Wednesday 25 march
Title of Procedure: Coronary artery bypass graft (CABG).
Procedure in Detail: The patient was brought to the operating room and given general endotracheal anesthesia. The
pulmonary artery catheter was inserted by anesthesia under sterile technique in the right internal jugular vein. The distal right saphenous vein was harvested from the medial malleolus to just
above the knee using multiple small serial incisions with skin bridges. It was a good quality vein. The leg was closed in layers with 2—0 and 3—0 Vicryl with 3—0 Vicryl subcuticular suture in the
A midline sternotomy was performed. The patient was heparinized. The ascending aorta was found to be extremely calcified after opening the pericardium. There was diffuse atherosclerosis with
visible plaque emanating from the ascending aorta. The aortic arch was cannulated beyond the ascending aorta. The atrium was cannulated, and the patient was placed on bypass. A vent was inserted
into the left ventricle via the right superior pulmonary vein. Coronaries were marked for bypass, including a very large posterior descending artery and a good-sized posterolateral branch just
prior to its bifurcation with two smaller branches. A single-clamp technique was utilized. The aorta was cross-clamped in the least calcified place. One liter of cardioplegia was given antegrade
to arrest the heart. It was packed with ice and then flushed posteriorly. Bypasses were accomplished, first using the reverse saphenous vein in an end-to-side fashion to the PDA, which was a good
quality 2.5 to 3-mm vessel. This was done with a reverse vein and running 7—0 Prolene suture. The second bypass was to the posterolateral branch, which was smaller but easily took a 1.5-mm probe.
This was done with a separate piece of vein and a running 7—0 Prolene suture. A bolus of cold cardioplegia was given, and the patient was rewarmed. With the cross-clamp still in place, a single
aortotomy was made in the ascending aorta. The area was thickened and calcified, but had a decent lumen to allow suture of the proximal end of the PDA up to the ascending aorta with running 5—0
Prolene suture in an end-to-side fashion. After concluding this anastomosis, hot cardioplegia was given into the aortic root. The cross-clamp was removed after a total of 30 minutes cross-clamp
time. The remaining proximal anastomosis of the posterolateral branch was brought onto the hood of the PDA graft. The PDA was isolated with bulldog clamps. Venotomy was made, and the end-to-side
anastomosis of the posterior left ventricle to the PDA was accomplished using running 6—0 Prolene suture in an end-to-side fashion. The system was backbled and de-aired, and the bulldog clamps
were removed. Vessels were inspected, and they were both hemostatic. Two atrial and two ventricular pacing wires were placed and brought out through the skin. One single chest tube was placed
into the mediastinum. Neither pleura was opened. The left ventricular vent was clamped and removed, and the pursestring was ligated. The lungs were inflated. The patient was ventilated and weaned
off bypass successfully without the aid of inotropic support. Protamine was started, and the atrial cannula was removed. Volume status was normalized, and the heparin fully reversed with
protamine. The aortic cannula was removed and the site ligated and reinforced with pledgeted 4—0 Prolene stitch. The chest tube was positioned. The wound was closed using figure-of-eight 0
Ethibond to reapproximate fascia, seven sternal wires, and two layers of running 2—0 Vicryl and a running 3—0 Vicryl in the skin. The patient tolerated the procedure and was transferred to the
intensive care unit in stable condition.
By VINOD NAIR