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Coronary Artery Bypass Graft (CABG) / Cardiac Bypass

Coronary Artery Bypass Graft surgery (CABG) is a procedure used to treat coronary artery disease in certain circumstances.

Coronary artery disease (CAD) is the narrowing of the coronary arteries (the blood vessels that supply oxygen and nutrients to the heart muscle), caused by a build-up of fatty material within the walls of the arteries. This build-up causes the inside of the arteries to become narrowed, limiting the supply of oxygen-rich blood to the heart muscle.

Hospital Stay: Hospital Stay: 8 days
Duration: Duration: 3-6 hrs
Cost Estimate: Cost Estimate: 4000 USD - 8200 USD These are indicative prices in Indian Hospitals

One way to treat the blocked or narrowed arteries is to bypass the blocked portion of the coronary artery with another piece of blood vessel. Blood vessels, or grafts, used for the bypass procedure may be pieces of a vein taken from the legs or an artery in the chest. At times, an artery from the wrist may also be used. One end of the graft is attached above the blockage and the other end is attached below the blockage. Thus, the blood is rerouted around, or bypasses, the blockage through the new graft to reach the heart muscle. This bypass of the blocked coronary artery can be done by performing coronary artery bypass surgery.

Traditionally, in order to bypass the blocked coronary artery in this manner, the chest is opened in the operating room and the heart is stopped for a time so that the surgeon can perform the bypass. In order to open the chest, the breastbone (sternum) is cut in half and spread apart. Once the heart is exposed, tubes are inserted into the heart so that the blood can be pumped through the body during the surgery by a cardiopulmonary bypass machine (heart-lung machine). The bypass machine is necessary to pump blood while the heart is stopped and kept still in order for the surgeon to perform the bypass operation.

While the traditional “open heart” procedure is still performed and often preferred in many situations, newer, less invasive techniques have been developed to bypass blocked coronary arteries. “Off-pump” procedures, in which the heart does not have to be stopped, were developed in the 1990’s. Other minimally-invasive procedures, such as key-hole surgery (performed through very small incisions) and robotic procedures (performed with the aid of a moving mechanical device), increasingly are being used.

Two other surgical improvements for persons undergoing CABG are endoscopic vein harvesting and endoscopic radial artery harvesting. In both of these procedures surgeons use an endoscope (thin surgical tube with a light and camera on the end) to locate blood vessels that will be used for bypassing the blocked coronary arteries. Veins are generally harvested from the inner thigh and calf areas of the legs, while the radial artery is harvested from the wrist.

Traditional (open) approaches involve making long surgical incisions down the inner thigh and/or calf. Research comparing traditional approaches with endoscopic methods indicates that patients generally have fewer complications, less leg pain, and shorter hospital stays with the endoscopic harvesting methods. Some persons, however, may not be eligible for these methods because of other health conditions.

Coronary artery bypass surgery is performed to treat a blockage or narrowing of one or more of the coronary arteries, thus restoring the blood supply to the heart muscle.

Symptoms of coronary artery disease may include, but are not limited to, the following:

  • Chest pain
  • Fatigue
  • Palpitations
  • Abnormal heart rhythms
  • Shortness of breath

Unfortunately, there may be no symptoms of early coronary artery disease, yet the disease will continue to progress until sufficient artery blockage exists to cause symptoms and problems. If the blood supply to the heart muscle continues to decrease as a result of increasing obstruction of a coronary artery, a myocardial infarction, or heart attack, may occur. If the blood flow cannot be restored to the particular area of the heart muscle affected, the tissue dies.

Before the Surgery

  • The patient should notify your doctor if he/she is sensitive to or allergic to any medications, latex, tape, and anaesthetic agents (local and general).
  • The patient will need to fast for a certain period of time prior to the procedure, usually overnight.
  • If the patient is pregnant or suspect that she may be pregnant, the doctor should be notified.
  • The doctor should be notified about all medications (prescription and over-the-counter) and herbal supplements that the patient is taking.
  • The patient may be asked to withhold certain medications prior to the procedure. The doctor will provide detailed instructions.
  • The doctor should be notified if the patient has a history of bleeding disorders or if the patient is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for the patient to stop some of these medications prior to the procedure.
  • The doctor may request a blood test prior to the procedure to determine how long it takes for the patient’s blood to clot. Other blood tests may be done as well.
  • The doctor should be notified if the patient has heart valve disease or if there is a pacemaker inserted.
  • If the patient is a smoker, smoking should be stopped as soon as possible prior to the procedure. This may improve the chances for a successful recovery from surgery and benefit the overall health status of the patient.
  • Based on the patient’s medical condition, the doctor may request other specific preparation.

