The doctor’s duty is to see patients, to adapt to the social environment and the needs of development, to carry out new technologies, to develop new technologies, to develop the medical career, to better treat more patients. When doctors face death than the average person is more painful, the reason for the pain is not only due to the natural reaction of seeing one of their own kind die, but also as a doctor facing death and can not rescue the helpless, helplessness is the greatest pain in the pain. In medical practice, the effort to reduce the death and complication rate of patients has never stopped, and the motivation for the effort comes from many sources, including the biological motivation to fight in the face of difficulties, and the social motivation of social development and technological progress (the reason why it is called social motivation is because our society is constantly developing and changing); another very important motivation comes from pain. Pain can make people do anything beyond the ordinary, even beyond their physical or mental limits. Pain can make you wander, or it can make you move forward. And when you do what you love, when you treat what you do as a career, the pain of death can only motivate you to find a way to alleviate that pain, a way that brings good news to both your career and your patients. I started to do bypass surgery in 1998, when there were not many units that could do coronary artery bypass in China, and I was still working in Beijing Chaoyang Hospital. I had just returned from abroad, and the director of the heart center at that time, Prof. Hu Dayi, gave me a hard rule to carry out bypass, and the first 50 cases should not have any death. Domestic bypass is just starting, and all aspects of work need to be perfected, so it is not easy to do this, but I did. But to do this, not only can I do the surgery, but I also need to understand the various risk factors of the patient, as well as the weight of the various risk factors, countermeasures; know how to face these risks, how to avoid risks and reduce risks as much as possible, because of the strict requirements in the early stage and afterwards, I constantly remind myself with risk awareness, the mortality rate of surgery can be kept at a low level, thanks to Professor Hu Dayi and my This is thanks to the strict requirements and constant encouragement and encouragement from Professor Hu and my colleagues. At present, the international mortality rate of conventional bypass surgery is 1~3%, which is a stable trend for many years, but how to control the mortality rate below 1% needs to be discussed in many aspects. The following is how to reduce the mortality rate of conventional coronary artery bypass grafting to do discussion with everyone (in the middle will involve emergency coronary artery bypass grafting part of the content). 1. First of all, we need to fully understand coronary artery bypass surgery. Coronary artery bypass grafting is a routine procedure accompanied by unconventional combination of vascular localization, lesion determination, and bypass grafting. The method of vascular anastomosis is fixed for each surgeon, and the myocardial protection and exposure techniques are relatively fixed, but the distribution of vessels varies for each patient, the degree of stenosis, the site of vessel occlusion is different, and there are other risk factors such as history of previous infarction, recent infarction, cardiac function, respiratory function, renal function, history of stroke, peripheral vascular disease, patient’s physical and psychological status, obesity, Hypertension, diabetes mellitus, small weight, diffuse vascular lesions, left main lesions, acute infarction, angina classification, type and distribution of coronary stenosis, thickness of blood vessels, complete vascularization, presence of valve problems, and the presence of other concomitant diseases, and many other factors, which factors are dominant and which factors are supplementary, should be analyzed and solved specifically in order to develop a suitable treatment plan for the patient. The treatment plan can be developed for the patient. 2, master the patient’s general condition: the overall cognition and evaluation of the patient is the most important part of cardiac surgery to avoid risk, especially important for coronary artery bypass graft patients, due to the age of coronary artery bypass graft patients, some patients are senior patients, the overall degree of tolerance to surgery is significantly lower than that of young patients, some patients have organ function in the edge of compensation, but the clinical auxiliary examination does not fully reflect This requires you to make a comprehensive analysis and judgment based on the overall condition of the patient, and to draw a reasonable conclusion by combining the results of the auxiliary examinations. Observe the patient’s gait, body shape, consciousness response, physical strength, diet, sleep, and degree of cooperation with treatment. At the time you see your patient, have a clear understanding of the patient’s external condition and the patient’s overall condition. If the patient has an original history of stroke and now has hemiplegia, but is clear-headed, has a better diet and physical strength, the increased risk is less; conversely, if the patient is not clear-headed, has slow reactions to things, and has difficulty coughing up and expelling sputum, the risk of surgery is significantly increased. Judging from the physical strength, if the patient can get out of bed, the size of the amount of activity that can be done will affect the early recovery after surgery, the amount of activity is close to normal, the recovery will be smoother, because the amount of activity is smaller because of the physical strength, the recovery after surgery is prone to complications, especially respiratory complications. If the low activity level is due to cardiac reasons, the analysis is more complicated and will be discussed under cardiac related risks. Patients who are already unable to move off the floor or even have the strength to be sedentary in bed prior to surgery are at great risk for surgery and will have to be evaluated to do so or not, and some patients will need to go through a process of physical exercise before making an evaluation and decision. Individual patients with persistent angina attacks, or who have been implanted with IABP, but with a short onset, although they cannot get out of bed, they do not lose their strength; there are also patients evaluated in emergency surgery, which cannot be evaluated according to the method described earlier. 