Perel A. Baral, DO and Alexander Schutz, MD
Baylor College of Medicine / Texas Heart Institute, Houston, TX, 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 Uthman Aluthman, MD, and Teresa M, Kieser, MD.
Essential Operative Steps
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Conduit choice and LIMA harvest, LIMA preparation
- Open pericardium, create pericardial well, survey ascending aorta for plaque burden with epiaortic ultrasound
- Systemic heparinization to goal ACT >250 seconds
- Sternal retractor, ± Trendelenburg position of operating room table ± lateral rotation of the table to expose distal target
without hypotension - Place posterior pericardial sutures and/or pericardial sling to position/elevate the heart for optimal exposure for distal
anastomoses - Octopus tissue stabilizer to stabilize the anastomotic site with possible use of Starfish heart positioner to aid in exposure
of target site and to improve hemodynamics during anastomosis completion. Possible placement of temporary atrial ±
ventricular pacing wires to stabilize rhythm and/or to counteract bradycardia especially if performing RCA distal
anastomosis - Place a proximal snare (with a silastic vessel loop) around the native coronary artery to control bleeding during
performance of distal anastomosis - Perform test occlusion of coronary with snare. If ECG or TEE changes, place an intracoronary shunt
- Distal anastomoses (LIMA-LAD first)
- Proximal anastomosis which may require a partial occluding clamp or aortic anastomosis device such as the Heartstring
- Check flows with transit time flow measurement
- Check for hemostasis
- Optional placement of arterial and/or ventricular pacer wire placement
- Chest tube placement
- Protamine administration for heparin reversal (test dose first)
- Assess hemostasis
- Sternotomy closure
Potential Complications and Pitfalls
- Stay midline during sternotomy
- Avoid injury to the innominate vein while making the pericardial well
- Avoid IMA injury: use pedicle, no touch technique
- Difficulty finding coronary arteries, including intramyocardial vessels: can use epicardial US
- Specific to off pump
- During performance of distal anastomosis: signs of ischemia, hypotension, hemodynamic compromise, and
ventricular arrhythmia/fibrillation during performance of distal anastomosis may necessitate placement of a shunt - Have a plan in place for on-pump beating heart vs on pump with cardiac arrest suboptimal bypass requiring
revision/redo of bypass - Consider alternatives to proximal anastomosis off aorta e.g. true no touch technique with either total arterial
revascularization (BIMA, gastroepiploic, Y graft off LIMA, or vein off innominate done with side biting clamp) - Injury to coronary artery/posterior wall while opening coronaries
- Opening coronary proximal to lesion: careful review of coronary angiogram preoperatively and even intraoperatively if
there are uncertainties. Can also use epicardial US for this - Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft
- Bleeding from distal anastomoses
- Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
Template Dictation
Preoperative Diagnosis: [BLANK]
Post-operative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Elective coronary artery bypass grafting (CABG) x3 off pump, LIMA-LAD, SVG-OM, SVG-RCA
(distal)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [NAME] is a [AGE] year old [SEX] with [DURATION] history of [COMPLAINT].
Preoperative coronary catheterization reveals [BLANK finding]. After extensive discussion of risks, benefits, and alternatives
to surgery, the patient elected to proceed with surgical coronary bypass. Of note, a discussion regarding use of cardiopulmonary
bypass vs off-pump technique vs on-pump beating heart technique was had, given that [REASON FOR CHOOSING TO DO
OFF PUMP], the decision was made to plan for off pump bypass.
Operative Findings: The patient had reasonable targets and good conduits. Heart function was normal without any regional
wall motion abnormalities seen on the TEE both preoperatively and postoperatively. TEE intraoperatively showed [BLANK].
Transit time flow measurement was appropriate with pulsatility index and diastolic flow pattern within normal limits.
Description of the Procedure: General anesthesia was induced and the patient was intubated without issue. A right internal
jugular central venous line, pulmonary artery catheter, and radial arterial line were inserted. Chest, abdomen, groins, and lower
extremities were prepped and draped in the usual sterile fashion. The chest was opened via midline sternotomy. The left internal
mammary artery was taken down with a pedicle. Simultaneous to this, a left lower extremity greater saphenous vein was
harvested by endovascular technique, performed by a physician’s assistant. Once all conduits were harvested and hemostasis
ascertained, the patient was heparinized to achieve a goal ACT of >250 seconds.