During the Surgery

Coronary artery bypass graft surgery requires a few days’ stay in a hospital.

Generally, a coronary artery bypass surgery follows this process:

  • The patient will be asked to remove any jewellery or other objects that may interfere with the procedure.
  • The patient will be asked to remove clothing and will be given a gown to wear.
  • The patient will be asked to empty the bladder prior to the procedure.
  • An intravenous (IV) line will be started in the arm or hand. Additional catheters will be inserted in the neck and wrist to monitor the status of the heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
  • The patient will be positioned on the operating table, lying on his/her back.
  • The anesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once the patient is sedated, a breathing tube will be inserted into the throat and into the trachea (breathing tube) to provide oxygen to the lungs, and the patient will be connected to a ventilator, which will breathe for him/her during the surgery.
  • A catheter will be inserted into the urinary bladder to drain urine.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • Once all the tubes and monitors are in place, incisions may be made in one or both of the legs or one of the wrists to obtain a section of vein to be used for grafts.
  • The doctor will make an incision (cut) down the center of the chest from just below the Adam’s apple to just above the navel.
  • The sternum (breastbone) will be divided in half with a special operating instrument. The doctor will separate the two halves of the breastbone and spread them apart to expose the heart.

Coronary artery bypass graft surgery – On-pump procedure

  • In order to sew the grafts onto the very small coronary arteries, the heart must be stopped to allow the doctor to perform the very delicate procedure. Tubes will be inserted into the heart so that the blood can be pumped through the body by a cardiopulmonary bypass machine.
  • Once the blood has been diverted into the bypass machine for pumping, the heart will be stopped by injecting it with a cold solution.
  • When the heart has been stopped, the doctor will perform the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage. If the internal mammary artery inside the chest is being used as a bypass graft, the lower end of the artery will be cut from inside the chest and sewn over an opening made in the coronary artery below the blockage.
  • The patient may have more than one bypass graft performed, depending on how many blockages he/she has and where they are located. After all the grafts have been completed, the doctor will examine them to make sure they are working fine.
  • Once the bypass grafts have been completed, the blood circulating through the bypass machine will be allowed back into the heart and the tubes to the machine will be removed. The heart will be restarted.
  • Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker and the heart can be paced, if needed, during the initial recovery period.

Coronary artery bypass surgery – Off-pump procedure

  • Once the chest has been opened, the area around the artery to be bypassed will be stabilized with a special type of instrument.
  • The rest of the heart will continue to function and pump blood through the body.
  • The cardiopulmonary bypass machine and the perfusionist who runs it may be kept on stand-by should the procedure need to be completed on bypass.
  • The doctor will perform the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery or internal mammary artery just below the blockage.
  • The patient may have more than one bypass graft performed, depending on how many blockages he/she have and where they are located.
  • Before the chest is closed, the doctor will examine the grafts to make sure they are working fine.

Procedure completion, both methods

  • The sternum will be pushed back together and sewn together with small wires.
  • The skin over the sternum will be sewn back together.
  • Tubes will be inserted into the chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to keep fluids pulled away from the heart.
  • A tube will be inserted through the mouth or nose into the stomach to drain stomach fluids.
  • A sterile bandage or dressing will be applied.

After the Surgery

After the surgery the patient may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored.  Alternatively, the patient may be taken directly to the ICU from the operating room. The patient will be connected to monitors that will constantly display the electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and oxygen level. Coronary artery bypass surgery requires an in-hospital stay of several days or longer.

The patient will most likely have a tube in the throat so that breathing can be assisted with a ventilator (breathing machine) until he/she is stable enough to breathe on their own. As the patient continues to wake up from the anaesthesia and start to breathe on their own, the breathing machine will be adjusted to allow them to take over more of the breathing. When the patient is awake enough to breathe completely on his/her own and is able to cough, the breathing tube will be removed. In general, the breathing tube will be removed quickly after the operation, usually the same day or by early the next morning. The stomach tube will also be removed at this time.

After the breathing tube is out, the nurse will assist the patient to cough and take deep breaths every two hours. This will be uncomfortable due to soreness, but it is extremely important that this id done in order to keep mucus from collecting in the lungs and possibly causing pneumonia. The nurse will show how to hug a pillow tightly against the chest while coughing to help ease the discomfort.

