Coronary Artery Bypass Grafting (CABG)
3353333534wRVU: 38.88 — CABG, arterial graft(s), two33535wRVU: 43.63 — CABG, arterial graft(s), three33536wRVU: 47.22 — CABG, arterial graft(s), four or more33510wRVU: 34.11 — CABG, venous graft(s) only, single33511wRVU: 37.49 — CABG, venous graft(s) only, two33512wRVU: 42.88 — CABG, venous graft(s) only, three33518wRVU: 7.73 — CABG, arterial + venous graft(s), one venous (add-on)33519wRVU: 10.23 — CABG, arterial + venous graft(s), three venous (add-on)
[Triple vessel disease / left main disease / multivessel CAD], not amenable to PCI, requiring surgical revascularization
Same
Coronary artery bypass grafting × [X]: LIMA to LAD [, SVG to RCA, SVG to OM1]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with [Swan-Ganz catheter / arterial line / TEE]
The patient is a [age]-year-old [male/female] with [triple vessel disease / left main disease / multi-vessel CAD with diabetes] with [stable angina / NSTEMI / stable ischemic heart disease] not amenable to complete PCI revascularization. EF was [X]%. Catheterization demonstrated [stenosis of LAD X%, RCA X%, OM1 X%]. Surgical revascularization was recommended after Heart Team discussion. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The LIMA was of [good / adequate / poor] quality and diameter. The greater saphenous vein was [harvested from the right leg / endoscopically harvested] ([adequate caliber, no varicosities]). The target vessels were [soft / calcified / small (<1 .5 mm)]< span>. All [X] grafts were constructed and confirmed patent on intraoperative transit time flow measurement (TTFM). The patient was positioned supine. A median sternotomy was performed. The pericardium was opened and the heart was exposed. The left internal mammary artery (LIMA) was harvested as a pedicle [with the pleura intact] from its origin to the bifurcation. [The right IMA (RIMA) was harvested bilaterally.] The greater saphenous vein was harvested from the right leg [via endoscopic technique] and prepared on the back table. Systemic heparin [300–400 units/kg] was administered and ACT confirmed [>480 seconds]. Cardiopulmonary bypass (CPB) was instituted via [ascending aortic / femoral] cannulation and [two-stage venous cannula / bicaval cannulation]. [Cold blood / del Nido / Buckberg] cardioplegia was administered antegrade [and retrograde]. The heart arrested in diastole. [Distal anastomoses:] [Proximal anastomoses:] [TTFM: LIMA-LAD flow [X mL/min], PI [X]. SVG-RCA [X mL/min], PI [X]. All grafts patent.] The patient was weaned from CPB without [/ with] inotropic support. The aortic cannula was removed. Protamine [X mg] was administered to reverse heparin. Hemostasis was achieved. [2] mediastinal and [1] pleural [chest tubes] were placed. The sternum was closed with [7] sternal wires. The subcutaneous tissue and skin were closed in layers. None None [X] mL [2] mediastinal chest tubes; [1] left pleural chest tube; [right pleural (if right IMA used)] The patient was transferred to the cardiac ICU intubated and sedated. Hemodynamic monitoring via arterial line, CVP, and PAC was continued. Extubation was anticipated in [6–12 hours] per fast-track protocol. CABG was performed off-pump (OPCAB) without cardiopulmonary bypass. The Medtronic Octopus [/ Guidant Acrobat] stabilizer was used to immobilize each target vessel. Intracoronary shunts were used during anastomosis to maintain distal perfusion. The Trendelenburg position and cardiac displacement were managed with a cardiac positioning device. Heparin [150–200 units/kg] was administered to ACT >300 seconds. All anastomoses were confirmed with TTFM. OPCAB avoids the systemic inflammatory response, coagulopathy, and neurological risks of CPB; it is preferred in patients with heavy aortic calcification (porcelain aorta), renal failure, or prior stroke.
The LAD was identified in the [mid / distal] portion and a [longitudinal / beveled] arteriotomy [7 mm] was made. The LIMA was anastomosed to the LAD with running [7-0 Prolene] suture. [SVG to the RCA: the RCA was opened in the [posterior descending] territory. The SVG was anastomosed end-to-side with [7-0 Prolene].] [SVG to OM1: the obtuse marginal was anastomosed as above.]
The aorta was side-clamped. [Aortotomies (4.5 mm) were made with an aortic punch and SVG proximal anastomoses were constructed with [6-0 Prolene] running suture.] Clamps were released, the heart was defibrillated [to sinus rhythm] and rewarmed on bypass.Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** vessel CAD: LAD ***%, RCA ***%, OM1 ***%
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: CABG × ***: LIMA to LAD, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, ETT, Swan, art line, TEE
INDICATIONS: .PTAGE-year-old .PTSEX with *** vessel CAD, EF ***%, not amenable to PCI. Heart Team decision: CABG. Consent obtained.
FINDINGS: LIMA quality ***. SVG from ***, adequate, no varicosities. Targets ***. All *** grafts TTFM confirmed: LIMA-LAD *** mL/min PI ***, SVG-*** *** mL/min PI ***.
PROCEDURE:
Supine. Sternotomy. Pericardium opened. LIMA harvested pedicle. [RIMA ***.] SVG *** endoscopic/open. Heparin *** units/kg, ACT >480. CPB: aortic cannula, ***-stage venous. [Cold blood/del Nido] cardioplegia antegrade/retrograde. Arrested. Distal: LIMA-LAD, ***. SVG-RCA, ***. SVG-OM1, ***. Proximal: aorta side-clamped, *** aortotomies 4.5 mm, SVG proximal anastomoses 6-0 Prolene. Clamps released, defibrillated, rewarmed. TTFM: all patent. Weaned CPB ***. Protamine *** mg. Hemostasis. *** chest tubes. Sternum *** wires. Closed.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: Cardiac ICU intubated. Fast-track extubation planned.
Signed: .ME, .MYDEGREE
.TODAYVariants
Off-Pump CABG (OPCAB)
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