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CORONARY ARTERY BYPASS. Paul J. Corso, M.D., FACS, FACC Chief Cardiovascular Surgery, Washington Hospital Center. Coronary Revascularization - Surgical. Historical Review: 1946 Vineberg IMA implant into cardiac muscle 1954 Murray Experimental anastomosis (IMA/SVG)

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CORONARY ARTERY BYPASS


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coronary artery bypass

CORONARY ARTERY BYPASS

Paul J. Corso, M.D., FACS, FACC

Chief Cardiovascular Surgery, Washington Hospital Center

coronary revascularization surgical
Coronary Revascularization - Surgical
  • Historical Review:
    • 1946 Vineberg IMA implant into cardiac muscle
    • 1954 Murray Experimental anastomosis (IMA/SVG)
    • 1962 Sabiston First CABG (SVG to RCA)
    • 1964 Garrett First CABG to LAD without pump
    • 1967 Kolessov Lima-LAD, thoracotomy
    • 1968 Favaloro Initial experience with SVG with pump
    • 1970 Johnson Expanded experience CABG
    • 1972 Ankeney USA 1st Single graft series w/o CPB
classic procedure same operation for all

Classic Procedure (Same Operation For All)

Sternotomy

IMA Harvest

SVG

Cannulation for CP Bypass

Arrest Heart

Anastomosis Heparin

Wean From Bypass

Reverse heparin and

Stop Bleeding

21 st century cabg

21st Century CABG

On pump with sternotomy

Off pump with sternotomy

Small incisions on pump

Small incisions off pump

coronary artery bypass grafting without cardiopulmonary bypass
CORONARY ARTERY BYPASS GRAFTING WITHOUT CARDIOPULMONARY BYPASS

Complications of cannulation/clamping

Bleeding – aorta and atrium

Dissection

Embolization

coronary artery bypass grafting without cardiopulmonary bypass12
CORONARY ARTERY BYPASS GRAFTING WITHOUT CARDIOPULMONARY BYPASS

Consumption of coagulation factors

Platelet damage Bleeding

Leukocyte damage (pyrogen) Fever

Leukocyte & platelet-mediated

endothelial damage Edema (increased

Complement-induced increased interstitial H2O)

vascular permeability

Bradykinin Vasoconstriction

Platelet & fibrin microemboli Organ dysfunction

cpb causes of neurological abnormalities
CPB – Causes of Neurological Abnormalities
  • Platelet micro-emboli
  • Air emboli
  • Atherosclerotic emboli
    • Aortic cross clamping
    • Aortic cannulation
    • Proximal graft placement
complications of cabg

COMPLICATIONS OF CABG

Death

MI

CVA

Infection

Bleeding

70% Related to use of CP Bypass

bleeding is a significant aspect of cabg

Bleeding is a Significant Aspect of CABG

300,000 Operations

46% received blood and/or blood products

2.5% returned to OR for bleeding

SOURCE – STS Database

complications of blood transfusion
Complications of Blood Transfusion
  • Death! – “With non-leukocyte reduced transfusions in randomized trials, multiorgan failure and death may occur in up to 10% of transfused intensive care unit patients versus 5% in recipients of leukocyte reduced blood transfusions” => at least 5% of patients may die as a result of blood transfusions!!!
  • Leukocyte-related target organ injury in 2 to 5%
  • Transfusion-related acute lung injury (TRALI) may be the most common complication!!
intraoperative rbc tx increases risk of low output failure
Intraoperative RBC Tx Increases Risk of Low Output Failure
  • 8004 Patients, Northern New England Cardiovascular Disease Study Group
  • Included only patients with <=3 units RBCs
  • nadir hematocrit associated with LOF (p<.02)
  • RBC TX also INDEPENDENTLY associated with LOF (p=0.047)!!

