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The largest research study of its kind has found that drugs can be just as effective as stents and surgery for treating blocked arteries. Results of the study, sponsored by the National Heart, Lung, and Blood Institute, were released on November 16.Calling the findings profound, Mukul Chandra MD, FACC, of Premier Cardiovascular Institute says he is eager to share the news with his patients. We have all the information we need. You dont have to have stents or surgery for stable chest pain. If youre not having a heart attack, we have another option, he says hell tell them.
Treatment For Coronary Artery Disease
However, for some patients, the blockage are so severe that surgery is necessary to make sure the heart continues to receive adequate blood flow. This surgical procedure is known as coronary artery bypass graft surgery .
What Are The Advantages Of This Procedure
CABG has several advantages that make it a useful and common part of treating heart problems.
- A long history of use. Surgeons performed the first CABG procedures in the early 1960s. In the decades that followed, additional studies and advancements helped make this procedure a key and reliable technique for treating ischemia of the heart.
- Better for multiple blockages or blockages in certain arteries. CABG is often the best choice when a person has multiple blocked arteries in their heart. Its also a superior procedure for blockages in certain places. Many studies have linked CABG with improved long-term outcomes, including better survival odds. This advantage often grows when used alongside advanced bypass techniques with durable results.
- Lower risk for follow-up procedures. The main alternative to CABG is percutaneous coronary intervention , often known as angioplasty. In many cases, PCI has a higher risk of needing a follow-up procedure.
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The Quintuple Bypass Procedure
The procedure is performed under general anesthesia and starts with blood vessels being taken from another area of the body, often the leg, and grafted onto the existing heart vessel before and after the blockage.
A quintuple bypass requires more vessels than any other procedure, so multiple sites, including the arm, left internal mammary artery , and other vessels may be used.
Obtaining adequate vessels to use for the grafts can be one of the most challenging aspects of the procedure if the vessels to the heart are diseased, it is likely that the vessels in other regions of the body are also affected.
These vessels are then used to detour blood around the blockage on the way to the heart, with the blood literally being routed around the blocked portion of the vessel.
Once the vessels needed for the grafts are harvested, the chest portion of the surgery begins with a sternotomy, the incision that opens the chest and divides the sternum in half to allow the surgeon access to the heart.
Quintuple bypass is most often performed “on pump” using a cardiopulmonary bypass machine to temporarily do the work of the heart and lungs, allowing the surgeon to stop the heart and perform surgery without the constant movement of the heart beating. In some cases the procedure is done “off pump,” but this is far less common.
For Severe Heart Disease Bypass Surgery Slightly Better Than Stenting With Caveats Study Finds
Among heart-disease patients in a study who received stents, the incidence of a major complication death, heart attack, stroke or the need for a repeat procedure was 10.6% after a year. Among bypass patients, the rate was 6.9%.
Patients with severe coronary artery disease generally fared better with bypass surgery than with stents to open blocked arteries, according to a major new multinational study led by Stanford Medicine investigators.
However, some patients benefited more from stents, particularly if their disease wasnt complex, the researchers found.
The good news for patients is that both groups did better than what was found in previous studies, and the differences between the two strategies has lessened, said William Fearon, MD, professor of cardiovascular medicine and principal investigator of the trial. He said the trial, the largest of its kind, will serve as a guide for determining which approach is best for individual patients.
I think it will have an immediate impact on how patients and physicians choose treatment, said Fearon, who is also the director of interventional cardiology at Stanford.
A paper describing the study, called the FAME 3 trial, was published online Nov. 4 in The New England Journal of Medicine. Fearon shares lead authorship on the paper with Frederick Zimmermann, MD, of Catharina Hospital in the Netherlands. Nico Pijls, MD, PhD, of Catharina Hospital, was the papers senior author.
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Minimally Invasive Cardiac Surgical Coronary Artery Bypass Graft
Some patients, even those with multiple coronary artery blockages, may undergo minimally invasive coronary artery bypass . This is a less invasive procedure than standard coronary artery bypass surgery.
Coronary artery bypass surgery is used to treat symptoms of coronary artery disease that do not improve with medication, lifestyle changes, or minimally invasive procedures, such as angioplasty. During coronary artery bypass surgery, blood vessels are removed from another part of the body and used to reroute the hearts blood supply past blocked arteries. This prevents the heart muscle from being permanently damaged by a lack of oxygen. MICS CABG allows the bypass to be done through a small incision between the ribs rather than through the larger chest opening required in standard CABG surgery.
