3. Definition
“Procedure in which occluded coronary
arteries are bypassed with the patient’s
own venous or arterial blood vessels orown venous or arterial blood vessels or
synthetic grafts” (Ignatavicius &
Workman, 2010).
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5. The major vessels of the coronary circulation
are the left main coronary that divides into left
anterior descending and circumflex branches,
and the right main coronary artery.
The left and right coronary arteries originate
at the base of the aorta from openings called
the coronary ostia located behind the aortic
valve leaflets.
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6. The left and right coronary arteries and their
branches lie on the surface of the heart, and
therefore are sometimes referred to as the
epicardial coronary vessels.
These vessels distribute blood flow to
different regions of the heart muscle.
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8. Purposes
Restore blood flow to the heart
Relieves chest pain and ischemia
Improves the patient's quality of life
Enable the patient to resume a normal lifestyle
Lower the risk of a heart attack
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15. • Robotic-assisted coronary artery bypass grafting
is a minimally invasive procedure.
• The surgeon makes several small incisions
between the ribs, and then inserts a small
camera and small robotic arms through thecamera and small robotic arms through the
incisions.
• During the procedure, the surgeon sits at a
console and controls the robotic instruments.
• The camera that was inserted provides images
of the heart at a high magnification.
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16. Common source grafts
Arterial Conduits.
Left Internal Thoracic (Mammary) Artery
(LIMA).
The ITA arise from subclavian artery just aboveThe ITA arise from subclavian artery just above
and behind the sternal end of the clavicle
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18. Radial Artery
The second artery that can be used as
arterial conduit for coronary graft is Radial
Artery (RA).
The RA arises from the bifurcation of theThe RA arises from the bifurcation of the
brachial artery in the cubital fossa and
terminates by forming the deep palmar arch
in the hand.
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20. Ulnar Artery
• when surgeons do not have other choice
they use Ulnar Artery as arterial conduit.
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21. Gastroepiploic artery
The Gastroepiploic artery is sometimes used as
an arterial graft when the IMA cannot reach the
posterior surface of the heart or when other
conduits are not availableconduits are not available
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22. Greater Saphenous Vein (GSV)
• The Greater Saphenous Vein (GSV) of the
lower extremity is the best choice.
GSV is harvested in two different ways:
Directly through multiple incisionsDirectly through multiple incisions
tunnelling over the vein along the medial
thigh and leg
Endoscopic vein harvest two small
incisions are made, one above the knee, and
the second upper thigh for this type of
harvest. 22
24. Procedure
• An endotracheal tube is inserted and secured by
the anaesthetist and mechanical ventilation is
started. General anaesthesia is maintained by a
continuous very slow injection of Propofol.continuous very slow injection of Propofol.
• The chest is opened via a median sternotomy
and the heart is examined by the surgeon
involves creating a 6 to 8 inch incision in the
chest (a thoractomy) .
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26. • The bypass grafts are harvested – frequent
conduits are the internal thoracic arteries, radial
arteries and saphenous veins.arteries and saphenous veins.
• When harvesting is done, the patient is given
heparin to prevent the blood from clotting.
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27. • "on-pump", the surgeon sutures cannulae into
the heart and instructs the perfusionist to start
cardiopulmonary bypass (CPB).
• Once CPB is established, the surgeon places
the aortic cross-clamp across the aorta and
instructs the perfusionist to deliver
cardioplegia to stop the heart and slow its
metabolism
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30. when there is concern about multiple anastomoses on aorta,
surgeon can construct two or more distal anastomoses with a
single vein graft.
Sequential Distal Vein Graft Anastomoses
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31. • Chest tubes are placed in the mediastinal and
pleural space to drain blood from around the heart
and lungs.
• The sternum is wired together and the incisions
are sutured closed.
• The patient is moved to the intensive care unit
(ICU) to recover.
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32. • Nurses in the ICU focus on recovering the patient by
monitoring blood pressure, urine output and
respiratory status as the patient is monitored for
bleeding through the chest tubes.bleeding through the chest tubes.
• If there is chest tube clogging, Thus nurses closely
monitor the chest tubes and under take methods to
prevent clogging so bleeding can be monitored and
complications can be prevented.
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34. Nursing Management
• Pre operative Phase• Pre operative Phase
• Intra operative Phase
• Post operative Phase
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35. Patient History
• Patient history of major illness, previous
surgery, medications, and usage of drugs and
smoking and drug history
• A systematic assessment of all systems
performed ,with emphasis on cardiovascular
functioning
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36. Physical Examination
Functional status of the cardiovascular system
determined by reviewing the patient symptoms,
including past and present experience
Chest pain, hypertension, palpation, cyanosis,
breathing difficulty, leg pain that occur withbreathing difficulty, leg pain that occur with
walking, Orthopnea, peripheral edema.
Because alteration in cardiac function (cardiac out
put can affect renal, respiratory, gastrointestinal ,
integumentary, hematological, and neurological
functioning ).
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37. Physical Examination continued…..
General appearance and behavior.
Vital signs
Nutritional and fluid status ,weight, height.
Inspection and palpation of the heart, noting theInspection and palpation of the heart, noting the
point of maximal impulses ,abnormal pulsation.
Auscultation of the heart ,noting pulse rate, rhythm
and quality S4 and S3 , murmur, and friction rib
Jugular venous pressure
Peripheral pulses
Peripheral edema
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38. Psychosocial Assessment
Meaning of the surgery to the patient and family
Coping mechanisms that are being used
Measures used in the past to deal with stress
Anticipated changes in life style
Support system in effect
Fears regarding the present and future
Knowledge and understanding of the surgical
procedure.
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39. Nursing Diagnoses
• Acute pain
• Decrease cardiac output
• Risk for infection
• Risk for alteration in fluid volume & electrolyte
imbalanceimbalance
• Risk for impaired gas exchange
• Risk impaired renal perfusion
• Impaired skin integrity
• Anxiety
• Fear
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42. Discharge Planning & Teaching
What to expect at home
Pain in your chest around the incision area
Swelling in the leg at harvest site
Itchiness or tingling feeling at incision site
Weakness
Cardiac rehabilitation
Lifestyle & diet modification
Smoking cessation
Cardiac diet (Low salt, low cholesterol, low fat)
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43. Discharge Planning & Teaching continued…
Activity
No driving for at least 4 to 6 weeks
Walking / climbing stairs are good exercise
Light household chores (folding clothes, setting tables
Self careSelf care
Shower & wash incision gently with soap and water
Do not use hot tubs until incision is completely healed
Adhere to all medication regimen
Have someone stay with you in your home for at least
first 1-2 weeks
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