3. Heart: The heart is the most priority part of the risk of coronary artery bypass surgery outside of the overall situation. A. First of all, coronary vessels, severe left main lesions, severe triple lesions, diffuse lesions, small caliber vessels, and distal stenosis are the risk factors affecting the surgery. Severe left main lesions and severe proximal stenosis vascular lesions are prone to ischemic events during surgery and should be prepared for emergencies, always be ready for transfer when doing non-extracorporeal circulation cardiac non-stop bypass; always be ready for emergency resuscitation when doing transfer cardiac arrest surgery. Severe vascular lesions and thin distal vessels are an important risk assessment indicator, which has not been analyzed in much of the literature due to the difficulty of making clinical criteria, and it is more difficult to calculate its coefficient when doing risk assessment. However, preoperative knowledge of the vascular lesion and its distribution cannot only exist on the film, but must be based on all aspects of the patient’s condition to analyze how thin the patient’s vessels are. Some of the vessels are falsely thin, while others are truly thin, which is difficult to determine correctly prior to surgery. When it is difficult to determine from the angiogram alone whether the patient’s vessels can be operated on or the risk of vascular disease associated with surgery, it is important to look at other aspects of the heart, including heart size, morphology, structure, motion, valves, and function, combined with the chest radiograph. If the other parties are better, the likelihood of being able to operate is higher and the risk of surgery is reduced by a lot. In most patients, collateral circulation can be seen after coronary vessel occlusion, and if there is collateral circulation and the image is satisfactory, it will be easier to determine whether the vessel can be bypassed; however, in some patients, collateral circulation cannot be seen on the angiogram after coronary vessel occlusion, or the image is very poor, and it is not possible to determine whether the vessel can be bypassed from the angiogram. If the patient’s coronary vessels are really thin, the operation will be very risky or have poor results. If the operation is actually not thin but is abandoned because the angiogram shows thinness, the prognosis for the patient is disastrous. B. CCS grading: The relationship between angina grading and surgical risk is proven by many literatures, but how to grasp it in clinical work is not strictly explained. According to my personal experience, if the patient’s CCS grading is grade III or above, the condition is unstable and prone to emergencies, especially grade IV, where the patient has persistent angina or short intervals, and its emergencies may occur at any time, leading to heart attack or cardiogenic shock, and should be treated as emergency. The onset of angina is also related to the adequacy of medication before surgery, whether blood pressure and heart rate have been adjusted to ideal values, and whether the patient has infection, hyperthyroidism or other factors. C. Cardiac function: The good or bad cardiac function not only has an impact on the perioperative period, but also affects the long-term outcome and survival of the patient. Also considered are ventricular size, LVEF, left ventricular end-systolic volume, and other atrial sizes. Overall cardiac function should be evaluated and prepared before surgery, and for patients with poor cardiac function, adequate evaluation and preparation should be made before surgery. If the patient has recurrent episodes of heart failure, it is important to determine whether the heart failure is caused by ischemia or is caused by poor cardiac function itself, whether there are valve problems, whether there are ventricular wall tumors, and whether there is ischemic cardiomyopathy. Most patients can be assessed by clinical symptoms and chest radiographs and cardiac ultrasound, and some patients require cardiac stress tests. If the heart is normal in size, with severe stenosis of coronary vascular lesions, no diffuse lesions or diffuse thinning of the coronary arteries, and no other problems such as valves, ischemia is mostly considered to be predominant. If the heart is significantly enlarged or even spherical, the vast majority of ventricular wall motion is poor, and some patients even have mitral valve insufficiency, these patients are at high risk and should be carefully considered for indications for surgery, fully assess the risk of surgery, and clearly design the surgical plan. D. History of old myocardial infarction: old infarction sometimes becomes an independent risk factor, sometimes not. The question is how much residual damage to the heart is caused by the original infarction? It is not quite easy to answer this question. First of all you have the situation of revascularization after the infarction, if the blood vessels are instantly revascularized after the infarction, the heart function is protected and there is little impact on the future, if the infarction causes irreversible