What is coronary artery bypass surgery?

Article written by Doctor of Cardiology - Thoracic Surgery, Vinmec Central Park International General Hospital

Coronary artery disease has a diverse clinical picture caused by impaired myocardial perfusion, most commonly due to atherosclerosis of the subendothelial layer leading to coronary artery stenosis or obstruction and thickening of the wall, which is a form of coronary artery disease. The most common heart failure can cause complications and lead to death.

Coronary artery bypass surgery is surgery using autologous blood vessels (internal thoracic artery, inverted great saphenous vein ...) to bypass the narrowing, allowing blood to reach the distal end of the vessel. coronary, the aim is to increase perfusion of the distal head.

Indications for coronary artery bypass grafting to improve the quality of life for patients (meaning reducing symptoms, increasing physical activity, prolonging life).
Coronary bypass surgery offers survival advantages compared with medical therapy in patients with (1) left main body stenosis, (2) tri-coronary artery disease, (3) ) bicoronary artery disease with proximal stenosis of the anterior interventricular artery, (4) compromised left ventricular function, and (5) polyarterial disease and severe ischemia.
Advances in new techniques have expanded the group of patients with single or multiple vascular lesions for whom percutaneous intervention is the logical choice or even the preferred first-line approach.
However, patients and cardiologists need to consider the incidence of recurrent angina and the need for repeat reperfusion interventions. For patients who are not favorable for percutaneous intervention or when percutaneous intervention is weak, surgery is considered a strong consideration.
Indications for surgery are based on the recommendations of the American College of Cardiology and the American Heart Association (1999).

Group I
Coronary artery bypass grafting should be performed in patients with mild or asymptomatic angina with significant stenosis of the left main coronary artery (A)
CABG should be performed in patients with severe angina Mild or asymptomatic angina with syndrome equivalent to left main branch: (3 70%) proximal stenosis of the anterior interventricular artery and proximal left circumflex artery (A) A coronary artery bypass graft is useful in patients with mild or asymptomatic angina in which three coronary artery trunks are injured. (survival rate is higher than the group of patients with abnormal left ventricular function)(C)

Class IIa
PCI may be beneficial for patients with mild or asymptomatic angina who have an anterior interventricular artery proximal to one or two injured arteries (this recommendation becomes class I if the ischemia is widespread). demonstrated by non-invasive studies and/or LVEF 0.5 )(A)
Class IIb
CAD may be considered for patients with mild or asymptomatic angina with 1-2 arteries Lesions do not include the proximal anterior interventricular artery (B).

Class I
PCI is recommended for patients with stable angina with significant left main coronary artery stenosis. (A) A PCI is recommended for stable angina patients with coronary equivalent syndromes. Main left: Significant stenosis (3 70%) proximal to the anterior interventricular artery and proximal left circumflex artery.(A) A coronary artery bypass graft is recommended for patients with stable angina with three damaged coronary arteries.( A) PCI is recommended for patients with stable angina with two damaged coronary arteries with significant stenosis (3 70%) of the proximal anterior interventricular artery as well as an FE 0.5 or ischemic sign. may be indicated on non-invasive testing.(A) PCI is beneficial for patients with stable angina pectoris with 1-2 damaged arteries without significant proximal anterior ventricular stenosis but with large area of ​​viable myocardium and high risk criteria on noninvasive testing.(B) PCI is beneficial for patients with stable angina who develop dysfunctional angina as determined by Whether With minimally invasive methods, surgery can be performed with acceptable risk. (B) Class IIa
PCI is reasonable for patients with stable angina who have anterior ventricular stenosis proximal to the lesion. 1 artery. (This recommendation becomes class I if widespread anemia is demonstrated by non-invasive studies and/or LVEF £0.5).(A) PCI is useful for patients with stable angina with stable angina. 1-2 injured arteries without significant stenosis proximal to the anterior interventricular artery but with significant viable myocardium and ischemia that can be demonstrated by noninvasive testing.(B) Group III
Coronary artery disease is not recommended for patients with stable angina with 1-2 artery lesions excluding significant stenosis proximal to the anterior interventricular artery, in patients with mild symptoms not associated with ischemia. myocardium , or the patient is not receiving medical therapy and: a) only a small area of ​​the myocardium is viable or (B)
b) no area is found by noninvasive testing (B)
CHD is not recommended Patients with stable angina with limited coronary artery stenosis (50-60% of the diameter outside the main left coronary artery) have no evidence of ischemia on noninvasive testing.(B) ) CNDMV without button Reported to patients with stable angina with significant coronary artery stenosis (less than 50% reduction in diameter) (B)