Surgenor, et al. Circulation 2006;114:43-48

adverse outcomes of blood transfusion after cardiac surgery vamvakas et al transfusion 2000
Adverse outcomes of Blood transfusion after cardiac surgeryVamvakas et al Transfusion 2000
  • Prolonged need for mechanical ventilation Habib et al Ann thorac surg 1996
  • Impaired wound healing Chmell et al J surg onc 1996
  • Multiple organ system failure Tran et al Nephro Trans 1994
  • Prolonged length of stay in hospital Vamvakas et al Trans 2000
  • Increased postoperative mortality Watering et al Circ 1998
slide19
Transfusion in CABG is associated with Reduced long term SurvivalBlackstone et al Ann Thorac Surg 2006 Cleveland Clinic
  • 10,289 patients from 1995 to 2002
  • Blood transfusion rate of 49%, Platelets in 9 %,FFP in 2.5 % and Cryo in 0.5 %
  • Risk adjusted: Increased early hazard at 6 months (p< 0.0001) and late hazard at 10 years ( p<0.0001)
  • Decreased survival is “dose dependant” i.e. no. of units
  • Unadjusted risk: 5-year survival in non-transfused vs. transfused was 80 % and 63 %
outcomes blood transfusion
Outcomes: Blood Transfusion

Landmark observational study – 10,289 isolated CABG patients

Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Colleen Gorman Koch, Liang Li, Andra I Duncan, Tomislav Mihaljevic, Floyd D Loop, Norman J Starr, Eugene H Blackstone. Ann Throac Surg 2006;81(5):1650-7.

outcomes blood transfusion21
Outcomes: Blood Transfusion

First large-scale study (10,949 patients) to closely examine isolated CABG surgery related transfusions and outcomes

Each unit of packed red blood cells transfused was associated with an increased risk of:

Morbidity and mortality risk associated with red cell and blood-component transfusion in isolated coronary artery bypass grafting. Colleen Koch, Liang Li, Andra Duncan, Tomislav Mihaljevic, Delos Cosgrove, Floyd Loop, Norman Starr, Eugene Blackstone. Crit Care Med 2006;34(6):1-9.

predictors of postoperative bleeding the big 6
Predictors of Postoperative Bleeding – The Big 6
  • Advanced age
  • Small body size or preoperative anemia (low RBC volume)
  • Anti-platelet & anti-thrombotic drugs.
  • Prolonged operation (CPB time) – high correlation with OR type.
  • Emergency operation
  • Other co-morbidities (CHF, COPD, HTN, PVD, renal failure, etc.)

Ferraris VA, et al. STS Guidelines. Ann Thorac Surg. 2005;79:1454-61.; Ferraris VA, et al. Ann Surg. 2002;235:820-7.

does aspirin cause increased postoperative bleeding
Does Aspirin Cause Increased Postoperative Bleeding
  • 21 studies reviewed the effect of aspirin on postoperative bleeding.
    • 5 of 6 randomized trials showed increased bleeding due to aspirin (Level A evidence).
    • Evidence less convincing in 15 observational studies (Level B or C evidence).

Ferraris VA, et al. STS Guidelines. Ann Thorac Surg. 2005;79:1454-61.

postoperative bleeding and aspirin
Postoperative Bleeding and Aspirin
  • Can estimate the amount of bleeding after operation due to aspirin
    • 200-400cc of increased chest tube blood loss
    • 0.5 to 1.0 unit of blood transfusion due to aspirin.
    • Lower doses of aspirin protect just as well and are associated with less bleeding.

Ferraris VA, et al. STS Guidelines. Ann Thorac Surg. 2005;79:1454-61.

blood conservation interventions class i recommendations is recommended
Blood Conservation Interventions – Class I Recommendations: “Is Recommended”
  • Identify high risk preoperatively.
  • High dose aprotinin; Low-dose aprotinin
  • Lysine Analogs
  • Cell saver
  • Blood transfusion algorithm w/ point-of-care testing.
  • Multimodality approach.

