Minimally Invasive Multivessel CABG

This is a video showing Coronary Artery Bypass Grafting being done through left 4th intercostal space by a 6-7cm incision.

We are routinely doing Coronary Artery Bypass Grafting, single vessel or multivessel through left 4th or 5th Intercostal Space depending on position of apex of heart and the target arteries on routine chest x-ray and coronary angiogram. We are using skeletonised LIMA and Free Radial Artery to construct a ‘Y’ and then pick all the vessels to be grafted sequentially. Single Lung ventilation using an endobronchial tube is essential.

Team Includes Dr.Kshitij Dubey (Chief Cardiac Surgeon), Dr. Vikas Gupta (Chief Cardiac Anaesthetist), Dr. Krishnpal Singh (Anaesthetist) Mr.M.V.Krishna Mohan (Sr.Clinical Perfusionist), Rajshree Hospital & Research Centre, Indore, Madhya Pradesh.

 

Heart attacks: What you should know

Three coronary artery bypass grafts, a LIMA to...

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. (Photo credit: Wikipedia)

Editor’s note: Dr. John P. Reilly is editor-in-chief ofsecondscount.org, the patient education website of the Society of Cardiovascular Angiography and Interventions, which is focused on raising awareness of heart attacks and other cardiovascular diseases. Reilly is the program director for the Cardiology Fellowship Program at Ochsner Medical Center in New Orleans.

(CNN) — If you are one of the nearly 785,000 Americans who suffer a first heart attack this year, what you do in the first few minutes can determine an entire lifetime.

Unfortunately, many people do not know what symptoms to look for or what life-saving steps to take. To help make sense of it all, the following can help you or someone you know survive a heart attack:

Q: What are the top three things I should know about heart attacks?

A: When a heart attack strikes, seconds count.

Seek medical attention immediately. The longer your symptoms persist, the greater the amount of heart muscle damage you may suffer. The start of your symptoms is a signal that blood flow to your heart muscle has been blocked. The emergency department and interventional cardiologist or surgeon will move quickly to restore blood flow to your heart to prevent further damage.

Call 911 for an ambulance. Don’t drive yourself or have someone else drive you. During a heart attack, your heart rhythm can become abnormal or even stop.

Emergency medical providers can perform an electrocardiogram, or EKG, on the way to the hospital and confirm whether you are having a heart attack and treat your heart rhythm abnormalities if needed. They can also call the hospital in advance to prepare a medical team for your arrival so treatment can start immediately.

If available, chew one uncoated aspirin while waiting for the ambulance. This may help slow the formation of blood clots that can cause heart attacks.

Q: What are the common symptoms of heart attacks, and how do they differ between men and women?

A: We’ve all seen the scenario where the actor grabs his or her chest in agonizing pain and falls to the ground. A heart attack seems obvious, but in real life, it’s not always that clear.

Heart attack symptoms can vary and don’t always involve debilitating chest pain. Many patients say their symptoms were not painful but more like an ache or discomfort. Symptoms may start with a dull pain in the chest or disguise themselves as indigestion, nausea, shortness of breath or heartburn. Other common symptoms include arm, neck, jaw, back or upper stomach discomfort, dizziness, change in heart rhythm and sudden cold sweats.

But these symptoms may differ for your wife, mother or sister because women do not always experience the same heart attack symptoms as men. Symptoms may be subtle and difficult to identify and may not even include chest pain.

While this does not mean women cannot have chest pain, other symptoms that may signal a heart attack for women include sudden weakness and fatigue, body aches or flu-like symptoms. Heart disease is the leading cause of death for women, so it’s important that you don’t ignore these symptoms, regardless of how subtle they are.

Q: What are my heart attack treatment options?

A: There are various treatment options available when you’re having a heart attack. The most effective treatment is angioplasty and stenting. In some cases, clot-busting medication is administered intravenously. In rare and severe cases, emergency coronary artery bypass grafting is needed.

Angioplasty is a minimally invasive, nonsurgical procedure that opens the blocked artery. During the procedure, a small mesh tube called a stent may be placed in the artery to restore blood flow and scaffold the vessel open.

Clot-busting medications melt away the blood clot that is blocking the artery. Coronary artery bypass grafting is open-heart surgery where a healthy artery or vein from elsewhere in the body is connected upstream and downstream from the heart artery blockage, bypassing the blockage and creating a new path for blood flow.

Fortunately, medical technology has advanced tremendously in recent years, and many patients can return home and back to their normal — if not better — quality of life within days of treatment.

Q: What should I do following my heart attack?

A: Experiencing a heart attack is a life-changing event and an important time to reflect upon your current lifestyle.