Class I
PCI should be performed in patients with unstable angina/NSTEMI with significant left main coronary stenosis. (A) PCI should be performed in patients with unstable angina/NSTEM h/c equivalent to the left main branch: significant stenosis (3 70% ) proximal stenosis of the anterior interventricular artery and the left proximal circumflex artery ( A ) A coronary artery bypass graft is recommended for unstable angina/NSTEM in this patient. Patients with poor reperfusion, and progressive anemia that do not respond maximally to nonsurgical therapies. (B) Class IIa
PCI is likely to be indicated for unstable angina/NSTEMI with stenosis. Anterior interventricular artery proximal to 1-2 injured arteries.(A)
Class IIb
PCI may be considered for patients with unstable angina/NSTEMI with 1-2 injured arteries without including the proximal anterior interventricular artery for which percutaneous reperfusion is poor or not possible. (if viable myocardium is present and high-risk criteria on noninvasive tests.(B)

Class I
Emergency or urgent coronary artery bypass grafting in patients with STEMI should be classified in the following situations:
Class IIa
Myocardial infarction can be performed as a perfusion measure First, in anatomically favorable patients who are not subjects to/or failed fibrinolytic therapy/PCI and in patients with early MI (6-12 hours) including myocardial infarction ST-elevation. This risk must be taken into account. Beyond 7 days post-infarction, the criteria for reperfusion described in the previous section apply. (B) Class III
Urgent coronary artery bypass grafting should not be performed in patients with persistent angina. The chest and a small area of ​​myocardium are at risk in whom the patient is hemodynamically stable. (C) Emergency coronary bypass should not be performed in patients with good but unsuccessful self-reperfusion. blood at the microvascular level.(C)

Group I
CNCV should be performed in patients with poor left ventricular function with significant left main coronary artery stenosis.(B) CNCV should be performed in patients with poor left ventricular function with h/c equivalent left main branch: significant stenosis (3 70%) proximal to the anterior interventricular artery and proximal left circumflex artery. (B) CPR should be performed in patients with poor left ventricular function with proximal anterior ventricular stenosis. with 1-2 damaged arteries. (B) Class IIa
CNCV can be performed in patients with poor left ventricular function with significant contractile strength, myocardium still perfused, and absent any anatomical abnormality.(B)
Class III
CNCV should not be performed in patients with poor left ventricular function without apparent claudication and with no apparent viable myocardium be reperfused.(B)

Class I
CNCV should be performed in patients with life-threatening ventricular arrhythmias caused by stenosis of the main left coronary artery. (B) CNCV should be performed in patients with life-threatening ventricular arrhythmias. caused by tri-coronary artery disease.(B) Group IIa
MI is reasonable when it is possible to bridge over 1-2 damaged arteries causing life-threatening ventricular arrhythmias. (This becomes Class I recommendation if the arrhythmia is reversed...sudden cardiac death or tolerable ventricular tachycardia.)(B) PCI is reasonable for life-threatening ventricular arrhythmias causing caused by damage to the proximal anterior interventricular artery with 1 or 2 arteries involved. (This becomes Class I recommendation if the arrhythmia is reversed...sudden cardiac death or tolerable ventricular tachycardia.)(B) Class III
MI is not recommended in ventricular tachycardia with injury. healing and no obvious signs of anemia.(B)

Class I
CNCV should be performed in patients after PTCA failure who also present with progressive ischemia or threatening obstruction with significant risk of myocardial ischemia.(B) CNCV should be performed in patients after failed surgery with hemodynamic instability. (B) Class IIa
PCI is reasonable after failed surgery with a foreign body located in an important anatomical site. (C) PCI may be beneficial later PTCA failure with hemodynamic instability in a patient with an abnormal anticoagulation system and no previous sternotomy. (C) Class IIb
PCI may be considered after failed PTCA with hemodynamic instability in the patient. Patients with an abnormal anticoagulation system and previous sternotomy. (C)
Group III
PCI is not recommended after failed surgery in patients without evidence of ischemia. (C) PCI is not recommended after ventricular surgery failure with no reperfusion due to anatomical reasons or no reflux.(C)

