Bypass the blocks to life
Coronary Artery Bypass Grafting (CABG) is probably the most commonly performed surgery the world over. Yet, a shroud of fear and ignorance seems to cover the face of this life saving procedure. Such misunderstandings have prevented many deserving persons from benefiting from what this surgery has to offer. This article thus aims to provide you with a clear view of what the surgery involves, and to dispel the myths.
Coronary Artery Disease
Coronary arteries – the blood vessels that supply the heart with its share of blood – may be affected by occlusive atherosclerotic disease, which is what is commonly referred to as coronary artery disease. Here, fatty substances get deposited on the walls of the arteries leading to their narrowing. One or more of the coronary arteries may then get blocked, decreasing the blood supply to regions of the heart.
This causes chest pain, which your cardiologist calls angina. A heart attack may occur in more severe cases, which damages the heart
permanently, decreasing its efficiency.
CABG is the popular acronym for Coronary Artery Bypass Graft. It refers to a surgery that aims to supply the starved heart muscle with more blood, by bypassing the blockages. The blood vessels from the patient’s own body, which he can spare, are used to perform these bypasses like the internal mammary arteries that supply blood to the chest wall and the breast bone. The Left Internal Mammary Arter (LIMA) is used to bypass the Left Anterior Descending Artery (LAD), which is the most important artery of the heart. The best results have been observed with use of this artery, which makes this the surgeon’s favourite.
The veins from the legs called the saphenous veins and the radial artery from the arm are also used. The surgeon studies the coronary arteries and tailors his plan of revascularisation (or the providing of new, additional or augmented blood supply) to suit the needs of the individual patient. Once the surgeon joins up the grafts, blood flows through them beyond the blocks thus bypassing them. The blocks, as you might have noticed, are not removed, but bypassed – and hence the name ‘bypass surgery
Connecting grafts to the blocked arteries is what CABG is about. When the heart- lung machine is used to perform the cardiopulmonary bypass surgery, it is classified as the conventional way of Coronary Artery Bypass Grafting. The heart-lung machine allows the heart’s beating to be stopped, so the surgeon can operate on a surface which is blood-free and still. But despite the lack of heartbeat, the heart-lung machine removes carbon dioxide from the blood and replaces it with oxygen, before pumping it around the body.
Beating heart bypass surgery
Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart, while it is still beating. The heartbeat may be slowed down by medication, but it still keeps beating during the surgery. This type of surgery may be an option for patients with single-vessel disease.
The heart-lung machine is not used in this surgery. Advanced operating equipment stabilise portions of the heart and helps bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.
Minimally invasive cardiac surgery
Improving patient comfort by reducing pain is one of the concerns of a cardiac surgeon. Making the procedure less invasive is one of the ways in which surgeons aim to achieve this. Minimally invasive surgery is performed through a small incision, often using specialised surgical instruments. The incision is about three to four inches instead of the six to eight inch incision required for traditional surgery.
Types of minimally invasive cardiovascular surgeries include:
- Coronary Artery Bypass Graft (CABG) surgery
- Epicardial lead placement: Placement of leads for biventricular pacemakers to pace the rhythm of the heart’s lower chambers (ventricles) so that the chambers contract at the same time. This is also called cardiac resynchronisation therapy.
- Atrial fibrillation: Rapid, uneven contractions in the heart chamber called the atria, which causes a lack of synchronism between heartbeat and pulse beat. Specialised instruments are used to create new pathways for the electrical impulses that trigger the heartbeat with this technique. Unlike traditional bsurgery for atrial fibrillation, the minimally invasive procedure has no large chest wall incision, and the heart is not stopped during the procedure.
Minimally Invasive Direct Coronary Artery Bypass Graft (MIDCABG) surgery is an option for patients who require a left internal mammary artery bypass graft to the left anterior descending artery. A small two to three inch incision is made in the chest wall between the ribs (whereas the incision made during traditional CABG surgery is about six to eight inches long and down the centre breastbone). Saphenous (leg) vein harvest may also be performed using small incisions.
For some surgical procedures, a keyhole or endoscopic approach may be used. This approach is also referred to as port access surgery or video-assisted surgery. This technique allows surgeons to use one to four small (5 to 10 mm) incisions or ports in the chest wall between the ribs. An endoscope or thoracoscope (a thin tube with a small camera at the tip) and surgical instruments are guided in through the incisions. The scope transmits live videos of the internal organs on a monitor, so the surgeon can get a closer view of the surgical area while performing the procedure. Video Assisted Thoracoscopy (VATS), also called thoracoscopy or pleuroscopy, is a minimally invasive surgical technique used during some types of thoracic surgeries.
Science fiction is coming true – highly specialised robots are employed to execute many steps in certain surgical procedures. Relatively newer procedures like hybrid coronary bypass – coronary bypass surgery and coronary stenting during the same operation – are being helped in by robots, and present the modern alternative to the traditional bypass surgery. Robotic manoeuvres can be very effectively combined with minimally invasive procedures.
7 benefits of minimally invasive surgery
1. Smaller incision
2. Smaller scar
3. Reduced risk of infection
4. Lesser bleeding
5. Lesser pain and trauma
6. Decreased length of stay in hospital after the procedure: the average stay is about three days after minimally invasive surgery, while average
stay after traditional heart surgery is five days.
7. Decreased recovery time: the average recovery time after minimally invasive surgery is two to four weeks, as compared to the average recovery time of six to eight weeks after traditional heart surgery