What is a coronary artery bypass?
Heart bypass, coronary artery bypass (CAB) or coronary artery bypass grafting (CABG) are all terms that describe a single type of surgical procedure performed under general anaesthesia by a cardiothoracic surgeon.
The aim of heart bypass is to provide 1 or more alternative routes for the blood supply that feeds the heart muscle. This becomes essential when the usual routes become too narrow. Coronary bypass procedures may include heart valve replacement when a heart valve – most commonly on the left-hand side of the heart – no longer functions correctly. A small number of surgeons are specialised in robotic-assisted coronary artery bypass (RACAB) surgery.
Coronary artery bypass surgery is possible with or without the use of a heart-lung (cardiopulmonary bypass) machine. When the patient’s blood flow is not rerouted to bypass rather than flow through the heart, surgery is referred to as off-pump (OPCAB) or beating heart coronary bypass. While the traditional approach is total sternotomy – a 15 to 25 cm incision that runs vertically through the middle of the breastbone - smaller incisions may be used and these methods are grouped under a range of terms: minimally invasive direct coronary artery bypass (MIDCAB), limited access coronary artery surgery, port access coronary artery bypass (PACAB) and totally endoscopic coronary artery bypass grafting (TECAB).
It should be mentioned that symptomatic coronary heart disease that limits oxygen supply to the body and causes low blood oxygen levels may be a contraindication to airline travel. Your treating physician could be asked to provide an assessment for your flight provider. If given the all-clear, short-haul flights traveling at under 8000 feet and/or use of an oxygen concentrator can lower the risk of chest pain and myocardial infarction. Remedazo can help you to arrange alternative transportation or help find approved medical equipment, as well as a medical professional to accompany you on your flight.
Why do I need heart bypass surgery?
The term heart bypass can be a little confusing as it doesn’t describe the surgery but the method by which some surgeries are carried out. The correct term is coronary artery bypass grafting, shortened to CABG and often referred to as a ‘cabbage’.
The heart is a large muscle that contracts and relaxes in order to pump blood around the body. It needs a constant supply of oxygen and energy in the form of glucose as well as protein to help muscle repair. All of these are contained within the blood.
The heart muscle or myocardium receives its blood supply from the coronary arteries. If you have been diagnosed with coronary artery disease and undergone some tests, your medical notes may feature abbreviations of the names of the affected coronary arteries.
The two main coronary arteries originate in the aorta, the body’s largest artery that supplies oxygenated blood to the rest of the body. These are called the left main coronary artery (LMCA) that supplies blood to the left side of the myocardium and the right coronary artery (RCA) that supplies the right side of the myocardium as well as the electrical system of the heart that stimulates how and when the heart contracts and relaxes to create a pumping motion.
The RCA continues downwards along the heart muscle but branches off at intervals. The most commonly listed of these arteries in terms of coronary artery disease are the right posterior (back) descending artery (PDA) and the right marginal artery that supplies the back and front of the right ventricle and some of the left ventricle.
The LMCA is the origin of arterial branches that spread over the more muscular side of the left side of the heart. The thicker muscle and more exaggerated movement may be one of the reasons why left coronary artery surgery is more common than surgery for right-sided coronary artery disease. The LMCA has two large branches called the left anterior descending artery (LAD or LADA) and the left circumflex (circular) artery often referred to as LCx. These supply blood to the left side of the heart.
Coronary artery disease (CAD) and ischemic heart disease (IHD) are terms used to describe narrowing of the coronary arteries due to fatty build-ups inside the blood vessel wall. In the latter case, symptoms have begun and some areas of heart muscle are occasionally or more frequently starved of oxygen.
The presence of fatty layers or plaque along portions of artery walls is medically referred to as atherosclerosis, a disease that becomes more common as we age, especially in combination with an unhealthy diet, sedentary lifestyle, various illnesses and damaging habits such as smoking. Atherosclerosis does not affect the veins directly but the presence of chemicals that are produced in response to atherosclerosis may cause veins to become inflamed. In the arteries, long-term effects of plaque build-up stiffen the walls, meaning they respond less well to chemical signals that tell them to open (dilate) or narrow (constrict) according to specific tissue requirements. This can mean your blood pressure remains high even when treated with blood pressure-lowering medication.
If the myocardium does not receive enough oxygen and energy, some of the muscle cells will die. Unlike other types of muscle tissue, heart muscle cells have less ability to heal and regenerate. Damaged heart muscle means that blood is pumped less efficiently throughout the body and other parts of the anatomy may present with mild to severe symptoms. In addition, heart valves can become damaged and require repair or heart valve replacement.
The electrical conduction system of the heart can also suffer from CAD, with specialised pacemaker cells either sending too many or too few signals, sometimes at the wrong time, or dying through a lack of oxygen. The heart contracts irregularly or skips beats; signals passing from the top of the heart to the bottom may become disrupted leading to slow responses. If vasodilator and/or antiarrhythmic drugs do not alleviate symptoms, surgery is advised. Where one or more coronary arteries becomes completely blocked the resulting myocardial infarction (MI), otherwise known as a heart attack, needs immediate emergency treatment.
