Coronary artery bypass surgery (commonly called ‘Bypass surgery’) is done to bypass the blockages in the heart arteries. Like other organs in the body, the heart also needs uninterrupted blood supply. This is supplied by the left and right coronary arteries. When these arteries become narrowed by deposition of fat – rich material on the inside (atherosclerotic plaque), coronary heart diseases develop. The chances of developing coronary artery disease increase with age, particularly if one or more risk factors are present – overweight, diabetes, hypertension, smoking habit, high cholesterol levels, or family history. Surgery is done to abolish chest pain, improve quality of life and reduce the risk of death from the disease.
While coronary angiogram (special dye injection and filming of the heart arteries) is mandatory to diagnose coronary heart disease, ECG, ECHO, stress test add vital information.
Coronary bypass surgery and angioplasty with stent insertion form the mainstay of treatment for patients with coronary artery blockages whose disease is amenable for the same. Those with minor disease burden, anatomy of the arteries and disease not suitable for intervention or those with severely depressed heart function may be treated with medication alone.
The American College of Cardiology/ American Heart Association guidelines clearly define the indications and scope of treatment by either CABG or percutaneous coronary intervention (PCI)/ (PCI is Angioplasty + stenting).
Broadly CABG is the preferred treatment for: –
- Disease of the left main coronary artery
- Disease of 2 or more coronary arteries
- Diabetics with more than one blocked artery. More than 7% Indian adults are diabetics.
- Patients with suboptimal heart function
Good hospitals have a multi disciplinary team approach to decide the best treatment for the individual patient. In the back drop of ACC/AHA guidelines, the cardiologist and the cardiac surgeon discuss the angiogram, the disease, the anatomy and involve the patient and suggest the right option. The patient should realize that he should also consult the heart surgeon before finalizing on the treatment mode.
CABG is amongst the most common operations performed worldwide. It is important to quit smoking for at least 4 weeks prior to surgery, have good control of blood sugar and also stop the blood thinning medicines (clopidogrel) at least 3-5 days before surgery. It may also be important to rule out blockages in arteries of the neck and legs before the surgery. The operation is done under general anesthesia through a midline cut in the chest; the conduits used for bypass are taken out from within the chest for most patients. They may also be harvested from the hand and the legs. The long term benefit (over 10-15 years) is maximum. If the conduits are taken from within the chest, as is the procedure in our centre, the surgery may be done on a stopped heart or on the beating heart (OFF PUMP CABG) as is more common. The procedure may last upto 4 hours or more depending on the complexity of the disease, number of bypasses and additional procedures.
Once shifted to the surgical intensive care the patient is maintained on ventilator to assist breathing for the first 3-4 hours, supported with analgesia and sedation. He/she is mobilised the same evening or within the next 24 hours and supported with physiotherapy and breathing exercises.
Minimally invasive cardiac surgery (‘key-hole’ CABG) is a CABG performed through a small incision in the left side of the chest between 2 ribs, and is usually supported by 2 tiny cuts below the main incision. The left coronary artery blockages may be bypassed generally through this technique provided the anatomy is suitable and the conditin is not too bad. Advantages include avoidance of midline split in the breast bone, less pain, less bleeding, less hospital stay, early recovery, and good cosmetic results.
What to expect after surgery – CABG
Early recovery: The patient would be in the ICU for 1-2 days while his heart rate, blood pressure, and oxygen levels are continuously monitored. He will have a couple of chest drains to drain the fluid accumulating near the heart and lungs during the first 24-48 hours. He will have intravenous lines in the arm/neck from which he receives medicines to regulate the blood pressure, a bladder tube to drain urine, and oxygen therapy through a mask.
The patient will have wound dressings on the chest and the leg/forearm. After 1 or 2 days he may be shifted to the high dependency unit or the ward and will be discharged in 4-6 days.
Recovery at home
It’s normal to: –
- Have reduced appetite – it will take days to few weeks for taste and appetite to return.
- Insomnia – difficulty in falling asleep or experiencing improper sleep – this will improve. A pain pill or sleeping pill at the bed time for few days can help.
- Be constipated – laxative, fruits and fibres will help.