Cardiac rehabilitation benefits many patients by helping them resume a healthy lifestyle following their heart attack. You’ll also be taking medication regularly. Adhering to your medical therapy and scheduling consistent follow-up visits with your cardiologist and primary care doctor are both beneficial habits to adopt.

In addition, it’s important to become your heart’s No. 1 health advocate. Assess your current lifestyle and see where you can make improvements. Can you eat healthier and exercise more, reduce your stress levels or quit smoking? These changes will greatly increase your odds of fighting off future heart attacks.

From CNN.com

Short-Term Stroke Risk Higher Following CABG Than Post-PCI

CABG

Among patients with complex coronary artery disease, coronary artery bypass grafting (CABG), as compared to percutaneous coronary intervention (PCI), is associated with a greater risk of periprocedural stroke, but not long-term stroke, according to a new analysis of the SYNTAX trial published on March 20 in JACC Cardiovascular Interventions. At four-year follow-up, there was no difference in stroke incidence between treatments.

The SYNTAX trial randomized 1,800 patients with de novo three-vessel and/or left main coronary disease to CABG or PCI. Overall, 33 and 20 strokes occurred at four years in the CABG and PCI groups, respectively. In the CABG group, nine of the 33 strokes occurred within 30 days of the procedure, whereas 18 of the 20 strokes in the PCI arm occurred more than 30 days after intervention. However, in a multivariate analysis, CABG was not significantly associated with an increased stroke risk (p=0.089).

Lead investigator Michael J. Mack, MD, FACC, Baylor Healthcare System, Plano, Texas, and colleagues concluded, “The overall incidence of stroke was low at four years in the SYNTAX trial in both CABG- and PCI-treated patients. Though more strokes occurred in the CABG arm than in the PCI arm early in the study, no significant differences were found at four years.”

In an accompanying editorial, Jesse Weinberger, MD, Mount Sinai School of Medicine, New York, and Craig Smith, MD, FACC, Columbia University School of Medicine, New York, noted that this analysis reports different stroke rates than the original study where rates were higher with CABG than with PCI (2.2 vs. 0.6 percent, p=0.003). The current analysis, “focused specifically on stroke, reports a stroke difference of 1 percent (CABG) vs. 0.2 percent (PCI) at 0 to 30 days by intent-to-treat (p=0.037), and three of the nine strokes in the CABG group occurred pre-operatively, so a statistically meaningful difference in an as-treated analysis is doubtful,” they wrote.

“The SYNTAX trial was not specifically designed to determine the etiology of stroke in patients treated with CABG or PCI. It is imperative to establish the causes of stroke during CABG and develop strategies to prevent these strokes,” the editorialists concluded. “A prospective study may be warranted.”

From CardioSource – Short Term Stroke Risk CABG PCI.

Effects of Off-Pump and On-Pump Coronary-Artery Bypass Grafting at 1 Year

From the New England Journal of Medicine

André Lamy, M.D., P.J. Devereaux, M.D., Ph.D., Prabhakaran Dorairaj, M.D., David P. Taggart, Ph.D., Shengshou Hu, M.D., Ernesto Paolasso, M.D., Zbynek Straka, M.D., Leopoldo S. Piegas, M.D., Ahmet Ruchan Akar, M.D., Anil R. Jain, M.D., Nicolas Noiseux, M.D., Chandrasekar Padmanabhan, M.D., Juan-Carlos Bahamondes, M.D., Richard J. Novick, M.D., Prashant Vaijyanath, M.D., Sukesh Kumar Reddy, M.D., Liang Tao, M.D., Pablo A. Olavegogeascoechea, M.D., Balram Airan, M.D., Toomas-Andres Sulling, M.D., Richard P. Whitlock, M.D., Yongning Ou, M.Sc., Janice Pogue, Ph.D., Susan Chrolavicius, B.A., and Salim Yusuf, D.Phil. for the CORONARY Investigators

March 11, 2013

DOI: 10.1056/NEJMoa1301228

Coronary-artery bypass grafting (CABG) reduces mortality among patients with extensive coronary artery disease.1 CABG is usually performed with the use of cardiopulmonary bypass (on-pump CABG). With this approach, perioperative mortality is about 2%, and myocardial infarction, stroke, or renal failure requiring dialysis develop in an additional 5 to 7% of patients. The technique of performing CABG on a beating heart (off-pump CABG) was developed to reduce perioperative complications, some of which may be related to the use of cardiopulmonary bypass and to the cross-clamping of the aorta associated with the on-pump CABG procedure, and to improve long-term outcomes.

Read the entire article here

An example of a heart attack, which can occur ...