Early stage, asymptomatic coronary heart disease does not always require treatment with surgery or medication. Lifestyle changes may be enough to slow down the disease (see below).
However, when symptoms appear, medical treatment is necessary. Failure to do so will increase the risk of heart attack, pulmonary embolism and stroke. When the heart pumps irregularly, small blood clots can form inside the heart and are forced into the circulation where they can seal off other blood vessels that supply oxygen and nutrients to the most essential organs - the brain, kidneys and lungs. In CAD, heart attack is due to compromised blood flow and oxygen supply to the heart muscle in combination with overwork; strokes are the result of small blood clots formed by irregular heart beats and heart muscle movement that travel into the aorta and on into the brain. Pulmonary embolism is the result of similarly-produced blood clots that make their way into the blood vessels of the lung via the left side of the heart. These 3 pathologies are medical emergencies.
Wherever atherosclerosis is significant, an affected artery must be made wider. This may be done through taking medication that makes all major arteries wider, pushing on the plaque to make the layer thinner and at the same time slightly push on the artery wall to widen it, or to scrape away and remove the plaque. When this is not possible, the section of narrow artery must either be removed or passed by using a different route, rather like adding an extra lane to a motorway. This final option is the basis of a coronary artery bypass grafting operation
Coronary artery bypass is achieved by placing new blood vessels that provide an alternative route and bypass the narrowed portion of artery. The vessels that form the new routes are called grafts.
Grafts can be autologous or non-autologous; the former involves the removal of one of your own blood vessels, the latter the use of animal tissue grafts. Autologous grafts are used in practically all graft surgeries and options for which arteries are used depend on whether the bypass is placed on the right or left side of the heart and the diameter of the affected area. The left side, with higher pressures and more exaggerated movement usually requires excision and repositioning of the left internal mammary – or mammarian - artery (LIMA), right internal mammary artery (RIMA), radial artery (RA), greater saphenous vein (GSV) or short saphenous vein (SSV). The LIMA may also be referred to as the LITA (left internal thoracic artery), and the RIMA as the RITA using the same adaptation. First choice is the LIMA, with RIMA and RA arteries coming a close second. As these are arteries they may also have been affected by atherosclerosis and may not be suitable as grafts. In this case, there is still the option of a leg vein. Harvesting of the radial artery or saphenous vein requires separate incisions in the arm or leg respectively. This part of the procedure is done by a vascular surgeon as the cardiothoracic surgeon gains access to the heart. The mammarian artery runs within the chest cavity and is removed by the cardiothoracic surgeon him or herself.
Can I prevent heart bypass surgery?
As already mentioned, coronary artery bypass surgery is the result of atherosclerosis. While hereditary factors may make us more susceptible, changing unhealthier lifestyle habits can have outstanding results and can prevent your need for medical intervention. If you have symptoms of coronary artery disease you should discuss an exercise regime with a cardiologist, as certain exercises may mean your heart has to work hard. When muscles work, they require more oxygen; if one or more of your coronary arteries are narrow, this may not be possible in one or more areas of heart muscle. High-intensity exercise may, in this case, increase your risk of requiring coronary artery bypass surgery.
Medical treatment of some of the causes of atherosclerosis such as cholesterol-lowering drugs may help to prevent further damage.
Avoiding stress is also important. Psychological stress creates physical symptoms such as rapid heart beat, high blood pressure, depression with associated lack of physical activity and even increases the risk of inflammation inside the body which contributes to atherosclerosis. Many men and women who have been diagnosed with CAD or undergone successful heart surgery after heart attack have been forced to accept that a busy career, lifestyle and/or environment are decided risk factors. Some have given up their jobs, taken time to rest (both physically and emotionally) and moved to quieter areas. These individuals have immediately noticed the positive results of the low-stress lifestyle.
The combination of integrating regular exercise, reducing stress, maintaining a healthy weight and steering clear of saturated fats, processed foods and added sugar diminishes many of the factors that contribute to atherosclerosis. The Mediterranean diet is most commonly advised (long) before, during and after CAD treatment. This eating plan is based upon oily fish, varied fresh fruit and vegetables, nuts and seeds and olive oil. Quitting smoking, controlling metabolic disorders such as diabetes and adding cholesterol-lowering spreads and drinks to the diet similarly contribute. Your early-stage disease can then be observed during biannual or annual visits to a cardiologist.
Regular health check-ups should always include medical imaging and resting and exercise electrocardiogram. Remedazo arranges full medical check-ups for every physiological system, carefully planning appointments with specialists, supplying transportation and even providing catering services that can introduce you to a new healthier, heart-protecting diet. We make extending your trip for treatment or leisure (if you prefer) so much easier.
How do I prepare for coronary artery bypass? What can I expect?
If you are reading this article you may have already been diagnosed with coronary artery disease after your general practitioner or cardiologist have detected signs on an electrocardiogram or been alerted by the presence of multiple risk factors. Alternatively, you may already have been given a diagnosis of IHD. You may have undergone further diagnostic tests or are perhaps looking for a complete diagnostic, pharmaceutical and/or surgical solution. Finding the right treatment centre with experienced and highly specialised cardiologists and cardiovascular surgeons can be overwhelming.