What Happens After Open
When you wake up after surgery, you will have two or three tubes in your chest. These are to help drain fluid from the area around your heart. You may have intravenous lines in your arm to supply you with fluids, as well as a catheter in your bladder to remove urine.
You will also be attached to machines that monitor your heart. Nurses will be nearby to help you if something should arise.
You will usually spend your first night in the intensive care unit . You will then be moved to a regular care room for the next three to seven days.
Taking care of yourself at home immediately after the surgery is an essential part of your recovery.
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When Should I See My Healthcare Provider
You should see your healthcare provider as recommended after your procedure. They’ll schedule follow-up visits where they can check your heart function, remove any remaining stitches or staples, and make sure your wounds are healing well.
During your recovery, you should also follow your providers guidance regarding the following:
When should I go to the emergency room?
You should go to the hospital right away if you have any of the following:
- Having a fever or chills.
- Fast heart rate or breathing.
A note from Cleveland Clinic
Coronary artery bypass grafting is a surgery that can make a big difference in how you feel and your overall length and quality of life. It’s also a major procedure, and its normal to worry or feel anxious about having this surgery. Talking to your healthcare provider is important because they can provide you with information and resources that can help you better understand whats happening. They can also guide you on what you can do to help yourself avoid complications and have the best possible outcome.
How Do I Manage Post
A cardiac anesthesiologist is also a pain management specialist for conditions related to surgery. Your anesthesiologist will talk to you about your options for managing post-operative pain. Before your surgery, the anesthesiologist may ask about your pain tolerance to help gauge how best to manage your post-operative pain, guiding decisions such as the proper narcotics dosage, the feasibility of nonnarcotic pain medication options, and the need for nerve blocks.
Although most heart surgeries are major surgeries, they are typically not a source of long-term pain. Even in the short term, the pain may be less severe than with operations on other areas of the body. Opioids are used when necessary, but there are many other pain management options, including:
- Lidocaine infusion
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What Is Heart Bypass Surgery
A heart bypass procedure involves attaching a blood vessel taken from elsewhere in the body to the diseased coronary artery. This results in a redirection of the blood flow around the blockage. When a person has a double bypass surgery, it means that two or three arterial blockages are rerouted.
Heart bypass surgery is done as an inpatient procedure. It’s often a planned procedure, but in some instances, an emergency heart bypass procedure is performed after a person has a heart attack.
Heart bypass surgery may sometimes be performed on infants and children, but not for the same reason adults have the procedure done. Rather, infants and children would be more likely to need heart bypass surgery because of congenital heart disease.
The steps involved in a traditional open method of heart bypass surgery include:
Verywell / Tim Liedtke
What Conditions Are Treated By This Surgery
The condition thats most likely to lead to CABG is coronary heart disease, a group of conditions that includes heart attack and coronary artery disease. Other conditions under coronary heart disease include angina pectoris, which is chest pain caused by ischemia in your heart, and silent myocardial ischemia, which is heart ischemia without any symptoms.
Conditions that fall under coronary heart disease usually involve a narrowing of the arteries in your heart because of a buildup of a fatty, wax-like residue called plaque. As plaque builds up on the inside of your heart’s arteries, the arteries become stiffer and narrower. If an area of plaque breaks open, blood clots can form there and create blockages in those arteries. Those blockages cause ischemia in parts of your heart, which can lead to a heart attack.
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Quit Smoking And Reduce Alcohol Intake If You Smoke Or Drink Alcohol
Smoking contributes to the development of atherosclerosis, making it more likely that plaques will form and increasing their overall growth rate. Smoking also affects the main artery in your body .
The day you quit smoking, your health will start to rebound. Quitting smoking may help raise your HDL levels, too. Talk with a doctor if you need help quitting smoking. They can recommend smoking cessation programs and other resources.
Too much alcohol can also affect your heart. The limited or preferably no alcohol intake.
Alcohol can also negatively affect your cholesterol levels.
Testing A Diagnostic Tool
As many as 40% of Americans older than 60 experience some narrowing of their coronary arteries caused by the buildup up of plaque in the walls of the blood vessels, according to the American Heart Association. Most cases arent serious enough to limit oxygen supply to the heart and can be treated with statins or aspirin. But significant blockages can cause chest pain and increase the risk of heart attack or death.
For years, clinicians relied exclusively on angiograms an X-ray of the coronary arteries to determine whether the vessels were sufficiently narrowed to warrant intervention. But angiograms can be misleading, showing a tight space within a vessel when none exists, Fearon said.
