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Coronary artery bypass graft surgery & Valvular Surgery

Coronary artery bypass graft surgery (CABG)

Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary artery disease. Coronary artery disease (CAD) is the narrowing of the coronary arteries – the blood vessels that supply oxygen and nutrients to the heart muscle. CAD is caused by a build-up of fatty material within the walls of the arteries. This build-up narrows the inside of the arteries, limiting the supply of oxygen-rich blood to the heart muscle. In bypass surgery we attach conduits distal to blockages so that extra blood is reaching heart via these conduits.

Why might I need coronary artery bypass surgery?

Your doctor uses coronary artery bypass graft surgery (CABG) to treat a blockage or narrowing of one or more of the coronary arteries to restore the blood supply to your heart muscle.

Symptoms of coronary artery disease may include:

  • Chest pain
  • Fatigue (severe tiredness)
  • Palpitations
  • Abnormal heart rhythms
  • Shortness of breath
  • Swelling in the hands and feet
  • Indigestion

Unfortunately, you may not have any symptoms in early coronary artery disease, yet the disease will continue to progress until there’s enough artery blockage to cause symptoms and problems. If the blood supply to your heart muscle continues to decrease as a result of increasing blockage of a coronary artery, you may have a heart attack. If the blood flow can’t be restored to the particular area of the heart muscle affected, the tissue dies.

There may be other reasons for your doctor to recommend CABG surgery.

What are the risks of coronary artery bypass surgery?

Possible risks of coronary artery bypass graft surgery (CABG) include:

  • Bleeding during or after the surgery
  • Infection at the incision site
  • Pneumonia
  • Breathing problems
  • Stroke
  • Abnormal heart rhythms
  • Failure of the graft
  • Death

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor before the procedure.

Note: Over all the combined risk is 3-5% of above mentioned complication. So 95-97% does not have any such complications. However the actual risk varies as per patient’s profile.

How do I get ready for coronary artery bypass surgery?

Your doctor will explain the procedure and you can ask questions.

  • You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if anything is unclear.
  • Along with a review of your health history, your doctor may do a complete physical exam to make sure you are in otherwise good health before having the procedure. You may need blood tests or other diagnostic tests.
  • You will be asked to not eat or drink for 8 hours before the procedure, generally after midnight.
  • You may be asked to shower with a soap or special cleanser the night before and the morning of surgery.
  • Tell your doctor if you are pregnant or think you could be.
  • Tell your doctor if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthetic medicines (local and general).
  • Tell your doctor about all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop some of these medicines before the procedure.
  • Your doctor may do blood tests before the procedure to find out how long it takes your blood to clot.
  • Tell your doctor if you have a pacemaker or any other implanted cardiac device.
  • If you smoke, stop smoking as soon as possible. This may improve your chances for a successful recovery from surgery and benefit your overall health.
  • Based on your medical condition, your doctor may ask you to do other things to get ready.

What happens during coronary artery bypass?

Coronary artery bypass graft surgery (CABG) requires a stay in a hospital. Procedure may vary depending on your condition and your doctor’s practices.

Generally, CABG follows this process:

  • You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  • You will change into a hospital gown and empty your bladder.
  • A healthcare professional will insert an intravenous (IV) line in your arm or hand. Other catheters will be put in your neck and wrist to monitor your heart and blood pressure, as well as to take blood samples.
  • You will lie on your back on an operating table.
  • The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated (put into a deep sleep), a breathing tube will be put into your throat and you will be connected to a ventilator, which will breathe for you during the surgery.
  • A catheter will be put into your bladder to drain urine.
  • The skin over the surgical site will be cleaned with an antiseptic solution.
  • Once all the tubes and monitors are in place, your doctor will make incisions (cuts) in one or both of your legs or one of your wrists to access the blood vessel(s) to be used for the grafts. He or she will remove the vessel(s) and close those incision(s).
  • The doctor will make an incision (cut) down the center of your chest from notch of sternum till the xyphoid process.
  • The doctor will cut the sternum (breastbone) in half lengthwise. He or she will separate the halves of the breastbone and spread them apart to expose your heart.

Coronary artery bypass graft surgery–on-pump procedure

  • To sew the grafts onto the very small coronary arteries, your doctor will need to stop your heart temporarily. Tubes will be put into the heart so that your blood can be pumped through your body by a heart-lung bypass machine.
  • Once the blood has been diverted into the bypass machine for pumping, your doctor will stop the heart by injecting it with a cold solution.
  • When the heart has been stopped, the doctor will do 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 your doctor uses the internal mammary artery inside your chest 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.
  • You may need more than one bypass graft done, depending on how many blockages you have and where they are located. After all the grafts have been completed, the doctor will closely check them as blood runs through them to make sure they are working.
  • Once the bypass grafts have been checked, the doctor will let the blood circulating through the bypass machine back into your heart and he or she will remove the tubes to the machine. Your heart may restart on its own, or a mild electric shock may be used to restart it.
  • Your doctor may put temporary wires for pacing into your heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period.

Coronary artery bypass surgery–off-pump procedure

  • Once your doctor has opened the chest, he or she will stabilize the area around the artery to be bypassed with a special instrument.
  • The rest of the heart will continue to function and pump blood through the body.
  • The heart-lung bypass machine and the person who runs it may be kept on stand-by just in case the procedure needs to be completed on bypass.
  • The doctor will do 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.
  • You may have more than one bypass graft done, depending on how many blockages you have and where they are located.
  • Before the chest is closed, the doctor will closely examine the grafts to make sure they are working.