With Remedazo, you are able to speak openly with up to 3 highly-renowned heart specialists with extensive experience, training and knowledge concerning a range of (or very specific) techniques that include transcatheter, robotic-assisted or keyhole (minimally invasive) coronary artery therapies. Treatment options will be described in detail further on.
It is also very possible that your CAD has no symptoms and you have been advised to wait for surgery and make lifestyle changes and perhaps take medication. Remedazo arranges complete health checks that cover all physiological systems and include personal appointments with a range of specialists at excellently equipped hospitals. If health problems are detected or your coronary artery disease begins to present with symptoms, treatment can be arranged during the same visit or at a later date according to your preferences, and with your choice of Remedazo partnered specialist, hospital and budget.
Pre-travel heart bypass surgery preparation
Preparation for heart bypass surgery requires specific advice based upon your current level of health. For example, increased exercise that makes the body stronger before any type of surgery may or may not be advised. A healthy, protein-rich diet is essential and you may or may not need to start or stop certain medication. Any smoking habit should be ceased immediately; all heart surgeries involve compromised oxygen supply and smoking can severely increase the risk of surgical and postoperative complications. Your surgeon may refuse to operate if you do not stop smoking before and after heart valve surgery.
Start a medically-advised exercise plan as long as possible before surgery and also breathing exercises to help shorten your recovery. If surgery is planned at a much later date, a vitamin and mineral cure may be worthwhile considering but only under the guidance of your cardiologist; some vitamins such as vitamin E can thin the blood. Correct nutrition also lowers the risk of contracting a cold or other contagious illnesses that might mean your surgery must be postponed. If you plan to return home shortly after surgery create a sleeping area downstairs and arrange home help such as cleaning staff, shopping help and even animal care if you have high-energy pets. You will not be able to drive a car for at least 4 weeks after more invasive surgery and alternative travel arrangements can be made before you leave for increased peace of mind
Most aviation authorities will not let you fly for approximately 10 days after cardiothoracic surgery; some of these will ask for a letter from your treating physician. It is a good idea to purchase an open-ended return. If you do not feel up to the journey or have been advised to wait you will not have to pay for a new ticket. During all long periods of relative inactivity you should wear compression stockings to reduce the risk of venous blood clots before and after surgery.
Initial diagnosis will probably have included tests such as an electrocardiogram. To confirm IHD diagnosis and to rule out or confirm other heart disorders, additional diagnostic interventions are planned. Ultrasound transthoracic echocardiography - where a flat probe (transducer) is moved around the skin of the chest above the heart to produce images of the heart on a screen - may be part of a stress test. This test asks you to exercise or take medicine to make the heart work harder, and ultrasound is immediately used to detect or rule out other problems such as coronary heart disease. Ultrasound can look inside large portions of the heart muscle.
Transthoracic echocardiograms are not able to give a satisfactory view of the atria of the heart and a transoesophageal echocardiography is the next step. You will not be able to eat of drink before this test. An intravenous catheter is inserted, a little sedation administered, and the back of the throat made numb with a local anaesthetic spray. A mouth guard is placed in your mouth and you are asked to lie on your side. The ultrasound probe is inserted into the oesophagus, the lower part of which lies close to the heart, and the structure and function of the heart muscle, coronary arteries and all 4 heart valves can be assessed.
Occasionally, an initial suspicion of ischemic heart disease – or any heart disorder – will send you for a chest x-ray to look at the size of your heart, although images of more specific areas can be unclear. When abnormalities are found with or without ultrasound, further testing is necessary. Methods include cardiac MRI with an intravenous injection of contrast dye for better viewing of the heart, and coronary angiography. Internal structures can be viewed by x-ray in real-time after a dye has been injected via a catheter placed in your groin, arm or sometimes the neck that is threaded via the artery near to the main coronary arteries.
The patency (usability) of your own blood vessels for use as grafts must also be evaluated.
You will need to share all medical reports in preparation for your 3 free Second Opinions. Remedazo always respects your right to privacy and only passes details on to your selected specialists. Unless a complete set of diagnostic reports has been provided it is not possible to indicate which surgical procedure best suits your condition. Additional tests can be arranged at home or with Remedazo. We will ensure your treatment follows as soon as is medically advised.
Approximately 2 weeks before your coronary artery bypass graft surgery you need to ask your home doctor to take blood for a preoperative blood test. Remedazo will inform you well beforehand which tests your doctor will need to take blood for. Some blood-thinning medications need to be temporarily stopped, others do not. Our or your own doctor will advise you what to do. A pre-surgical meeting with your treating doctor may lead to further or repeated testing, depending on how recently your diagnosis was made. Most coronary artery surgery candidates are expected to arrive at least a week before the operation in order to undergo a full physical examination by the treating surgery, further blood tests and the regulation of other conditions ,for example high blood pressure and diabetes. This is also an opportunity to recover from your flight and settle in to your accommodation, lowering your stress level.
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