A better diagnostic tool, known as fractional flow reserve, or FFR, can measure whether blood flow has been reduced to a dangerous level. Doctors thread a wire with a small sensor on the tip into the artery to measure the pressure of the flow. In a significantly narrowed vessel, the blood pressure will drop in that segment of the vessel beyond the narrowing, signaling the need for intervention.
In the FAME 1 study, whose results were published in 2009, Fearon and his colleague found that use of FFR led to fewer stent placements and fewer complications when compared with stenting based on angiogram images alone. Among patients with FFR-guided stents, the rates of death, heart attack and the need for repeat procedures were significantly less, they found.
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Who Will Help Perform The Bypass Surgery
Throughout the surgery, several types of specialists ensure the procedure is performed properly. A perfusion technologist works with the cardiopulmonary bypass machine.
A cardiovascular surgeon performs the procedure and an anesthesiologist ensures anesthesia is delivered to your body properly to keep you unconscious during the procedure.
Imaging specialists may also be present to take X-rays or help ensure that the team can view the site of the surgery and the tissues around it.
When you wake up from heart bypass surgery, youll have a tube in your mouth. You may also feel pain or have side effects from the procedure, including:
- pain at the incision site
- pain with deep breaths
- pain with coughing
Youll likely be in the ICU for one to two days so your vital signs can be monitored. Once youre stable, youll be moved to another room. Be prepared to stay in the hospital for several days.
Before you leave the hospital, your medical team will give you instructions on how to care for yourself, including:
- caring for your incision wounds
- getting plenty of rest
- refraining from heavy lifting
Even without complications, recovery from heart bypass surgery can take 6 to 12 weeks. Thats the least amount of time it takes for your breastbone to heal.
During this time, you should avoid heavy exertion. Follow your doctors orders regarding physical activity. Also, you shouldnt drive until you get approval from your doctor.
- fever over 100.4°F
- increasing pain in your chest
- rapid heart rate
Why Is Coronary Bypass Surgery Done
Your heart works 24/7, supplying your entire body with blood. To do its job, your heart also needs blood flow, which it gets through a network of supply arteries that wrap around it. When tissues in your body arent getting enough blood flow, this causes a problem called ischemia .
The muscle cells in your heart are especially sensitive to ischemia, and when it’s severe, those heart muscle cells will start to die. Coronary artery bypass grafting treats ischemia by restoring blood flow to the affected heart muscle.
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Considering Complexity Of Heart Disease
The researchers looked at results based on the patients underlying coronary disease. They found that patients with less complex coronary artery disease did better with stents, as physicians could limit the number of the mesh tubes they had to place.
I think the study results will guide both physicians and patients on the best strategy for their circumstances, Fearon said. If patients have very complex disease that would require numerous stents, then bypass might be a better option. If they have less complex disease, they can feel reassured that by receiving the latest generation of drug-eluting stents guided by FFR, their outcomes would be just as good as they would be with surgery.
He said stents also have an advantage in that they entail shorter hospital stays and faster recoveries. Patients who receive stents generally go home the same day and recover quickly. Bypass patients, on the other hand, may remain in the hospital for as many as five days or longer, with a recovery time of six to eight weeks. In the study, bypass patients also had a higher incidence of major bleeding, arrythmia, acute kidney injury and rehospitalization within 30 days.
The FAME 3 trial was initiated by Fearon and two of the other investigators and was sponsored by Stanford Medicine. Medtronic Inc. and Abbott Vascular Inc. provided research grants for the study but were not involved in its design or implementation.
- Ruthann Richter Ruthann Richter is a freelance writer.
Agerelated Changes In Cardiovascular Physiology
In all, 80% of patients > 80years have identifiable cardiovascular disease.7 Agerelated changes occur in small and large vessels and in the heart itself, reducing physiological reserves. Most patients show no signs of impaired haemodynamic performance at baseline, but stresses of anaesthesia will often uncover their limited cardiac reserve.7
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Endoscopic Saphenous Vein Harvesting
Endoscopic saphenous vein harvesting is a less invasive method of removing the veins from your legs.
Rather than making a large cut in your leg, the surgeon makes a number of small ones near your knee. This is known as keyhole surgery.
A special device called an endoscope will be inserted into the cut.
An endoscope is a thin, long flexible tube with a light source and video camera at one end, so that images of the inside of your body can be relayed to an external television monitor.
The endoscope allows the surgeon to locate your saphenous vein. Surgical instruments can also be passed along the endoscope to remove a section of the vein. Nearby tissue is then sterilised with antibiotic fluid and the cut is healed.
The main advantages of this technique are that there’s likely to be a:
- shorter hospital stay
- lower risk of leg wound infections
- quicker recovery from CABG