Bypass Surgery: An Overview of Bypass Surgery for Heart Health

Overview

Coronary artery bypass surgery (CABG) or coronary artery bypass graft is performed to treat coronary artery disease (CAD). The blood channels that transfer nutrients and oxygen to the heart tissue are known as the coronary arteries, and CAD is the shrinking of these blood vessels. CAD happens when there is an accumulation or blockage of fatty substances in the artery. The blockage narrows the arteries and lowers the quantity of blood rich in oxygen that reaches the heart. A bypass surgery is done to create a new path for this oxygen rich blood by taking blood vessels from a part of the body.

Portions of a vein from the leg or an artery from the chest are usually used as grafts or blood arteries, for the bypass surgery. An alternative is to utilise a wrist artery. The graft can be attached to one side well above the blockage as well as the other underneath the blockage by the doctor. To reach the heart muscles, blood passes through the fresh graft and around the obstruction.

How a bypass surgery is done

The surgeon makes a large chest incision to bypass the coronary artery that is clogged while stopping the heart temporarily. The doctor will split the sternum (breastbone) that opens up the chest in half. The doctor exposes the heart and places tubes. Thus, the bypass unit of heart–lung may pump blood through the body when it is exposed. Blood has to be pumped through a bypass machine when the heart is stopped.

There are less obtrusive methods to bypass clogged coronary arteries ; however, the classic “open heart” surgery is still preferred for most cases. The 1990s saw the development of “off-pump” operations where it’s not required to stop the heart. Other non-invasive techniques include keyhole surgery and robotic treatments (which are conducted by making small incisions).

The heart bypass surgery cost varies in different cities and countries. A heart bypass surgery cost in India can be somewhere between Rs 1 lakh and Rs 4.5 lakh or more, depending on the seriousness of the patient’s condition and other factors.

Types of heart bypass surgery

On-pump CABG

• On-pump CABG is a traditional surgery during which the heart is stopped.  When the heart stops, the other organs in the body still need to have access to blood flow. For this, surgeons use the cardiopulmonary bypass unit, which is sometimes referred to as a “heart-lung device” or a “pump”. This device creates an artificial circulatory system that performs the functions of the lungs and heart.
• Pipes (cannulas) are inserted into the heart to transport the patient’s contaminated blood to the pump, where it gets cleaned before being pumped back into the body. Hence, the heart could be comfortably stopped by utilising specific drugs that not only halt the heart from beating but also sustain it when it is at rest. After that, the bypass transplants are built.
• The heart is restarted following the surgery. The cardiopulmonary bypass equipment is unplugged once the heart is free of the pipes and is functioning properly.Nowadays, on-pump CABG is a safe surgery with a low risk of death or other consequences. For a low-risk individual, the typical risk of this surgery is between 1% and 2%. These hazards are increased by the patient’s other serious medical issues.
• The heart-lung unit is quite safe because of the advancement of modern technology. Having gained knowledge of the several root causes of issues in this type of surgery, surgeons are now able to recognise them and take the appropriate preventative measures. The on-pump CABG approach is known to produce bypass transplants that are fully functional and exceptional to other techniques.

Off-pump CABG

• Off-pump CABG is the more recent technique for CABG. The invention of this procedure was initiated to avert the side effects of on-pump CABG, such as stroke and a decline in basic brain functioning.
• Without the aid of a heart-lung unit, this surgery is carried out while the heart is still pumping. This procedure introduces an additional difficulty by connecting transplants to the heart when it’s continuously functioning and full of blood. This technique eliminates the placement of special pipes for the device, the use of simulated circulation, and increased alteration of the aorta.
• Modern techniques can mechanically support the necessary heart region so that suturing can be done on a comparatively stable surface.  There have been worries that continuous mobility could lead to a poor grafting method, which could negatively impact the performance of these grafts.
• However, the outcomes achieved by surgeons who have adjusted to and mastered this procedure are great. In a low-risk patient, the probability of death or complications following an off-pump CABG is likewise between 1% and 2%.
• Several skilled surgeons are currently doing this extremely specialised treatment with positive outcomes. Lower risks of stroke, neurological damage, organ failure, and atrial fibrillation are some of the procedure’s claimed perks.

