Coronary Artery Bypass Graft Surgery
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Coronary Artery Bypass Graft Surgery
Coronary artery bypass graft surgery is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the leg, arm, or chest.
Coronary artery bypass graft surgery (also called coronary artery bypass surgery, CABG, and bypass operation) is performed to restore blood flow to the heart. This relieves chest pain and ischemia, improves the patient's quality of life, and in some cases, prolongs the patient's life. The goals of the procedure are to enable the patient to resume a normal lifestyle and to lower the risk of a heart attack.
The decision to perform coronary artery bypass graft surgery is a complex one, and there is some disagreement among experts as to when it is indicated. Many experts feel that it has been performed too frequently in the United States. According to the American Heart Association, appropriate candidates for coronary artery bypass graft surgery include patients with blockages in at least three major coronary arteries, especially if the blockages are in arteries that feed the heart's left ventricle; patients with angina so severe that even mild exertion causes chest pain; and patients who cannot tolerate percutaneous transluminal coronary angioplasty and do not respond well to drug therapy. Coronary artery bypass graft surgery often is the treatment of choice for patients with severe coronary artery disease (three or more diseased arteries with impaired function in the left ventricle).
Coronary artery bypass graft surgery ideally should be postponed for three months after a heart attack. Patients should be medically stable before the surgery, if possible.
Coronary artery bypass graft surgery builds a detour around one or more blocked coronary arteries with a graft from a healthy vein or artery. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart. In the fall of 2003, a cardiac surgeon in Brazil reported success using a synthetic coronary artery bypass graft called the CardioPass on both an adult and pediatric patient. The company that makes the graft, CardioTech, was one of only two companies at the time in clinical trials on humans with synthetic grafts. This could be important, as some patients do not have a healthy graft to use in bypass surgery.
Coronary artery bypass graft surgery is major surgery performed in a hospital. The length of the procedure depends upon the number of arteries being bypassed, but it generally takes from four to six hours—sometimes longer. The average hospital stay is four to seven days. Full recovery from coronary artery bypass graft surgery takes three to four months. Within four to six weeks, people with sedentary office jobs can return to work; people with physical jobs must wait longer and sometimes change careers.
Coronary artery bypass graft surgery is widely performed in the United States. About 516,000 of these procedures were performed in 2001. The number performed has declined somewhat in the past five to 10 years due increased use of less invasive coronary angioplasty and stent therapy procedures.
The surgery team for coronary artery bypass graft surgery includes the cardiovascular surgeon, assisting surgeons, a cardiovascular anesthesiologist, a perfusion technologist (who operates the heart-lung machine), and specially trained nurses. After general anesthesia is administered, the surgeon removes the veins or prepares the arteries for grafting. If the saphenous vein is to be used, a series of incisions are made in the patient's thigh or calf. More commonly, a segment of the internal mammary artery will be used and the incisions are made in the chest wall. The surgeon then makes an incision from the patient's neck to navel, saws through the breastbone, and retracts the rib cage open to expose the heart. The patient is connected to a heart-lung machine, also called a cardiopulmonary bypass pump, that cools the body to reduce the need for oxygen and takes over for the heart and lungs during the procedure. The heart is then stopped and a cold solution of potassium-enriched normal saline is injected into the aortic root and the coronary arteries to lower the temperature of the heart, which prevents damage to the tissue.
Next, a small opening is made just below the blockage in the diseased coronary artery. Blood will be redirected through this opening once the graft is sewn in place. If a leg vein is used, one end is connected to the coronary artery and the other to the aorta. If a mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta. The procedure is repeated on as many coronary arteries as necessary. Most patients who have coronary artery bypass graft surgery have at least three grafts done during the procedure.
Electric shocks start the heart pumping again after the grafts have been completed. The heart-lung machine is turned off and the blood slowly returns to normal body temperature. After implanting pacing electrodes (if needed) and inserting a chest tube, the surgeon closes the chest cavity.