Note:

  • In patients with renal diseases, severe COPD (Chronic Obstructive Pulmonary Disease) and patient with very weak heart, Off-pump Coronary Surgery has got much less morbidity and much faster recovery.
  • The risk of neurological complication in Off-pump Coronary Surgery is much less as compared to On-pump Coronary Surgery. In our institute we do 98% Off-pump CABG procedure.

Procedure completion, both methods

  • Your doctor will sew the sternum together with small wires (like those sometimes used to repair a broken bone).
  • He or she will insert tubes into your chest to drain blood and other fluids from around the heart.
  • Your doctor will sew the skin over the sternum back together.
  • Your doctor will put a tube through your mouth or nose into your stomach to drain stomach fluids.
  • He or she will then apply a sterile bandage or dressing.

Long Term benefits of Coronary artery bypass graft surgery:

  • It improves the quality of life which more often is hampered in these patients because of angina pain or breathlessness.
  • It increases the longevity of life.
  • It decreases the amount of medicine taken by patient by less than half. So it decreases the long term economic burden to the patient.

Myths and facts associated with Coronary artery bypass graft surgery:

  • Myth: Lot of blood loss in CABG.
    Fact: Average blood loss is 2 units.
  • Myth: Heart vessels are replaced in bypass surgery.
    Fact: In bypass surgery native vessel of heart remain as it is and we attach conduits distal to blockages so that extra blood is reaching heart via these conduits.
  • Myth: It is the procedure of last resort.
    Fact: It is the procedure which gives the maximum number of incidence free survival of the patient. So a young patient if having multi vessel disease is much more likely to be benefitted from the procedure done earlier.
  • Myth: It has high morbidity.
    Fact: Patient is on his foot and walking by third day and goes home by sixth day and by two weeks resumes all his normal activities.
  • Myth: Cannot do hard work or strenuous thing after CABG
    Fact: After two months patient can do all the physical activity as per his physic & fitness.
  • Myth: Nothing can be done if the patient has any heart problem after CABG.
    Fact: Patient depending on the problem can be treated by redo CABG or stenting.
  • Myth: Lot of restriction in diet & a boiled blend diet.
    Fact: The diet is normal as for any other person with everything in moderation.

Valvular Heart Surgery:

What is heart valve surgery?

Heart is pump of body which pump blood to all other organ and pump is distend to fail if valves are not working properly so heart valve surgery or other procedures are performed to repair or replace a valve in the heart that is not working properly.

Why is it done?

  • There are four valves in the heart:
  • Tricuspid
  • Pulmonary
  • Mitral
  • Aortic

Valves control the flow of blood by making it move in one direction through the different chambers or parts of the heart. If a valve is not working correctly, blood flow is impaired. For example, if a valve does not close properly, blood may leak between the chambers or flow backwards, a condition known as valve regurgitation, insufficiency, or incompetence. If a valve is narrowed (also called stenosed), blood flow through the heart may be restricted.

If the valve problem is minor, it may be treated with medication. But if the heart valve damage is severe, a procedure may be required to repair or replace the malfunctioning valve.

Valve repair or replacement may be required if a valve has been damaged by:

  • Rheumatic heart disease.
  • Congenital heart defect.
  • Mitral and/or aortic valve disease.
  • Normal aging and wear.
  • Infection (endocarditis).

What are the different types of Heart Valve Malfunction?

  • Leaky Valve (Regurgiation) that enables the blood to flow in a reverse direction
  • Narrowed valve (Stenosis), in which there is a narrowing, thickening and fusion of valve leaflets that restricts the blood flow across the valve.

What are the different types of Valve Surgeries?

Depending upon the extent and location of damage, valves can be either repaired or replaced by different procedures like:

  • For Valve Narrowing (Stenosis): Closed or open valvulotomy is performed. In this procedure, an incision is made in a fused/narrow valve to restore the valve opening. However, if the restructure of the valve is deranged then a valve replacement is done using a mechanical/metallic or a bioprosthetic (porcine valve).
  • Valve Regurgitation: Advanced repair techniques are used for valve leaflets as well as subvalvular apparatus. In case, its repairing is not feasible then valve replacement is done. We have experienced surgeons who can repair and replace valves depending on the condition of valve.

Is there a non-surgical technique available?

For patients suffering from severe aortic stenosis determined to be at very high surgical risk for open heart surgery, transcatheter aortic valve replacement, TAVR, sometimes referred to as TAVI, is a less invasive procedure that does not require open heart surgery.

What is a TAVR? (Also called TAVI)

This minimally invasive surgical procedure repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI).

Valve-within- valve — how does it work?

Somewhat similar to a stent placed in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter.

Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating blood flow.

Who is a good candidate for this type of valve surgery?

At this time the procedure is reserved for those people for whom an open heart procedure poses very high risk. For that reason, most people who have this procedure are in their 70s or 80 and often have multiple other medical conditions that make them a better candidate for this type of surgery. TAVR can be an effective option to improve quality of life in patients who otherwise have limited choices for repair of their aortic valve.

Our experts specialize in the techniques required for stenotic aortic valve. Consult our team to know which an appropriate procedure is for you.

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