The mammary retractor was exchanged for the sternal retractor. The LIMA was trimmed to an appropriate length and
spatulated. The patient was placed in deep Trendelenburg position with a heart sling attached to the posterior pericardium 1cm
away from the border of the left atrium, 2/3 the distance from the inferior vena cava and 1/3 the distance from the left inferior
pulmonary vein. The heart was elevated. A slit in the pericardium was created for passage of the LIMA. The Octopus tissue
stabilizer was used to stabilize the site of the LIMA to LAD anastomosis. A silastic vessel loop was placed around the LAD
proximal and distal to the location of the anastomosis. A test occlusion of the LAD was performed. There were no ECG or
TEE changes so a shunt was not placed, but was available if needed. The LIMA was trimmed to an appropriate length and
spatulated distally. The LAD was carefully dissected out with a Beaver blade and opened with a #15 blade. A running 7-0
prolene suture was used to create an end-to-side anastomosis with the pedicled LIMA graft. This anastomosis was hemostatic
and transit-time flow was used to check the flow, resistance (pulsatility index), and diastolic filling; these parameters were
found to be adequate. Using the previously placed proximal snare to occlude the LAD, we tested for competitive flow, and
there was none. The heart was placed in the neutral position and transit-time flows were re-measured and were found to be
good.
The reversed saphenous vein was then gently distended to check for leaks. The patient was placed deeper in the Trendelenburg
position and the OR table was rotated toward the surgeon’s side; the heart sling was repositioned so as to expose the lateral
wall of the left ventricle. The obtuse marginal artery was identified and the Octopus tissue stabilizer was used to stabilize the
intended location of the distal anastomosis. Proximal and distal snares with test occlusion were then employed in an identical
manner to the LIMA-LAD anastomosis, and the saphenous vein was anastomosed to the obtuse marginal artery in end-to-side
fashion with continuous 7-0 prolene.
The patient and heart were then repositioned for the distal right coronary artery anastomosis. Proximal and distal snares with
test occlusion were then performed. There was some inferior lead ST elevation on the ECG so a shunt was placed. The
saphenous vein graft was then anastomosed to the distal right coronary artery with 7-0 prolene in a similar manner to the
previous two anastomoses, with the exception of the shunt being removed just prior to the completion of the anastomosis. The
heart and patient were then both placed in a neutral position.
The proximal saphenous vein to ascending aorta anastomoses were then completed using the Heartstring device so as to avoid
any clamping of the ascending aorta. The anastomoses were performed using 6-0 prolene and hemostasis was confirmed.
Transit-time flow measurement was then used to measure graft flow, resistance, and diastolic filling; these parameters were
found to be adequate.
Protamine was given to reverse the heparin. All graft flows were checked again with transit-time flow. Blake drains were
placed in the left pleural cavity and in the anterior and posterior mediastinum. Pacing wires were not placed.
The sternum was closed with #7 stainless steel sternal wires x 8. The fascia and subcutaneous layers were closed with 2-0
vicryl. The skin was closed with 4-0 monocryl in running subcuticular fashion.
The patient tolerated the procedure well. There were no immediate complications. All instrument, sponge, and needle counts
were confirmed to be correct, twice, at the end of the operation. The patient was kept intubated and brought to the cardiovascular
intensive care unit in stable condition.
The total OR time: [BLANK]
TEE findings: [BLANK]
Transit-time flows were as follows: LIMA-LAD: [BLANK]mL/minute / pulsatility index [BLANK] / diastolic filling
[BLANK%]; with proximal snare was [BLANK]mL/minute / pulsatility index [BLANK] / diastolic filling [BLANK%]. Post
Protamine: [BLANK]ml/minute / pulsatility index [BLANK] / diastolic filling [BLANK].
The SVG-OM: [BLANK]mL/minute / pulsatility index [BLANK] / diastolic filling [BLANK%]; with proximal snare was
[BLANK]mL/minute / pulsatility index [BLANK] / diastolic filling [BLANK%]. Post Protamine: [BLANK]ml/minute /
pulsatility index [BLANK] / diastolic filling [BLANK].
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
A 77 year old male is undergoing 2-vessel off-pump CABG, and the surgeon is planning her cannula placement. What is the
best modality for assessing the aorta for safe aortic cannulation?
A. TEE
B. Review of preoperative CT chest
C. Manual palpation
D. Epiaortic ultrasound
E. Preoperative angiography
Answer: D. The best way to decrease the risk of stroke in patients undergoing CABG is to not manipulate the aorta. However,
as this is not feasible in the majority of instances, a “no-touch technique” should be employed as much as possible. This means
avoiding palpation and attempting to identify areas of plaque so as to cannulate and clamp in areas where there is no plaque
present. Extensive investigation of this issue with comparison of patients in whom epiaortic ultrasound was used vs those in
whom it was not used, showed that use of epiaortic US was associated with a significantly lower risk of embolic stroke in
CABG patients.
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in Coronary Artery Bypass Grafting. Ann Thorac Surg. 2020 Jan;109(1):294-301.
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Bishawi M, Grover FL; Veterans Affairs ROOBY-FS Group. Five-Year Outcomes after On-Pump and Off-Pump CoronaryArtery Bypass. N Engl J Med. 2017 Aug 17;377(7):623-632.
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