Success rate of coronary artery bypass graft surgery
About 90% of patients experience significant improvements after coronary artery bypass graft surgery. Patients experience full relief from chest pain and resume their normal activities in about 70% of cases; the remaining 20% experience partial relief. In 5-10% of coronary artery bypass graft surgeries, the bypass graft stops supplying blood to the bypassed artery within one year. Younger people who are healthy except for the heart disease do well with bypass surgery. Patients who have poorer results from coronary artery bypass graft surgery include those over the age of 70, those who have poor left ventricular function, or are undergoing a repeat surgery or other procedures concurrently, and those who continue smoking, do not treat high cholesterol or other coronary risk factors, or have another debilitating disease.
Long term, symptoms recur in only about 3-4% of patients per year. Five years after coronary artery bypass graft surgery, survival expectancy is 90%, at 10 years it is about 80%, at 15 years it is about 55%, and at 20 years it is about 40%.
Angina recurs in about 40% of patients after about 10 years. In most cases, it is less severe than before the surgery and can be controlled by drug therapy. In patients who have had vein grafts, 40% of the grafts are severely obstructed 10 years after the procedure. Repeat coronary artery bypass graft surgery may be necessary, and is usually less successful than the first surgery.
Minimally invasive coronary artery bypass graft surgery
There are two new types of minimally invasive coronary artery bypass graft surgery: port-access coronary artery bypass (also called PACAB or PortCAB) and minimally invasive coronary artery bypass (also called MIDCAB). These procedures are minimally invasive because they do not require the neck-to-navel incision, sawing through the breastbone, or opening the rib cage to expose the heart. Both procedures enable surgeons to work on the coronary arteries through small chest holes called ports and other small incisions. Port-access coronary artery bypass requires the use of a heart-lung machine but minimally invasive coronary artery bypass does not. Advantages of these procedures over standard coronary artery bypass graft surgery include a shorter hospital stay, a shorter recovery period, and lower costs.
Port-access coronary artery bypass enables surgeons to perform bypasses through smaller incisions. Using a video monitor to view the procedure, the surgeon passes instruments through ports in the patient's chest to perform the bypass. Mammary arteries or leg veins are used for the grafts. Minimally invasive coronary artery bypass is performed on a beating heart and is appropriate only for bypasses of one or two arteries. Small ports are made in the patient's chest, along with a small incision directly over the coronary artery to be bypassed. Generally, the surgeon uses a mammary artery for the bypass.
Early data on outcomes for port-access coronary artery bypass and minimally invasive coronary artery bypass are favorable. Mortality rates with port-access coronary artery bypass and minimally invasive coronary artery bypass are both less than 3%—about the same as in standard coronary artery bypass graft surgery. One clinical trial indicated that survival at seven years was the same in minimally invasive coronary artery bypass and standard coronary artery bypass graft surgery, but that another intervention was necessary five times more often with minimally invasive coronary artery bypass than with standard coronary artery bypass graft surgery. The American Heart Association Council on Cardio-Thoracic and Vascular Surgery feels that both procedures appear promising but that further study is needed. More data covering longer term outcomes are necessary in order to fully assess these procedures.
The patient is usually admitted to the hospital the day before the coronary artery bypass graft surgery is scheduled. Coronary angiography has been previously performed to show the surgeon where the arteries are blocked and where the grafts might best be positioned. The patient is given a blood-thinning drug—usually heparin—that helps to prevent blood clots. The evening before the surgery, the patient showers with antiseptic soap and is shaved from chin to toes. After midnight, food and fluids are restricted. A sedative is prescribed on the morning of surgery and sometimes the night before. Heart monitoring begins.