ESVH (Endoscopic saphenous vein harvesting)

• A less aggressive way to remove the veins from the legs is called endoscopic saphenous vein harvesting (ESVH).
• The doctor makes several little incisions close to the knee instead of a big incision. It’s referred to as “keyhole surgery”.
• The cut will be treated by inserting an endoscope, a specialised tool.
• An endoscope is a lengthy, tube-like structure that is narrow and has a source of light and a camera on one end to transmit pictures of the interior of the body to an outside digital screen.
• The surgeon will use an endoscope to find the saphenous vein. A portion of the vein could be cut out using surgical tools that can be inserted through the endoscope. The cut is then treated with an antibiotic solution to disinfect the surrounding tissues and repair it.
  The key benefits of this approach include preventing surgical site infections, a shorter hospital stay, and a fast recovery.

TECAB (Totally endoscopic robotically assisted coronary artery bypass)

TECAB surgery is also among the newer methods of cardiac surgery.

• The lungs are emptied during the TECAB transplant, and several tiny incisions are made between the ribs.
• The operation is performed using robotic systems that are guided by the surgeon. The robotic systems are equipped with an endoscope, giving the surgeon access to the body, and allowing them to view the results of the operation on a monitor. TECAB transplantation can be performed off-pump or with a heart-lung bypass unit.
• With this kind of surgery, there are fewer wound infections, fewer scars, and a quicker recovery.
  Compared to other surgical procedures, this technique has only been used on a handful of patients, so it is challenging to determine its efficiency and how secure it will be over the long run.

What are the advantages of a heart bypass surgery?

CABG is a helpful and frequently used component of treating heart issues due to several its benefits, they are:

• Preferable for several blockages or specific artery obstructions: When a person has several blocked cardiac arteries, CABG is frequently the best option. Also, it’s a better method for clearing specific types of obstructions. Several studies have connected CABG with the best long results, notably increased survival rates. When combined with modern bypass methods that produce long-lasting outcomes, this advantage frequently increases.
• A prolonged usage history: The very first CABG surgeries were carried out by surgeons in the 1960s. This treatment became a vital and effective method for treating cardiac ischemia in the years that followed because of increased research and technological developments.
• Reduced risk of additional procedures: Percutaneous coronary intervention (PCI), sometimes called angioplasty, is the primary replacement for CABG. A follow-up operation is frequently required after PCI, which increases the risk, unlike in the case of CABG.

What happens before the coronary artery bypass surgery/heart bypass surgery?

You will first visit with the surgeon to review your health information, the medications you use, and any concerns you may have before the procedure.

For your surgeon to carefully arrange your treatment and be aware of any concerns for the heart and your current state of health, you may additionally require some testing.
You may undergo tests before having bypass surgery, such as:

• Cardiac catheterisation: By using this technique, you may see into the coronary arteries and search for problems. A vein in the groin, arm, or neck is punctured with a long, narrow tube (catheter), and the catheter is carried to the heart. A contrasting solution is injected into the artery by the doctor, who then uses X-rays to look for blockages and other irregularities.
• Chest X-ray: Blood arteries, ribs, and spinal bone can be seen in addition to the lungs and heart in this test.
• Echocardiogram: The anatomy and operation of the heart tissue and valves are evaluated using sound vibrations in this examination. Stenosis (tightness) and leakage are examined in the valves. During your procedure, these issues might be resolved.
• Electrocardiogram: The heart’s electrical impulses are captured by this examination. You can use it to determine whether the heart pumps blood regularly or whether any parts of the heart require attention.