An example of a heart attack, which can occur after the use of a performance-enhancing drug. (Photo credit: Wikipedia)

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The Mixed Blessing of Heart Surgery

Three coronary artery bypass grafts, a LIMA to...

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. (Photo credit: Wikipedia)

Angioplasty and heart bypass surgery are giants among medical procedures in America. They are performed more than a million times each year and together drive a $100-billion industry. But an article in the recent issue of Harvard Magazine explores a frightening truth: There’s no evidence that they improve life expectancy by even a single day. – See more at:

The mixed blessing of heart surgery.

Coronary Artery Bypass (CABG) Surgery

Three coronary artery bypass grafts, a LIMA to...

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. (Photo credit: Wikipedia)

Your doctor has recommended that you have coronary artery bypass surgery. But what does that actually mean?

Your heart is located in the center of your chest. It is surrounded by your rib cage and protected by your breastbone. Your heart’s job is to keep blood continually circulating throughout your body.
The vessels that supply the body with oxygen-rich blood are called arteries.

The vessels that return blood to the heart are called veins.
Like any other muscle in the body, the heart depends on a steady supply of oxygen rich blood. The arteries that carry this blood supply to the heart muscle are called coronary arteries.

Sometimes, these blood vessels can narrow or become blocked by deposits of fat, cholesterol and other substances collectively known as plaque.
Over time, plaque deposits can narrow the vessels so much that normal blood flow is restricted. In some cases, the coronary artery becomes so narrow that the heart muscle itself is in danger.

Coronary bypass surgery attempts to correct this serious problem. In order to restore normal blood flow, the surgeon removes a portion of a blood vessel from the patient’s leg or chest, most probably the left internal mammary artery and the saphenous vein.

Your doctor uses one or both of these vessels to bypass the old, diseased coronary artery and to build a new pathway for blood to reach the heart muscle. These transplanted vessels are called grafts and depending on your condition, your doctor may need to perform more than one coronary artery bypass graft.

Of course, operating on the heart is a complex and delicate process and in the case of bypass surgery, your doctor will most likely need to stop your heart before installing the graft.

During the time that your heart is not beating, a special machine, called a heart-lung machine, will take over the job of circulating and oxygenating your blood.

By using this machine, your doctor is able to repair the heart without interfering with the blood flow to the rest of the body.

Following surgery, your heart will be restarted and you will be disconnected from the heart-lung machine

Coronary Bypass Surgery

From MedStar Union Memorial Hospital.  They say “Last year alone, our doctors performed more than 880 open-heart surgeries and 6,100 catheter-based procedures, including nearly 2,000 angioplasties. No hospital in Maryland or nationally performs a higher percentage (94 percent) of beating-heart bypass surgeries.”

Warning – graphic video!

Monday – 3 Weeks Post-op

I’ve decided to do a sort of timeline in case anyone is interested.  This is all from memory so future posts should be more accurate.

Week Zero, January 28, 2013 was the actual CABG surgery.  The hospital experience  can be found here.

DH came home on Thursday of that week and the first visiting nurse arrived on Saturday. Luckily, DS was able to stay until Sunday and he was a big help.

DH wasn’t allowed to lift any more than 5 pounds, so couldn’t raise himself out of bed.  He slept on a recliner in the living room and either DS or I slept on the sofa in case he needed any meds or help during the night.

Week One, February 4, 2013, one week from surgery.

The visiting nurse came twice and is pleased with wound healing.  Blood pressure is sometimes low.  The nurse thought he should have more fluids.  One lobe of the lung isn’t working to capacity and she wants more use of the incentive spirometers.  DH has two types from the hospital – the traditional one and one that our dog thinks looks like a dog toy that she should have.

incentive spirometer

Week Two, February 11, 2013 two weeks from surgery.  DH continues to lose weight.  He’s still sleeping in the recliner and I’m still on the sofa but there is much less getting up at night.

The Oxycodone is down to half pills much less often than prescribed.

The first (and only) visit to the surgeon’s office this week.  We saw her nurse practitioner who was very impressed with how DH is doing as was his PCP.  The nurse practitioner was so pleased, she said we don’t have to go back unless there are any problems.

The PCP ran blood tests, glucose, liver enzymes, cholesterol and others.

We saw the visiting nurse twice.  She thought DH was doing so well that she discharged him on Thursday.

DH made a few phone calls this week, worked a little, had a visitor on Sunday.

Week Three, February 18, 2013, three weeks from surgery

DH slept in the bed for half the night last night and seems to be doing ok.  He still took a half Oxycodone this morning.

