CABG: Prevention of postoperative complications

One of the most devastating complications of coronary artery bypass surgery is neurologic injury. Stroke is estimated to occur in approximately 3-5% of patients after CABG performed using cardiopulmonary bypass techniques. Our efforts in our practice have been focused on the reduction or the elimination of such complications of the surgical treatment of cardiac disease using a variety of new and innovative techniques.

Neurologic injury following cardiac surgery can arise from a variety of sources. Emboli from the ascending aorta are a major source of concern for us as we perform these procedures. To minimize the likelihood of such emboli, we use an epiaortic ultrasound device to carefully examine the ascending aorta so areas of plaque and calcification can be avoided during aortic manipulation. Using this technique we have been able to avoid problem areas of the aorta and thereby significantly reduce the incidence of embolic injury in our practice. Neurologic injury has been associated with the use of the heart-lung machine for cardiopulmonary bypass. A variety of explanations have been proposed including micro emboli of gasses, fat globules, platelet clumps, and a variety of other toxic factors. To avoid these effects we have adopted the use of “off-pump, beating heart techniques” to perform coronary bypass procedures. By avoiding the use of the heart lung machine during these operations we are again able to eliminate that device as a source of neurologic injury in our patients. Postoperative neurologic injury can arise from several sources. Postoperative atrial fibrillation occurs in approximately 20-30% of patients. Emboli from the fibrillating left atrial appendage are well-recognized agents of injury. We now ligate the left atrial appendage in all patients undergoing cardiac surgery to effectively eliminate those emboli.

Infection is another devastating complication associated with cardiac surgery. In addition to careful sterile technique, the use of antibiotics has been invaluable in the reduction of such complications. We have used intranasal Bactroban to reduce nasal colonization of Staphylococcus that is associated with postoperative mediastinitis. With the introduction of this therapy, the incidence of postoperative mediastinitis has been reduced to nearly zero in our practice – a truly gratifying development.