[[100 Welcome to Outlines of Technique in Cardiac Surgery]] # Technical Outline of Coronary Artery Bypass Grafting ## Positioning - [[Positioning for Cardiac Case]] - Position Options for Conduit Harvest - [[Positioning for Radial Artery Harvest]] ## Preparation and Draping - [[Sonosite Ultrasound for Greater Saphenous Vein]] - [[Preparation and Draping]] - Time-out Checklist ## [[Sternotomy]] ## Conduit Harvest - Consider option of [[Pericardiotomy Before Conduit Harvest]] - Internal Mammary Artery Harvest - [[Deploy RUL-tract Mammary Retractor]] - [[Opening the pleura]] - [[Anatomic Considerations of Internal Mammary Artery Harvest]] - Left Internal Mammary Artery Harvest - [[Pedicled Left Internal Mammary Artery Harvest]] - [[Skeletonized Left Internal Mammary Artery Harvest]] - [[Right Internal Mammary Artery Harvest]] - [[Special Situations in Mammary Artery Harvest]] - Greater Saphenous Vein Harvest - [[Anatomic Considerations of Greater Saphenous Vein Harvest]], also relevant to emergency vein harvest - [[Endoscopic Vein Harvest]] - [[Preparation of Venous Conduit]] - [[Radial Artery Harvest]] - Administer Heparin [^a] ## Cannulation - [[Pericardiotomy]] and [[Creation of the Pericardial Well#CABG Pericardial Well]][^b] - [[Aortic Cannulation Pursestring]][^c] - [[Double-Stage Venous Cannulation Pursetring]] - [[Aortic Cannulation]] - [[Venous Cannulation]] - Is Retrograde Cardioplegia Necessary? [[The Philosophy of Retrograde Cardioplegia]] - [[Retrograde Pursetring and Insertion of Retrograde Cannula]] - [[Antegrade Pursetring and Insertion of Antegrade Cannula]] ## Cardiopulmonary Bypass and Cardiac Arrest - [[Initiate Cardiopulmonary Bypass]] - Stop ventilation - [[Cross Clamp]] - [[Cardiac Arrest]] and [[Myocardial Protection]] - [[Preparation for Proximals]] - [[Preparation for In Situ Arterial Grafts]] ## Coronary Artery Bypass Grafting - Distal SVG Anastomosis, see [[200 A Coronary Anastomosis Primer]] - Proximal SVG Anastomosis, see [[200 A Coronary Anastomosis Primer]] - [[Proximal Free Arterial Anastomosis]] - Preparation of In Situ Arterial Grafts - Distal Arterial Anastomosis - Preferred Order of Typical Bypass Grafts - Maintenance of Cardioplegia during Bypass Grafting ## Reperfusion of the Heart and Termination of Cardiac Arrest - Placement of Epicardial Pacing Wires - Reperfuse Heart with Warm Blood - Defibrillation - Restoration of Stable Rhythm - Check Anastomoses for Hemostasis - Secure Epicardial Pacing WIres to Skin ## Weaning Cardiopulmonary Bypass - Trial Wean/De-Airing Wean/Diagnostic Wean - Add Chemical Support - Remove Cardioplegia Catheters - Final Wean - Protamine Administration ## Decannulation - Venous Decannulation - Aortic Decannulation ## Hemostasis Ritual - Preparation for Hemostasis Ritual - Hemostasis Ritual ## Sternotomy Closure - Chest Tube Placement - Xyphoid Fascial Figure-of-Eight - Sternal Closure - Periosteal Layer - Five Minute Rules - Dermal Layer - Subcuticular Layer - Dressings - Chest Dressing - Leg Dressing [^a]: See [[Philosophies in the Timing of Heparin Administration]] [^b]:See also [[Creation of the Pericardial Well#Philosophy of Pericardial Well Creation]] [^c]: See [[Philosophy of Aortic Cannulation]]