- Have swelling – if you have leg incision. Elevation of the limb and elastocrepe bandage will help. Wear leg stockings (Crepe or elastic stockings) for at least 2 weeks.
- This reduces the swelling. Remove at bedtime, wash the stockings with mild soap and water, and dry them over a line.
- Swelling at the top of chest incision – will disappear with time.
- Numbness in the chest on side of the incision or itching over the incision – normal, will disappear with time.
- Muscle pain/discomfort over the shoulder, upper back – will better with time. Pain medicines will help.
- Generalized body ache and pain over incisions are common. Pain medicines can be taken at regular intervals for 10-5 days. No prizes for avoiding pain pills during this period.
Care of the incision – Chest
- Bathe with mild soap and warm water.
- Avoid scrubbing over the wound dressing.
- Avoid ointments, oils, lotions, powder over the incision.
- Contact your surgeon for drainage of fluid from the incision, persistent fever, pain, redness, or swelling.
Take medicines as advised for control of blood pressure, diabetes, and cholesterol lowering. These medicines apart from the obvious actions, also aid in reversing the effects of the disease on the heart.
Symptoms needing urgent attention
- Heart rate more than 120 and shortness of breath.
- Sudden numbness/weakness in arm/leg
- Severe abdominal pain
- Extreme fatigue
- Persistent oozing/bleeding from incision
- Stop any activity if short of breath, have irregular heart beat or have chest pain – rest for 20 minutes.
- Rest – Balance rest and exercise. Take short naps.
- Dress – Comfortable loose fitting clothes.
- Walking – Gradual increase of activities at your own pace.
- Stairs – Climb at slow pace. Use legs to climb, do not pull yourself up with arms when using handrail.
- Sexual – Resume activity when comfortable, about 4-5 weeks’ time.
- Driving – You can ride in a car as a passenger. After 6 weeks you can ride a two – wheeler or drive a car. It takes about 6 weeks for the breast bone (sternum) to heal.
- Lifting – Avoid lifting more than 3-5 kg of weight for 6 weeks, this includes carrying children, bags, moving furniture etc.
- Work – Light work can be resumed 6 weeks after surgery. Heavy work, cycling, sports, swimming, heavy house work can be resumed after about 3 months – confirm with your surgeon.
Do-it- yourself – Pulse assessment
Monitoring your pulse rate helps keep your activities within safe heart rate range. To take your pulse, place your index and middle figure on lower part of your thumb, then slide your fingers down to your wrist. Once you feel the pulse, count it for 15 seconds and multiply by 4. This tells the heart rate per minute. Sixty to ninety is safe range.
Choosing a Heart Surgeon and Hospital
If one is shopping for a car, it is easy to find information on mileage, repairs, durability etc. You can also compare models. But, can we do the same with heart surgeons?
We can, but not easy. Narayana Health monitors complications and death rates from heart operations amongst its surgeons and compares them with the data available from the best centres in Europe and America. At Narayana Multispeciality Hospital, Mysore, the heart surgeon has had CABG mortality rate at par with the best in the world and so is the rate for valve surgeries For heart surgeries, you need the type of sophisticated comprehensive medical care available at hospitals of repute with the brand name in heart care. The hospital should provide care for multi organ failure and have critical care intensivists in the hospital.
Good surgeon attribute
You should also find a surgeon with significant experience and expertise. Use of multiple arterial grafts is the standard of care and should be the routine in his practice. Quality standards include completeness of revascularisation – all blocked arteries should be bypassed, the surgeon should have low readmission rates for complications, and should be doing a large number of procedures. While the hospital mortality rate is important, so is the overall well-being and late death rates, say at 10-15 years. At Narayana Multispeciality Hospital, Mysore, the surgeon performs around 500 operations a year, and the hospital follows up the patients with phone calls and questionnaires and checkups at regular intervals.
Atherosclerosis is an age related process and hastened by risk factors like smoking, diabetes, hypertension, high cholesterol levels, obesity, sedentary life style and strong family history. Regular heart checks are a must in people above 40 years. Coronary artery diseases are diagnosed only by an angiogram and treatment could be medical or interventional – CABG.
Dr Ravi MN
Consultant, Cardiac Surgery-Adult
Narayana Multispeciality Hospital, Mysore