damage and leads to a significant change in the morphological blood aspect of the heart, which in turn affects the heart function and creates a risk factor for surgery. Secondly, the site of the infarction, the anterior wall infarction may have the greatest impact on cardiac function, the inferior wall may be second, and the lateral wall may have the least impact. However, this ranking is not absolute, and sometimes it can be misleading to study the patient’s risk in this order, taking into account the size of the infarct, the presence of infarct complications, etc. The third is the infarct complications just discussed. If perforation, mitral regurgitation (where clinically significant), and ventricular wall tumors occur after the infarct, the infarct complications will have a significant impact on the outcome of the procedure. F. History of recent infarction: There are many studies on the effect of recent infarction on the outcome of surgery, but there are no conclusive results for clinical use to date. The most accepted theory is that in the early stages of infarction, surgery within 24 hours will significantly increase the risk of surgery, and after more than a week, the risk of surgery decreases to close to that of conventional surgery. The more common clinical approach is to operate after 2 weeks for inferior wall or non-ST-segment elevation infarction and 4 weeks for anterior or extensive anterior wall infarction, provided the patient is stable, or on an individual basis if the patient has post-infarction angina or other conditions requiring emergency surgery or earlier surgery. G. Ventricular wall tumors: The most common site of ventricular wall tumors is located in the anterior left ventricular wall near the apex, other sites include inferior wall ventricular wall tumors, middle left ventricular wall ventricular wall tumors and lateral wall ventricular wall tumors. In principle, all ventricular wall tumors should be treated surgically, but not every ventricular wall tumor is treated in the same way, and the impact on the outcome of the surgery varies. Small ventricular wall tumors in the apical region are simple to operate on and have little impact on the outcome; ventricular wall tumors in the inferior and lateral walls that do not protrude significantly can be left untreated or simply treated during surgery, which also has little impact on the outcome. If a ventricular wall tumor is large and has a significant impact on cardiac function, it will have a significant impact on the outcome of the surgery. However, in general, ventricular wall tumors with a clear demarcation from the normal ventricular wall are better handled during surgery and have a much better outcome than those without a clear demarcation or extensive enlargement of the left ventricle. F. Arrhythmias: Arrhythmias include many kinds, the common ones are ventricular premature beats, atrial premature beats, atrial fibrillation, ventricular tachycardia and ventricular fibrillation. Ventricular premature beats and atrial premature beats generally do not have a substantial impact on the outcome, and particularly frequent atrial premature beats and ventricular premature beats can generally be controlled satisfactorily with the application of drugs, while individual drugs that are not satisfactorily controlled and have an impact on hemodynamics will have an impact on the perioperative period, and it is unknown whether they have an impact on the long-term outcome. The incidence of perioperative atrial fibrillation ranges from 7% to 25%, which has a perioperative impact and delays the patient’s recovery process, but generally does not have malignant consequences. Atrial fibrillation can particularly affect the surgical procedure in OPCAB, causing intraoperative hemodynamic instability. The impact of atrial fibrillation on OPCAB is mainly reflected in the unstable blood pressure of the patient. In addition, the operator may feel uncomfortable and affect the operator’s psychology because the instability of the rhythm changes the habit of operating in a rhythmic rhythm that the operator has developed in OPCAB. Atrial tachycardia is an arrhythmia that requires prompt management. Sustained atrial tachycardia significantly affects the patient’s hemodynamics and significantly impacts the surgical process and perioperative prognosis. The majority of patients can return to sinus rhythm after timely and effective management, unless a history of atrial fibrillation or other factors are present. Recurrent ventricular tachycardia or/and ventricular fibrillation before surgery is the most dangerous arrhythmia, which occurs for many reasons. Even if arrhythmia analysis or even cardiac electrophysiological markers are performed, there is no good method to accurately locate its origin, and treatment is also difficult, with a high chance of recurrence and high mortality after bypass or removal of the shaped ventricular wall tumor, or even if the patient does ablation therapy at the same time. 4, pulmonary function: in the clinical practice of cardiovascular disease may we all appreciate that there is no organ more closely interrelated and echoed than the lung and heart. Therefore, while evaluating lung function, we should pay attention to the impact of heart function, and while evaluating heart function, we should also be concerned about the status of lung function. There is no clear clinical boundary as to what level of pulmonary function is an indication or counter-indication for surgery. In addition, we do not advocate that every patient undergoing coronary artery bypass grafting should have pulmonary function tests before surgery, because the score of patients may induce angina pectoris or more serious results during pulmonary function tests. The evaluation methods include: observation of the patient’s general condition and the number and depth of breathing, chest X-ray, blood gas analysis, some patients need to do pulmonary function tests, chest CT, etc. It can be clearly said that pulmonary function is a clear risk factor affecting the outcome of surgery and should be paid attention to before surgery. 