Open the chest along the middle of the sternum, stopping the bleeding of the sternum.
Dissect and preserve the internal mammary artery for a bridge graft and wrap the pedunculated graft in soft papaverine-impregnated gauze.
High therapeutic dose heparin (300U/kg) is given at this time to achieve an ACT of 480 seconds (550 seconds if aprotinin was used).
Open the skin of the lower leg and/or thigh to remove the umbilical vein, 20-40 cm depending on the number of bridges, flush the vein with serum heparin, prepare the anastomosis.
Open the pericardium and closely examine, palpate and examine the ascending aorta to detect atheroma or calcification and select the location of the aortic cannula. The aorta and pulmonary artery are separated, leaving space between the aorta to place the pair of aorta.
Use silk thread 2.0 or 3.0 (ethibond) sutured in the peritoneum to canule the aorta, usually in adults use canule number 20F, ensuring maximum flow up to 5800mL/min.
For venous return, a double canule (single dual-stage) is usually used and placed through the right atrium, IV canule 32/34F. If using an IUD with a suction system, an asperatif canule can be used.
The downstream cardiac palsy is placed in the middle of the ascending aorta. Cardiac paralysis solution is usually crystalloid (50 meq sodium bicarbonate and 60 meq potasium), which can be combined with blood solution for later times. Coordinate with the Shumways method.
Hypothermia £ 34°C or less if surgery is prolonged.
Flow LVEF: 1.8-2.2l/min/m2, ensure peripheral arterial pressure 50mmHg or higher if the patient has peripheral artery disease.
Pair the aorta and pump the paralytic solution (800-1000ml) to completely stop the heart. Cardiac paralysis and cryotherapy solutions should be aspirated. When the heart has stopped completely, it will be lifted and examined the coronary vessels
Locate the anastomosis on the coronary artery, open the coronary artery along the arterial axis, usually distal (end-to-lateral) or anastomous anastomosis. anastomosis will be performed first (between the vein graft and coronary artery), monofilament thread (prolène 7.0), surjet suture. After each free graft has been anastomosed, approximately 100 ml of hemopoietic fluid can be injected to identify bleeding sites in the anastomosis or in the body of the venous grafts.
After the distal anastomosis has been completed, prepare the anastomosis in the internal mammary artery, check the flow of this artery, and make an anastomosis with the anterior interventricular artery end-to-side.
Warm your heart with matelas.
Proximal anastasias can be performed while the aortic pair is still present, but most surgeons prefer to open the thoracic aortic pair and the thoracic aorta to make these anastomosis with only prolene 6.0, to allow reconstruction. coronary perfusion during anastomosis, shortening the time of myocardial ischemia.
Before closing the last proximal anastomosis, ventilate the lungs, the heart is filled with blood, the air escapes through the aorta up and out through the position to loosen the sutures at the proximal anastomosis, then tighten the sutures and close the mouth. connect.
Good pulmonary ventilation, gradually weaning the RA and stopping completely when hemodynamically stable, withdrawing the canules, neutralizing heparin with protamine, suturing the cannula sites, placing pleural, mediastinal and closed drainage.

The goal of coronary artery bypass grafting is to increase myocardial perfusion, reduce symptoms of chest pain, reduce the risk of heart attack, and improve quality of life.

Coronary artery bypass surgery is one of the difficult techniques, requiring medical facilities to have a team of highly qualified and experienced cardiologists and a system of modern medical equipment. . Vinmec's Cardiology Department has always received much praise and satisfaction from domestic and international customers, being the pioneers in successfully applying the world's most advanced techniques in the treatment of cardiovascular diseases.
A team of highly qualified and experienced specialists: qualified doctors from Master's to Professor's and Doctor's degrees, reputable in medical treatment, surgery, interventional cardiac catheterization. Intensive training at home & abroad. In particular, Prof. TS.BS Vo Thanh Nhan - Cardiology Director of Vinmec Central Park was recognized as the first and only expert in Vietnam to be awarded the "Proctor" certificate on TAVI. State-of-the-art equipment, comparable to major hospitals in the world: The most modern operating room in the world; The most modern silent magnetic resonance imaging machine in Southeast Asia; The CT machine has a super-fast scanning speed of only 0.275s/round without the use of drugs to lower the heart rate; The 16-sequence PET/CT and SPECT/CT systems help detect damage to the cardiovascular organs early even when there are no symptoms of the disease. Applying the most advanced advanced cardiovascular techniques in the world in treatment: Painless open heart surgery; Percutaneous aortic intervention without general anesthesia; Treatment of mitral regurgitation through the catheter has a success rate of 95%; Ventricular-assisted artificial heart transplantation for patients with end-stage heart failure prolongs quality of life beyond 7 years. Cooperating with leading cardiovascular centers in Vietnam and the world such as: National Heart Institute, Cardiology Department of Hanoi Medical University, University of Paris Descartes - Georges Pompidou Hospital (France), University of Pennsylvania (France), University of Pennsylvania (France), University of Pennsylvania (France). United States)... with the aim of updating the most modern cardiovascular treatments in the world. To be examined and treated with leading Vinmec cardiologists, please book an appointment online at the website or contact Vinmec Health System nationwide for service.