Your doctor may order an echocardiography or CT angiography of the carotid arteries (the arteries in the throat that deliver blood to the brain) if they display signs of irregular blood circulation. If you have had a stroke or mini-stroke, or if the heart disease is especially severe, doctors may additionally perform these tests.

A pulmonary function exam may be required when you suffer from a lung condition like chronic obstructive pulmonary disease (COPD) to see if the lungs are healthy enough to withstand surgery. This examination can also help identify whether the concerns are linked to a heart condition or a lung condition.

What happens after coronary artery bypass surgery?

• You’ll need 24 hours of continuous nursing care following bypass surgery. To assist you in breathing, you might be connected to a ventilator machine. After you recover from anaesthesia and can breathe effectively by yourself, you are taken off the ventilator. Usually, patients are only kept on the ventilator for a short time following surgery, until they are awake, attentive, and capable of breathing without assistance.
• Painkillers and additional sedation will keep you comfortable when you begin to wake up while the breathing tube is in place. Nurses are always seated by the bed when you wake up. They’ll supervise your health and give you medicine accordingly. After surgery, you will have catheters and sensors attached to you, including a tube for urine drainage in the bladder, a heart monitoring device, and a monitor for blood pressure.
• Once the ventilator has been removed, your medical team will assist you in using a breathing device every hour that you are awake. Coughing and taking deep breaths are crucial for avoiding obstruction and lung issues. If you experience pain, let a person on your medical team know. Your comfort matters and has an impact on your ability to breathe. The faster you heal, the better your breathing will be. The heart and oxygen levels will be monitored. The medical staff will help you sit in a comfortable chair.
• The lungs and bowels return to normal functioning when your exercise level rises. You will be urged to consume food and liquids immediately after the catheter is removed. Feeling nauseous or not wanting to consume food is a frequent consequence of the anaesthetic fading off. Your stomach may become upset if you take narcotic painkillers.
• You may begin using a walker with medical assistance two days after surgery to move small distances inside the room and outside in the hallway. Among the most crucial activities you can engage in to aid in your rehabilitation is walking. It relieves stiffness and aids in lung expansion. At least 2–4 minutes per day, you should take a walk.
• After this, your activity levels will slowly increase under supervision. After heart bypass surgery, it’s normal to experience some bloating from fluid retention. To assist your body in eliminating excess fluid, the surgeon can recommend specific medication.
• Following heart bypass surgery, patients normally are hospitalised for 4 to 6 days.
• When you can eat normal foods, have regular bowel movements, are capable of walking around the hospital, have a normal body temperature, and the catheters and monitoring devices have been taken out, you will be discharged.
• You could need a brief stay in an outpatient facility if you don’t seem ready to return home or if you think you need a little more healing time. Your medical team can assist in making this decision.

What are the at-home recovery measures after heart bypass surgery?

• You may have to constantly take analgesics (painkillers) at home for a couple of weeks to get rid of any persistent pain where the incisions were made . It can also be beneficial to dress comfortably and loosely so that nothing rubs against your wounds.
• You’ll most likely feel exhausted a lot of the time during the first three to six weeks of therapy. This is due to the energy your body is spending to restore itself. You should be capable of carrying out most of your daily tasks in six weeks, and you should be completely recovered in three months.
• You can generally return to work in approximately 6 to 8 weeks if your recovery is going well and the job is not physically demanding. But if you encounter any difficulties or your job necessitates a considerable amount of standing and lifting, you will need some extra time off. It’s important to gradually increase your tasks while healing and be certain to take frequent breaks whenever you feel fatigued.
• It’s normal to experience mental health issues following a bypass surgery. There will be both happy and sad days. Rehabilitation takes time and is not linear in nature. The majority of uncomfortable symptoms should go away within 4 to 6 weeks after surgery.
• Depending on your age, overall fitness, and the seriousness of your disease, a complete recovery could take up to three months. If you need additional guidance or help as you recuperate, talk to your doctor.