thorax (chest). ... Right internal thoracic artery and its branches. ... Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a disease state that occurs when the blood supply to a part of the heart is interrupted. ... A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure. ... Great saphenous vein and its tributaries. ... angina tonsillaris see tonsillitis. ... Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a disease state that occurs when the blood supply to a part of the heart is interrupted. ... For other uses, see Stroke (disambiguation). ...

General surgical

• Infection at incision sites or sepsis.
• Deep vein thrombosis (DVT)
• Anesthetic complications such as malignant hyperthermia.
• Keloid scarring
• Chronic pain at incision sites
• Chronic stress related illnesses
• Death

An infection is the detrimental colonization of a host organism by a foreign species. ... Sepsis (in Greek Σήψις, putrefaction) is a serious medical condition, resulting from the immune response to a severe infection. ... This article is about Deep-vein thrombosis. ... Anesthesia or anaesthesia (see spelling differences) has traditionally meant the condition of having the perception of pain and other sensations blocked. ... Malignant hyperthermia (MH or MHS for malignant hyperthermia syndrome, or malignant hyperpyrexia due to anesthesia) is a rare life-threatening condition that is triggered by exposure to drugs used for general anaesthesia, such as volatile anaesthetics or the depolarizing muscle relaxant suxamethonium chloride. ... A keloid is a special type of scar which results in an overgrowth of tissue at the site of a healed skin injury. ... Chronic pain was originally defined as pain that has lasted 6 months or longer. ... Chronic stress is stress that lasts a long time or occurs frequently. ... For other uses, see Death (disambiguation). ...

Procedure (Simplified)

1. The patient is brought to the operating room and moved onto the operating table.
2. An anesthetist places a variety of intravenous lines and injects an induction agent (usually propofol) to render the person unconscious.
3. An endotracheal tube is inserted and secured by the anesthetist or a respiratory therapist and mechanical ventilation is started.
4. The chest is opened via a median sternotomy and the heart is examined by the surgeon.
5. The grafts are harvested - frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins.
6. The surgeon stops the heart and initiates cardiopulmonary bypass; or in the case of "off-pump" surgery, places devices to stabilize the heart.
7. One end of each graft is sewn onto the coronary arteries beyond the blockages and the other end is attached to the aorta.
8. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In some cases, the Aorta is partially occluded by a C shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. This reduces time spent on the heart lung machine.
9. The sternum is wired together and the incisions are sutured closed.
10. The person is moved to the intensive care unit (ICU) to recover. After awakening and stabilizing in the ICU (approximately 1 day), the person is transferred to the cardiac surgery ward until ready to go home (approximately 4 days).

An operating theatre or operating room is a room within a hospital within which surgical operations are carried out. ... An anesthesiologist (American English), or anaesthetist (British English), is a medical doctor trained to administer anesthesia. ... An intravenous drip in a hospital Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. ... Propofol is a short-acting intravenous anesthetic agent used for the induction of general anesthesia in adult patients and pediatric patients older than 3 years of age; maintenance of general anesthesia in adult patients and pediatric patients older than 2 months of age; and sedation in medical contexts, such as... Diagram of an endotracheal tube (10) that has been inserted into the airway of a patient. ... Respiratory therapy is an allied health field involved in the treatment of breathing disorders which include chronic lung problems (i. ... mechanical or forced ventilation is the use of powered equipment, e. ... Median sternotomy is a surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or cracked. This procedure provides access to the heart and lungs for surgical procedures such as heart transplant, corrective surgery for congenital heart defects (CHDs... Right internal thoracic artery and its branches. ... In human anatomy, the radial artery is the main blood vessel, with oxygenated blood, of the lateral aspect of the forearm. ... Saphenous vein usually refers to the great saphenous vein, but may also refer to the small saphenous vein. ... A Heart-Lung Machine (upper right) in a Coronary Artery Bypass surgery (CABG) Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery. ... Off-pump coronary artery bypass (OPCAB) is very similar to the conventional coronary artery bypass grafting (CABG) procedure. ... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ... Coronary heart disease (CHD), also called coronary artery disease (CAD) and atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the muscle of the heart). ... The aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ... The sternum (from Greek στέρνον, sternon, chest) or breastbone is a long, flat bone located in the center of the thorax (chest). ... For other uses, see Suture (disambiguation). ... ICU room An Intensive Care Unit (ICU) or Critical Care Unit (CCU) is a specialised department in a hospital that provides intensive care medicine. ... Look up ward in Wiktionary, the free dictionary. ...