The patient recovers in a surgical intensive care unit for at least the first two days after the surgery. He or she is connected to chest and breathing tubes, a mechanical ventilator, a heart monitor and other monitoring equipment, and a urinary catheter. The breathing tube and ventilator usually are removed within six hours of surgery, but the other tubes remain in place as long as the patient is in the intensive care unit. Drugs are prescribed to control pain and to prevent unwanted blood clotting. The patient is closely monitored. Vital signs and other parameters, such as heart sounds and oxygen and carbon dioxide levels in arterial blood, are checked frequently. The chest tube is checked to ensure that it is draining properly. The patient is fed intravenously for the first day or two. Daily doses of aspirin are started within six to 24 hours after the procedure. Chest physiotherapy is started after the ventilator and breathing tube are removed. The therapy includes coughing, turning frequently, and taking deep breaths. Other exercises will be encouraged to improve the patient's circulation and prevent complications due to prolonged bed rest.
If there are no complications, the patient begins to resume a normal routine around the second day. This includes eating regular food, sitting up, and walking around a little bit. Before being released from the hospital, the patient usually spends a few days under observation in a non-surgical unit. During this time, counseling is usually provided on eating right and starting a light exercise program to keep the heart healthy. Patients should eat a lot of fruits, vegetables, grains, and non-fat or low-fat dairy products, and reduce fats to less than 30% of all calories. An exercise program usually will be tailored for the patient, who will be encouraged to participate in a cardiac rehabilitation program where exercise will be supervised by professionals. Cardiac rehabilitation programs, offered by hospitals and other organizations, also may include classes on heart-healthy living.
Full recovery from coronary artery bypass graft surgery takes three to four months and is a gradual process. Upon release from the hospital, the patient will feel weak because of the extended bed rest in the hospital. Within a few weeks, the patient should begin to feel stronger.
While the incision scar from coronary artery bypass graft surgery heals, which takes one to two months, it may be sore. The scar should not be bumped, scratched, or otherwise disturbed. An exercise test often is conducted after the patient leaves the hospital to determine how effective the surgery was and to confirm that progressive exercise is safe.
Coronary artery bypass graft surgery is major surgery and patients may experience any of the complications associated with major surgery. The risk of death during coronary artery bypass graft surgery is two to three percent. Possible complications include graft closure and development of blockages in other arteries, long-term development of atherosclerotic disease of saphenous vein grafts, abnormal heart rhythms, high or low blood pressure, blood clots that can lead to a stroke or heart attack, infections, and depression. There is a higher risk for complications in patients who are heavy smokers, patients who have serious lung, kidney, or metabolic problems, or patients who have a reduced supply of blood to the brain. A 2003 report also described poverty as a risk factor for complications and death following coronary artery bypass surgery. It is likely that being poor is associated with a greater degree of stress, social isolation, and inadequate access to quick or preventive treatment.
"CardioPass Synthetic Coronary Artery Bypass Graft Implanted in Baby." Medical Devices & Surgical Technology Week September 7, 2003: 79.
"Graft Functioning Well in Coronary Artery Bypass Patient." Cardiovascular Week September 15, 2003: 38.
"Poverty Increases Risk of Complications and Death After CABG." Heart Disease Weekly September 7, 2003: 19.
Simonsen, Michael. "Changing Role for Cardiac Surgery as Use of Stents Continues Growth." Cardiovascular Device Update March 2003: 1-7.
Smith, Laquita Bowen. "Not-So-Open Heart Surgery: New Equipment Allows for a Three-Inch Incision." Memphis Business Journal 18, no. 53 (May 12 1997): 49.
American Heart Association. 7320 Greenville Ave, Dallas, TX 75231. (214) 373-6300. http://www.americanheart.org.
Texas Heart Institute. Heart Information Service. P.O. Box 20345, Houston, TX 77225-0345. http://www.tmc.edu/thi.
Aorta — The main artery that carries blood from the heart to the rest of the body The aorta is the largest artery in the body.
Graft — To implant living tissue surgically. In coronary artery bypass graft surgery, healthy veins or arteries are grafted to coronary arteries.
Mammary artery — A chest wall artery that descends from the aorta and is commonly used for bypass grafts.
Saphenous vein — A long vein in the thigh or calf commonly used for bypass grafts.
Ventricles — The left and right ventricles are the large chambers of the heart. The ventricles propel blood to the lungs and the rest of the body.