Ferraris VA, et al. STS Guidelines on blood conservation. Ann Thorac Surg, May 2007;83:S27-89

blood conservation class iia recommendations is reasonable
Blood Conservation - Class IIA Recommendations: “Is Reasonable”
  • Preoperative Epogen
  • Intervention in Patients with thrombocytopenia
  • Autologous predonation
  • Off pump Bypass
  • Alternatives to Blood sampling
  • Total Quality Management
  • Discontinue plavix 5 to 7 days preop
  • RBC Transfusion for Hemoglobin < 6: Higher trigger in elderly, CVA, cardiac dysfunction, ischemia
  • Blood component transfusion for clinical bleeding

Ferraris VA, et al. STS Guidelines on blood conservation. Ann Thorac Surg, May 2007;83:S27-89

mangano co workers conclusion
Mangano & co-workers Conclusion
  • ‘Association between aprotinin & serious end-organ damage indicates that continued use is not prudent. In contrast, the less expensive generic medications, EACA & TXA, are safe alternatives.’

Mangano, 2006, NEJM

aprotinin workforce on evidence based surgery response nejm
Aprotinin – Workforce on Evidence Based Surgery Response NEJM
  • ‘…data mostly representing level A evidence suggests that high-dose aprotinin has an acceptable risk-benefit profile and is indicated for blood conservation (class I, level A) in patients at increased risk for bleeding.’

Ferraris, Bridges and Anderson, 2006, NEJM

evidence based blood conservation strategies pennsylvania hospital
Evidence-Based Blood Conservation Strategies: Pennsylvania Hospital
  • Top 4
    • Preoperative interventions
      • Epogen: Hgb =16 ideally
      • Limit anti-thrombotic & anti-platelet drug effect.
    • Limit blood loss during operation
      • High-dose aprotinin or anti-fibrinolytics
      • Meticulous hemostasis
      • Speed of operation
      • Perfusion strategies (minipump)
    • Salvage & sequester blood (not as helpful in high-risk)
      • Cell saver, pump salvage, RAP, AAP, etc.
      • Normovolemic Hemodilution (predonation)
    • Manage blood resources (process of care variables)
      • Multimodality approach including postop epogen/iron
      • Transfusion algorithm & point-of-care testing.
pah cardiac surgery blood conservation protocol pre operative measures
PAH Cardiac Surgery Blood Conservation ProtocolPre Operative measures
  • Consult Bloodless Medicine Team for all patients
  • Outpatients seen by Bloodless Medicine on the same day of Cardiac visit
  • Erythropoetin administration:
  • 40,000 U SQ weekly (caution in renal failure, cancer)
  • In selected cases, acute Coronary syndromes may be stabilized with stenting culprit vessel and elective CABG/Hybrid approach

Courtesy of Dr. Bridges

pah cardiac surgery blood conservation protocol pre operative measures32
PAH Cardiac Surgery Blood Conservation protocolPre operative measures
  • Avoid daily labs in the Inpatients awaiting surgery
  • Serum Ferritin levels in all patients
  • Bloodless Medicine will decide the need for Ferrlecit 125 mg IV/day 3 times
  • Angio - Seal recommended for all patients who may need surgery in the next 48 hrs ( blood loss upto 1 to 2 gms Hb from cath site reported)
  • Vitamin K 10 mg oral for selected patients pre operatively

Courtesy of Dr. Bridges

pah cardiac surgery blood conservation protocol manage r isk factors for transfusion
PAH Cardiac Surgery Blood Conservation protocolManage risk factors for transfusion
  • Coumadin – normalize INR preoperatively; convert to Lovenox as needed
  • Stop Lovenox 24-48 hrs prior to surgery
  • Aspirin (low risk patients/Jehovah’s witnesses), Plavix to discontinue for 5 to 7 days
  • Celebrex
  • Ginka and other herbal supplements
  • Garlic, Vitamin E, Saw Palmeto
  • No Alcohol for at least 1 week
  • Pre operative anemia – major risk factor for transfusion