Conduits used for bypass

The choice of conduits is highly surgeon and institution dependent. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the Left Anterior Descending artery and a combination of other arteries and veins is used for other coronary arteries. The right internal thoracic artery (RITA), the great saphenous vein from the leg and the radial artery from the forearm are frequently used. The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen. Right internal thoracic artery and its branches. ... The LAD, or left anterior descending artery (or anterior interventricular branch of the left coronary artery, or anterior descending branch) passes at first behind the pulmonary artery and then comes forward between that vessel and the left auricula to reach the anterior interventricular sulcus, along which it descends to the... Great saphenous vein and its tributaries. ... In human anatomy, the radial artery is the main blood vessel, with oxygenated blood, of the lateral aspect of the forearm. ... The right gastro-omental artery (or right gastroepiploic artery) runs from right to left along the greater curvature of the stomach, between the layers of the greater omentum, anastomosing with the left gastroepiploic branch of the splenic artery. ... In anatomy, the stomach is a bean-shaped hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. ... For the human abdomen, see human abdomen. ...

Graft patency

Grafts can become diseased and may occlude in the months to years after bypass surgery is performed. Patency is a term used to describe the chance that a graft remain open. A graft is considered patent if there is flow through the graft without any significant (>70% diameter) stenosis in the graft.

Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly.

Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the subclavian artery) left internal thoracic artery with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta). Saphenous vein grafts have worse patency rates, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries. The subclavian artery is a major artery of the upper thorax that mainly supplies blood to the head and arms. ...

Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.^[5][6] These water valves are operated by handles. ... The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the heart. ...

Minimally Invasive CABG

Alternate methods of minimally invasive coronary artery bypass surgery have been developed in recent times. Off-pump coronary artery bypass surgery (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine). Futher refinements to OPCAB have resulted in Minimally invasive direct coronary artery bypass surgery (MIDCAB) which is a technique of performing bypass surgery through a 5 to 10 cm incision. Off-pump coronary artery bypass (OPCAB) is very similar to the conventional coronary artery bypass grafting (CABG) procedure. ... A Heart-Lung Machine (upper right) in a Coronary Artery Bypass surgery (CABG) Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery. ... Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) is a less invasive method of coronary artery bypass surgery. ...

See also

• Angioplasty
• Cardiothoracic surgery
• Dressler's syndrome
• Hybrid bypass
• Off-pump coronary artery bypass surgery (OPCAB)
• Minimally invasive direct coronary artery bypass surgery (MIDCAB)
• Homer's Triple Bypass

This article does not cite any references or sources. ... In medicine, the field of (cardio)thoracic surgery or cardiovascular surgery is involved in the surgical treatment of diseases affecting organs inside the thorax, i. ... Dresslers syndrome is a form of pericarditis that occurs in the setting of injury to the heart or the pericardium (the outer lining of the heart). ... Hybrid coronary bypass is a relatively new procedure and alternative to traditional bypass surgery. ... Off-pump coronary artery bypass (OPCAB) is very similar to the conventional coronary artery bypass grafting (CABG) procedure. ... Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) is a less invasive method of coronary artery bypass surgery. ... Homers Triple Bypass is the eleventh episode of The Simpsons fourth season, which originally aired on December 17, 1992. ...

References

External links

• Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures
• Cardiothoracic Surgery Notes an online interactive review developed by residents in cardiothoracic surgery
• Contenidos de Enfermería y Cirugía Cardiaca
• CTSNet: The Cardiothoracic Surgery Network
• Curso de Enfermería y Cirugía Cardiaca
• Heart Assist Devices
• LVAD Simulator
• Perfusion Line
• The CardioThoracic Surgery Network: Residents Section
• The Implantable Artificial Heart Project
• The Virtual Textbook Of Extracorporeal Technology
• Yale: Introduction to Cardiothoracic Imaging