CABG – Redo

• In open heart surgery a general anesthesia is usually involved since it is considered as one of the major surgeries.
• An incision down the middle of the chest is made by the cardiac surgeon. He then uses a saw like movement to access the breastbone or the sternum. This cutting of the middle of the sternum is referred to as median sternonomy.
• The heart has to be cooled with iced salt water. Along with this a preservative solution has to be injected in the arteries of the heart. This procedure is referred to as cardioplegia where damage is minimized due to reduced blood flow happening during the surgery.
• A cardiopulmonary bypass must be established before a bypass surgery can take place.
• For channelizing venous blood out of the body, plastic tubes must be placed in the right atrium. A membrane oxygenator which is like a plastic sheeting is employed to channelize it to the heart lung machine.
• The oxygenated blood is then returned to the body. To allow the bypasses to connect with the aorta the main aorta is cross clamped during the surgery. This maintains a bloodless field.
• Saphenous vein from the leg is the commonly employed vessel for the bypass grafting.
• Beyond the narrowing of the vessel or the coronary artery, the graft vessel is sewed to the coronary arteries. The other end of the grafted vein or vessel is made to attach with the aorta.
• Nowadays, chest wall arteries or more specifically the internal mammary artery is used commonly for the purpose of bypass graft. The artery is then separated from the wall of the chest to connect to the left anterior descending artery. It can also be connected to one of the major branches which is beyond the blockage. Internal mammary arteries have an advantage over venous grafts is that it remains open for a longer period of time. The percentage rate of being open in case of venous grafts are 66% while for internal mammary arteries it is 90%. but then artery grafts are of limited lenghth and can hence be only employed to bypass diseases which are located near the proximal or beginning of coronary arteries. The time required in CABG where internal mammary arteries are employed is more since they must be separated from the chest wall. Hence they are not very suitable for emergency cases where blood flow must be quickly resolved to restore the condition of the coronary artery.
• The aorta must be clamped off for only 60 minites while the body is supported bycardiopulmonary bypass for a period of 90 minutes. The use of 3, 4 or 5 bypasses have grown very common.
• After the end of the surgery the sternum with the help of stainless steel is wired together while the incision madein the chest is sewn. Plastic tubes are kept undisturbed to allow any blood drainage from the region around the heart.
• Exploration may be required for 5% f patients within first 24 hours to monitor bleeding after surgery. While chest tubes are removed right after surgery along with the breathing tube.

What are the alternatives for CABG?
The other alternatives for CABG can be balloon surgery or angioplasty which is a less invasive technique but then your cardiologist is the best person to decide which of the surgeries is best suited for  the patient. Percutaneous coronary intervention can also be employed where a stent may be used to keep the artery open. This is also a less invasive technique.

Aftercare and recovery
The patients are transferred out of ICU right after the day of the surgery. Heart rhythm disturbances are found in 25% patients within a period of 3 or 4 days after the surgery. They are temporary atrial fibrillations which are associated with surgical trauma. They respond well to standard mediacal therapies used. They can be weaned within a period of a month after the surgery. From one week to 1 day, the range of stay in the hospital may vary, Young patients are usually discharged within two days. The recovery time can be very long and the physical activities must be kept minimum.
How long will the effects last?
Unfortunately even after such a major surgery, problems can again come back requiring another surgery where heart blocakges can get detected.

Pros and Cons

Pros

• Reduces pain or angina and other symptoms of coronary heart diseases
• One can resume a normal lifestyle
• the pumping action of heart improves after suffering the damage from a heart attack
• chances of pumping action improves

Cons

• Very invasive procedure
• can be quite expensive and complicated
• requires quite a lot of preparation before the surgery
• significant change in lifestyle after surgery