Meghan E. Halub, MD and John M. Stulak MD
Mayo Clinic, Rochester, MN, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Damien J. LaPar, MD, MSc and Gorav Ailawadi MD
Essential Operative Steps
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Conduit choice and IMA harvest (LIMA vs. BIMA), radial artery harvest, and/or saphenous vein harvest
- Open pericardium, creation of pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound
if the patient has high-risk features); consideration of safe cannulation and proximal anastomosis sites - Systemic heparinization (400 units/kg)
- Arterial cannulation
- Venous cannulation
- Myocardial protection cannula placement (antegrade cardioplegia in aortic root, ± retrograde cannula in coronary sinus)
- Check ACT (>400 seconds)
- Initiate CPB
- Aortic crossclamp (reduce CPB flow rate, apply crossclamp, increase CPB flow to 2.0-2.5L/min/m2)
- Antegrade cardioplegia ± topical cooling with ice or cold saline for cardiac arrest (± retrograde cardioplegia)
- Distal anastomoses (start with the right side for possible instillation of cardioplegia down completed vein graft for better
right heart myocardial protection) - Proximal anastomoses
- Antegrade warm blood “Hot Shot” administration for rewarming of myocardium and washout of cardioplegia
- Remove aortic crossclamp with pump flow reduced
- Check for hemostasis
- Arterial and ventricular pacer wire placement, if needed
- Chest tube placement
- Resume ventilation and wean from CPB
- Venous decannulation, myocardial protection cannula removal
- Protamine administration for heparin reversal (test dose first)
- Aortic decannulation
- Assess hemostasis
- Sternotomy closure
Potential Complications and Pitfalls
- Stay midline during sternotomy
- Avoid injury to innominate vein while making pericardial well
- Avoid IMA injury: use cautery at a lower setting of 20 and clip/cut when branches are encountered to avoid thermal
injury. Minimal touch technique - Cannulation catastrophe: avoid aortic dissection/bleeding by making sure to only take partial thickness bites on the aorta
and controlling blood pressure at 100mmHg or less before arterial cannulation. Avoid right atrial tears by using pledgets
if needed for poor tissue - Optimize the location of aortic cannula/crossclamp: if it is calcified, this could lead to stroke. Avoid this by using epiaortic
ultrasound if needed - Insufficient myocardial protection and cardiac arrest: crossclamp not fully occlusive, aortic insufficiency, insufficient
venous drainage - Coronary sinus injury with retrograde cardioplegia cannulation
- Difficulty finding coronary arteries, including intramyocardial vessels
- Injury to coronary artery/posterior wall while opening coronaries
- Opening coronary proximal to lesion
- Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft. Avoid by measuring the vein graft
from the distal anastomosis, reflection of the pericardium superiorly, and to the planned insertion site of the aorta with
the heart filled - Improper deairing prior to removal of aortic root vent
- Bleeding from distal anastomoses
- Decannulation catastrophes
- Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. Unstable angina, 90% stenosis LAD, 80% stenosis proximal PDA]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Coronary artery bypass grafting. (DETAILS: e.g. LIMA to LAD, SVG to PDA)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
EBL: [ml]
Complications: (if encountered)
Products: [FFP/Platelets/PRBCs]
CPB Time: [Minutes]
Aortic Crossclamp Time: [Minutes]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT: e.g. increasingly worse
chest pain and shortness of breath]. Preoperative coronary catheterization reveals [FINDINGS: e.g. 90% stenosis of LAD and
80% stenosis of proximal PDA with estimated ejection fraction of 50-55%].
Description of the Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
obtained. A right internal jugular central venous line, pulmonary artery catheter, and radial arterial line were
inserted. Preoperative TEE was then performed to evaluate cardiac function and valve function. We then proceeded to prep
and drape the chest, abdomen, groins, and lower extremities in sterile fashion. A timeout was performed. Median sternotomy
was then performed. Simultaneous to this, a right lower extremity endoscopic saphenous vein harvest was performed by a
physician’s assistant. After performing the sternotomy, we then proceeded to harvest the left ± right internal mammary artery
in a pedicled/skeletonized fashion. The saphenous vein or radial artery were harvested. Once dissected, full dose heparin
[UNITS] was administered prior to distal division. Hemostasis of the LIMA ± RIMA bed was confirmed. Following harvest
of the LIMA, the IMA retractor was removed and a sternotomy retractor placed. After identification of the innominate vein,
the pericardium was opened, and a pericardial well was created. The aortic cannulation sutures were then placed in the
ascending aorta below the level of the innominate artery. The aortic cannula was then inserted, secured, and deaired. The right
atrial cannulation sutures were then placed within the right atrium. The venous cannula was then placed and secured in the
right atrium. A retrograde cannula (if utilized) was placed through the right atrium and verified to be in the coronary sinus with
palpation ± TEE visualization and pressure monitoring verification with ventricularization of the waveform. A DLP vent was
then inserted into the ascending aorta for administration of antegrade cardioplegia. The aortic crossclamp was placed.