5, kidney function: the impact of kidney function on bypass is obvious, and many patients with coronary artery disease have kidney damage before surgery, either caused by hypertension, or diabetes, or the kidney itself is diseased, etc.. Careful evaluation of renal function before surgery is necessary for every bypass patient, and for patients with severe renal impairment it is necessary to evaluate and judge together with the internist. 6, history of stroke: the incidence of perioperative stroke during coronary artery bypass grafting is about 0, 5% to 3%, and a history of stroke will increase the incidence of perioperative cerebrovascular complications by up to 1 to 7 times, as reported in the literature. How to avoid reducing the risk in this area includes many aspects. The first step is to evaluate the extent and sequelae of the previous or preceding strokes and the degree of sequelae. If the stroke is small in extent and has no sequelae, it will have less impact on the surgery; if there are significant sequelae that significantly affect the patient’s muscle strength or even ability to become conscious, the impact on the surgery will be greater. Patients with sequelae should also be evaluated for the impact on respiratory muscles, the impact on coughing and sputum removal, and the impact on treatment cooperation. In stroke prevention it is also important to know if there are lesions in the cerebral vessels. Methods include carotid and cerebrovascular ultrasonography, cranial CT, cranial MRI, cerebral angiography or CT 3D imaging to evaluate the carotid artery, intracranial vessels, vertebral artery and subclavian artery for significant stenosis. There are other tests specific to neurology that can be discussed with the appropriate personnel if necessary. In addition, some patients with a history of stroke may have a poor ability to adapt to the outside world and their bodies, and these patients are more likely to have psychiatric symptoms after surgery, so adequate evaluation and psychotherapy before surgery is beneficial to the reduction and treatment of psychiatric symptoms after surgery. For patients with definite carotid stenosis, it is still controversial whether to perform carotid endarterectomy at the same time, but we prefer to perform the surgery at the same time, with carotid endarterectomy first and then coronary artery bypass grafting in the same surgery, which has achieved satisfactory results. 7. Diabetes mellitus and hypertension: both of these may be listed as risk factors in most risk analyses of coronary artery bypass grafting in the literature, but it is difficult to determine their direct relationship with post-operative complications in clinical work. In patients with diabetes, unsatisfactory glycemic control can affect incisional healing and in severe cases may lead to disturbance of the internal environment, so it is important to control blood glucose well during the perioperative period, and adherence to insulin rather than oral hypoglycemic agents to control blood glucose before patient discharge can significantly reduce the effect of blood glucose on the patient. Continuous micro-pumping of insulin during ICU can maintain a relatively stable blood glucose level more easily, and in addition, close blood glucose testing starts before surgery and continues throughout the surgery and afterwards until the patient is discharged. If the patient is predominantly hypertensive after surgery, controlling blood pressure to the ideal level can play an appropriate protective role for the heart, and this protective role will be more important for those with cardiac insufficiency. 8. Small weight and female: These two factors are also frequently mentioned in the discussion of risk factors, but most of the discussions do not discuss in depth why these two factors are put in. According to my personal analysis, I believe that small body weight is mostly the result of fine blood vessels, of course, there are also other diseases that cause small body weight, but also the majority of women. There is a relationship between female body shape and physical strength. Of course, the effect of female and male body shape on post-operative recovery, especially on respiratory function, deserves attention and further analysis. 9. Advanced age: Our center treats patients aged ≥80 years as advanced age, and the evaluation and requirements before surgery for patients in the advanced age group are more stringent and cautious than those in other age groups. From my personal experience, the majority of patients aged 80 years and above can tolerate coronary artery bypass surgery better, and among the more than 100 patients operated by me, only one case died (the case was an emergency bypass, and the patient had cardiogenic shock before the surgery). Stricter procedures and criteria need to be implemented in patient selection. Every suspected organ should be examined, relevant evaluations should be done, and the function of every organ system should be carefully evaluated, except for the focus on the heart. If a senior patient has renal, respiratory or neurological problems, an analysis should be done to see the extent to which these problems can affect the patient, and a relevant professional should be available to assist in the evaluation. Satisfactory vascularization is the key to successful surgery. If you see an angiogram of a patient in the general age group and consider his or her vascular lesions to be in the category of routine surgery, you can usually do it in this group of advanced age, but conversely, you should consider it carefully and also look at your personal experience and how sure you are.