#13. CORONARY ARTERY BYPASS GRAFTING

TITLE OF OPERATION: Coronary artery bypass grafting surgery.

DESCRIPTION OF OPERATION: The patient was delivered to the operating room and was placed upon the operating room table supine. Swan Ganz catheter and radial artery line were inserted. General endotracheal anesthesia was administered. The patient was prepared with Betadine and draped in a sterile fashion.
The saphenous vein was harvested from the lower extremity, sufficient for three bypass grafts. The tributaries of the vein were controlled with silk clips and silk ligatures. The venous bed was irrigated with antibiotic-containing saline and closed in layers.
The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary artery was fully mobilized. The patient was heparinized systemically after which, the internal mammary was transected distally and prepared for anastomosis. The pericardium was opened. Arterial cannulation was achieved. The distal ascending aorta and venous were placed with a dual-stage venous cannula. Via the right atrial appendage, cardiopulmonary bypass was initiated.
The patient was cooled systemically to approximately 32 degrees C. With application of the aortic crossclamp, the cold blood cardioplegia solution was administered to effect a good cardiac arrest. Cardioplegia was administered in 15-20 minute intervals throughout the period of the aortic occlusion. After hypothermia was achieved, iced saline slush and phrenic nerve protector was employed. The distal anastomoses were accomplished first. Individual segments of reverse saphenous vein were sewn to the obtuse marginal, to the posterolateral branch of the circumflex artery, and to the distal right coronary artery respectively. Each of these anastomoses were carried out with running sutures of 7-0 Prolene. The left internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending vessel with a running suture of 8-0 Prolene. At the termination of this, warm blood cardioplegia was administered and the aortic crossclamp was then released. A partial occluding clamp was placed on the aorta. Three buttons of aortic tissue were excised and used as three proximal anastomoses for the saphenous grafts which were carried out with running sutures of 6-0 Prolene. Temporary pacing wires were placed on the surface of the right atrium and right ventricle.
With the patient fully re-warmed, the heart resumed a good contractility and resumed a normal sinus rhythm. The patient was weaned from cardiopulmonary bypass. This was tolerated without difficulty or need for inotropic support. Excellent Doppler signals were appreciated over all grafts. Protamine was administered to reverse the heparin effect. Decannulation was accomplished. All cannulation sites were reinforced. The patient's hemodynamics remained stable. The entire wound was inspected for hemostasis and was felt to be adequate. One mediastinal tube and one left pleural tube were placed.
The chest was closed in layers in the usual fashion and dry sterile dressing was applied. The patient tolerated the procedure well.