What are coronary artery bypass surgery options?

Anthony L. Komaroff, MD
Internal Medicine
Several options in coronary artery bypass surgery now exist. The old standby is conventional open-heart surgery, known medically as coronary artery bypass grafting. In addition, two so-called minimally invasive procedures are also sometimes used: beating-heart surgery and minimally invasive bypass surgery. The procedure you undergo will depend largely on the nature and extent of your heart disease, your overall health, and your surgeon's expertise.
There are two types of CABG operations currently available: on-pump and off-pump surgery. On-pump procedures require the surgeon to open the chest bone (sternum), stop the patient's heart, and place the patient on a heart-lung machine. This machine takes over the function of the patient's heart—delivering oxygenated blood throughout the body and brain—while the bypass is performed.

A new, minimal access procedure, the off-pump method eliminates the need for the surgeon to stop the heart and to place the patient on bypass. The surgeon operates directly on the beating heart, reducing the risk for perioperative bleeding and stroke associated with the on-pump procedure. Selection of an on- versus off-pump procedure partly depends on the health of the individual patient.

An important issue in both on- and off-pump CABG is selection of an appropriate conduit (vein or artery) to bring the new blood supply to the heart. Most often, the internal mammary artery, which is located on the inside of the chest wall, serves as the best conduit because it has been shown to last the longest. In 90% of cases, this conduit will last for the rest of the patient's life. During the bypass procedure, the surgeon will take the internal mammary vessel down from inside the chest wall and attach it to the front of the heart. Alternatively, the saphenous vein in the leg may be used as a conduit.

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