"There is a high degree of procedural variability in performing on-pump coronary artery bypass grafting. Standard direct aortic and dual stage venous cannulation are utilized with cannula style and size a function of the patient´s body surface area and surgeon preference. Following cannulation and verification of safe aortic entry with perfusion (pulsatility and congruent back pressures), a site is chosen for placement of the antegrade cardioplegia cannula. The surgeon must consider how many grafts will be sewn to the aorta and in what orientation, as it is not uncommon for the antegrade site to serve as a proximal landing zone for one of the grafts. The distal targets are evaluated and marked prior to the institution of cardiopulmonary bypass.
Perfusion will be asked to reduce and terminate bypass flow for application of the cross-clamp. Following clamp application, antegrade cardioplegia is administered down the root with constant attention to root pressure and left ventricular distension. After cardiac arrest is obtained, the distal anastomoses are performed in the following order: right, lateral wall and anterior descending artery. After each anastomosis, cardioplegia is administered down the conduit (if vein graft) and root.
It is important for the perfusion and surgical staff to maintain close communication during administration of cardioplegia as a high pressure or poor flow may denote a problem with conduit orientation or with the distal anastomosis. Once the distal anastomoses are completed, an appropriate number of proximal sites are created with a punch device. Proximal anastomoses can be performed with complete or partial occlusion. In patients with an atherosclerotic aorta, the risk of embolic phenomena must be weighed against a shorter clamp time..."