Courtesy of Dr. Bridges

pah cardiac surgery blood conservation protocol intra operative measures
PAH Cardiac Surgery Blood Conservation ProtocolIntra operative measures
  • Trasylol ( Aprotinin) to be used in high risk patients ex: Plavix, combined procedures, aortic surgery, JW
  • Auto donation: ( Normovolemic hemodilution)

Red cell volume > 900 - 1 unit

Red cell volume > 1100- 2 units

Red cell volume > 1400- 3 units

“One sponge technique”

  • Blood returned to the patient after cardiopulmonary pass
  • Fibrillatory arrest for redo AVR patients with patent IMA

Courtesy of Dr. Bridges

pah cardiac surgery blood conservation protocol intra op measures bypass circuit
PAH Cardiac Surgery Blood Conservation ProtocolIntra Op measures- Bypass circuit
  • Miniature Cardiopulmonary Bypass Circuits
  • CELL SAVER ONLY
  • Leg elevation, chair position improves venous drainage
  • Antegrade and Retrograde priming
  • Smaller venous line 3/8 as opposed to ½ - less prime
  • ‘Follow through’–retrieve all blood from bypass circuit
  • Full rewarming to 36 deg before weaning bypass

Courtesy of Dr. Bridges

best strategy optimize cardiopulmonary bypass technology
Best Strategy: Optimize Cardiopulmonary Bypass Technology
  • 1. Reduces systemic inflammatory
  • response syndrome and preserves platelet function. Aprotinin enhances this effect
  • Decreases Blood Loss
  • Avoids Reduced Graft Patency of Off Pump Bypass
  • Applicable to all situations
low prime circuits benefits
Low Prime Circuits: Benefits
  • Reduced Priming Volume
    • Reduced hemodilution
    • Decreased blood component usage
  • Reduced foreign surface area
    • Less contact activation (systemic inflammatory response)
summary low prime circuits
Summary – Low Prime Circuits
  • Demonstrated safety and efficiency
  • Proven results regarding clinical factors that influence patient outcomes (nadir HCT/Frequency of blood transfusions)
  • Confirmed cost avoidance
  • Low impact to surgical technique
  • Procedure independent – can by utilized on all procedures requiring CPB
pah cardiac surgery blood conservation protocol intra op measures hemostatic agents
PAH Cardiac Surgery Blood conservation ProtocolIntra Op measures–Hemostatic agents
  • Thrombin, Gelfoam, Surgicel for sternum
  • Bio Glue and Fibrin glue ( ex Tissel) as needed
  • ‘Point Of Care Testing’ to be evaluated

Courtesy of Dr. Bridges

pah blood conservation program post op measures bleeding patients
PAH Blood Conservation ProgramPost op measures – bleeding patients
  • Coagulation profile- Protamine as needed
  • Correct temperature
  • Replace volume with 5% Albumin
  • Positive Airway Pressure
  • Cryoprecipitate
  • Early re exploration

Courtesy of Dr. Bridges

pah cardiac surgery blood conservation protocol post op measures minimize labs
PAH Cardiac Surgery Blood Conservation ProtocolPost op measures – Minimize labs
  • Avoid routine labs
  • Use peripheral lines
  • Small “pediatric” tubes
  • Stable patients – labs on alternate days

Courtesy of Dr. Bridges

conclusions
Conclusions
  • A multimodality approach to blood conservation is essential
  • Guidelines are useful to help guide therapy and reduce variability in practice.
  • Aprotinin is an important adjunct to a comprehensive cardiac surgery blood conservation program in high risk patients, Jehovah’s witnesses, and other “transfusion free” cardiac surgery patients
  • The avoidance of blood transfusion in cardiac surgery patients decreases costs, morbidity and is likely to decrease mortality as well.