We see the cardiologist this afternoon.  That report will be in the Week Four post. I imagine that we’ll be talking about rehab at this appointment.

Weeks Four and Beyond will have their own posts.

More on CABG (Coronary Artery Bypass Grafting)

From the NIHWhat To Expect After Coronary Artery Bypass Grafting

Checkmark
What DH had

Recovery in the Hospital

CheckmarkAfter surgery, you’ll typically spend 1 or 2 days in an intensive care unit (ICU). Your health care team will check your heart rate, blood pressure, and oxygen levels regularly during this time.

CheckmarkAn intravenous (IV) line will likely be inserted into a vein in your arm. Through the IV line, you may get medicines to control blood flow and blood pressure. You also will likely have a tube in your bladder to drain urine and a tube in your chest to drain fluid.

CheckmarkYou may receive oxygen therapy (oxygen given through nasal prongs or a mask) and a temporary pacemaker while in the ICU. A pacemaker is a small device that’s placed in the chest or abdomen to help control abnormal heart rhythms.

CheckmarkYour doctor also might recommend that you wear compression stockings on your legs. These stockings are tight at the ankle and become looser as they go up the legs. This creates gentle pressure that keeps blood from pooling and clotting.

CheckmarkWhile in the ICU, you’ll also have bandages on your chest incision (cut) and on the areas where arteries or veins were removed for grafting.

After you leave the ICU, you’ll be moved to a less intensive care area of the hospital for 3–5 days before going home. (only 2!)

Recovery at Home

Your doctor will give you instructions for recovering at home (yes to all), such as:

  • How to care for your healing incisions
  • How to recognize signs of infection or other complications
  • When to call the doctor right away
  • When to make followup appointments

You’ll also learn how to deal with common side effects from surgery. Side effects often go away within 4–6 weeks after surgery, but may include:

  • Discomfort or itching from healing incisions
  • Swelling of the area where arteries or veins were removed for grafting
  • Muscle pain or tightness in the shoulders and upper back
  • Fatigue (tiredness), mood swings, or depression
  • Problems sleeping or loss of appetite
  • Constipation
  • Chest pain at the site of the chest bone incision (more frequent with traditional CABG)

Full recovery from traditional CABG may take 6–12 weeks or more. Nontraditional CABG doesn’t require as much recovery time.

Your doctor will tell you when you can become active again. It varies from person to person, but there are some typical timeframes.

Often, people can resume sexual activity and return to work after about 6 weeks. Some people may need to find less physically demanding types of work or work a reduced schedule at first.

Talk with your doctor about when you can resume activity, including sexual activity, working, and driving.

Ongoing Care

Care after surgery may include periodic checkups with doctors. During these visits, you may have tests to see how your heart is working. Tests may include an EKG (electrocardiogram), stress testingechocardiography, and a cardiac CT scan.

CABG is not a cure for coronary heart disease (CHD). After the surgery, your doctor may recommend a treatment plan that includes lifestyle changes. Following the plan can help you stay healthy and lower the risk of CHD getting worse.

Lifestyle changes might include changing your diet, quitting smoking, being physically activelosing weight or maintaining a healthy weight, and reducing stress.

For more information about lifestyle changes, go to the National Heart, Lung, and Blood Institute’s “Your Guide to Living Well With Heart Disease.”

Your doctor also may refer you to cardiac rehabilitation (rehab). Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems.

Cardiac rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help you return to an active life. Your doctor can tell you where to find a cardiac rehab program near your home.

Taking medicines as prescribed also is important after CABG. Your doctor may prescribe medicines to manage pain during recovery, lower your cholesterol and blood pressure, reduce the risk of blood clots forming, manage diabetes, or treat depression.

Two Weeks After CABG

Sounds like a fairy tale of some kind involving veggies like cabbage, lettuce and other greenery.  But it’s not.  CABG is the abbreviation for Coronary artery bypass grafting, something I had no idea about 2 weeks ago.

CABG

DH had 3 of those grafts, the mammary artery and 2 from his leg vein.

From NIH:

Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. Surgeons use CABG to treat people who have severe coronary heart disease (CHD).

CHD is a disease in which a waxy substance called plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart.

Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort called angina< (an-JI-nuh or AN-juh-nuh).

If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.

CABG is one treatment for CHD. During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle.

Surgeons can bypass multiple coronary arteries during one surgery.

I have to say it’s amazing how quickly the body can begin to heal after such an assault.  So far, we’ve seen the surgeon’s nurse practitioner and the visiting nurse.  Both say he’s doing very well for such a short amount of time.

There’s still some pain, some coughing, and other inconveniences but it’s amazing what modern medicine can do!