The surgical incision may be tender or sore for several days after a CABG procedure. Pain relievers can be taken for soreness as recommended by the physician. Aspirin or certain other pain medications may increase the chance of bleeding. Hence only recommended medications should be taken.

The patient may be on special IV drips to help stabilize the blood pressure and the heart, and to control any problems with bleeding. As the patient’s condition stabilizes, these drips will be gradually decreased and turned off.

Once the breathing and stomach tubes have been removed and the patient’s condition has stabilized, he/she may start liquids to drink. Diet may be gradually advanced to more solid foods as and when the patient is able to tolerate them.

When the doctor determines that the patient is ready, he/she will be moved from the ICU to a postsurgical nursing unit. Patient’s recovery will continue to progress. Physical activity will be gradually increased as he/she gets out of bed and walks around for longer periods of time. The patient will then be discharged.

Rehabilitation

Once the patient is home, it will be important to keep the surgical area clean and dry. The doctor will give specific bathing instructions. The sutures or surgical staples will be removed during a follow-up visit, in the event they were not removed before leaving the hospital.  The patient should not drive until the doctor permits him/her to drive. Other activity restrictions may apply.

Notify the doctor to report any of the following:

  • Fever and/or chills
  • Redness, swelling, or bleeding or other drainage from the incision site
  • Increase in pain around the incision site

The doctor may give additional or alternate instructions after the procedure, depending on the patient’s particular situation.

Physical aspects of recovery

The pace of physical recovery will depend significantly on the patient’s health before the bypass surgery. For example, if the patient had coronary artery disease (CAD) but no other medical conditions, it will probably take less time to resume a normal activity level than if the patient is older or has other medical conditions.

Recovery will take at least 4 to 6 weeks. During recovery from CABG surgery, life will probably be quite different from how it was before surgery. The table below lists “normal” physical conditions after CABG surgery.

During CABG surgery recovery
It is normal to: Why? For how long? What can I do?
Not have much of an appetite. The thought of food makes you feel nauseated, or you cannot taste anything. A few weeks to months
  • Be patient; your appetite will soon be back to normal.
  • Eat healthy foods.
  • Try eating frequent, small meals.
Have swelling in your arm or leg where blood vessels were removed. You have incisions there as well as missing blood vessels that your surgeon used to bypass your coronary arteries. A few weeks
  • Keep your swollen arm or leg elevated.
  • Wear support hose if ordered by your doctor.
  • Tell your doctor if it doesn’t improve.
Have difficulty sleeping. You are in pain and/or are not very physically active. A few weeks
  • Take your pain medication before you go to bed.
  • Try not to take naps during the day.
Have sore or tight muscles in your shoulders and upper back. You were in the same position during your surgery and early recovery. A few weeks
  • Be patient.
  • Take your pain medication.
  • Try warm, moist packs and massage.
Have a lump over your incision. Your skin and muscle are healing. About 6 weeks
  • Do nothing.
  • Watch for signs of infection: redness, discharge, fever, and pain.
Be constipated. It is a side effect of some medications, and/or you are not very physically active. Depends
  • Eat more fruits and foods with fiber.
  • Ask your doctor to recommend a laxative.

 

Emotional aspects of recovery

Recovering from CABG surgery means not only getting back physical strength but also emotional and mental well-being. The fatigue and pain experienced by the patient may make them feel depressed. The patient may:

  • Have mood swings.
  • Cry easily.
  • Feel afraid or anxious.
  • Get frustrated.
  • Be irritable.
  • Not be able to concentrate.
  • Have good days and bad days.

Also, limitations on physical activity can leave the patient with few options to get out of the house for some recreation.

The patient should be aware that these feelings of depression are common for people who have had major heart surgery. The patient may also feel lonely and envious of other people who are living their lives without the discomfort and pain that they are experiencing right now.

It can be important to keep family and friends around during recovery. They can go on walks with the patient or just sit and chat.

In most instances, ischemic heart disease, i.e., coronary artery disease and/or coronary heart disease, is a result or consequence of arteriosclerosis (hardening of the arteries) and atherosclerosis (fatty deposits within the arteries). When the coronary artery becomes affected by arteriosclerosis or atherosclerosis, it may become occluded, causing impaired blood supply to the myocardium. Ischemic heart disease is frequently a forerunner of atrial fibrillation.

A person’s coronary anatomy (i.e., location of blockages in the coronary arteries) is the primary criteria for considering one’s suitability for the surgery. Symptoms of coronary artery disease may include, but are not limited to, the following:

  • Chest pain
  • Fatigue
  • Palpitations
  • Abnormal heart rhythms
  • Shortness of breath

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