Antegrade cardioplegia was administered and there was rapid arrest of the heart after administering [BLANK]mL of antegrade
cardioplegia followed by retrograde cardioplegia. Ice or cold saline was applied to the heart.
After administering [BLANK]mL of cardioplegia, a suitable site on the [TARGET: e.g. posterior descending coronary
artery] was located. Using a #15C blade, the artery was opened. A saphenous vein graft was trimmed and spatulated; a running
7-0 prolene suture was used to create an end-to-side anastomosis. Antegrade cardioplegia was then administered through the
SVG and flow through the graft was confirmed along with hemostasis. A suitable site on the [TARGET: e.g. left anterior
descending coronary artery] was identified along the mid portion. Using a #15C scalpel blade, the artery was opened. The
LIMA was then trimmed to an appropriate length and spatulated. A bulldog was placed on the LIMA. The distal LIMA
anastomosis was performed using running #7-0 prolene in an end-to-side fashion. We then tested the anastomosis by removing
the bulldog clamp to confirm patency of the graft and hemostasis. An adequate length of the [LEFT/RIGHT] sided saphenous
vein graft to the PDA was then assessed by briefly filling the heart and measuring its length to the aortic root. The vein was
trimmed proximally and spatulated. The heart was then drained, and the site for proximal anastomosis was selected. A #11
blade was used to create an aortotomy. An aortic punch was then used to enlarge the aortotomy and the proximal anastomosis
was completed using running #6-0 prolene.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure
Multiple Choice Question(s)
What are class I indications for CABG based on the 2011 ACCF/AHA Guideline For Coronary Artery Bypass Graft Surgery?
A. Significant (>50% in diameter stenosis) left main coronary artery disease
B. Significant (>70% in diameter stenosis) in 3 major coronary arteries
C. Significant (>70% in diameter stenosis) in the proximal LAD plus 1 other major coronary artery
D. Survivors of sudden cardiac death with presumed ischemia mediated tachycardia caused by significant (>70% diameter)
stenosis in a major coronary artery)
E. All the above
Answer: E. All of the above are the Class I indications that were found in the 2011 ACCF/AHA Guideline for Coronary Artery
Bypass Surgery. At the time of this publication, there was the release of the 2021 ACC/AHA/SCAI Guideline for Coronary
Artery Revascularization, but these guidelines were not endorsed by American Association for Thoracic Surgery (AATS) and
Society of Thoracic Surgery (STS). Due to the controversial nature of the 2021 Guidelines, knowledge of the Class I indications
for CABG should be known and followed.
Sources
Doty D.B., Doty J.R. Cardiac Surgery Operative Technique: 2nd Edition. Elsevier Saunders. 2012. ISBN: 9781416036531.
Hillis L.D., Smith P.K., Anderson J.L., et al. “2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines”. Journal of
the American College of Cardiology. 2011;58:e123-e210.
Kaiser L.R., Kron I.L., Spray T.L. Mastery of Cardiothoracic Surgery: 3rd Edition. Lippincott Williams and Williams. 24
December 2013. ISBN/ISSN: 9781451113150.
Lawton J.S., Tamis-Holland J.E., Bangalore S, et al. “2021 ACC/AHA/SCAI Guideline for Coronary Artery
Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines.” Journal of the American College of Cardiology. 2022 January 18; 145(3): e18-e114.
Sabik JF 3rd, Bakaeen FG, Ruel M, Moon MR, Malaisrie SC, Calhoon JH, Girardi LN, Guyton R; American Association for
Thoracic Surgery and Society of Thoracic Surgeons. The American Association for Thoracic Surgery and Society of Thoracic
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