Cardiology

Coronary Artery Bypass Graft Surgery

What is coronary artery disease?

The heart is a powerful muscular organ that requires adequate supply of oxygen and nutrition to function efficiently. Oxygen-rich blood is carried to the heart through three arteries that branch into a network of smaller vessels. Coronary Artery Disease affects the blood vessels (arteries) on the surface of the heart. These arteries bring blood (rich with oxygen and nutrients) to the heart.

Ageing and other complex factors cause these ordinarily soft and compliant blood vessels to harden. In addition, fat, cholesterol and minerals from the blood are deposited on the inner surface of the coronary arteries. When these materials build up, they form a plaque that may restrict the blood flow through the coronary artery. Such plaque may also change the surface of the artery from smooth to rough. The rough surfaces stimulate the formation of a blood clot, which may slowly build up and narrow the artery even more.

A blood clot can also build up quickly and abruptly close off the artery.

What are the affects of coronary artery disease?

Narrowed coronary arteries means the amount of blood that reaches the heart muscle is reduced. Fatigue, tightness in the chest or a peculiar crushing-type of chest pain called Angina Pectoris may accompany the decreased blood flow. Exercise and emotional stress, which cause the heart to need more blood may produce these symptoms. These symptoms however are relieved by rest. A coronary angiogram will demonstrate the exact number of arteries with blocks and the type of blocks.

If a Coronary Artery suddenly gets blocked, blood flow to a part of the heart may stop completely. In this case, some of the heart muscle may be permanently damaged. This is often accompanied by severe chest pain that won't disappear. This is called Myocardial Infarction, or more commonly, a heart attack. The heart muscle can heal, but muscle is replaced by scar tissue that doesn't contract. If the scar is small, recovery can be complete. If the scar is large however, it may permanently affect the pumping ability of the heart. It is therefore important that blood supply to the heart muscle be restored before a heart attack can occur.

What can be done to relieve blockages in the coronary arteries?

Plaques that block the coronary arteries usually occur in localised portions of the arteries. The part of the artery beyond the narrowing or closure is often not blocked. When the disease is localised in one or two arteries, the blockage can sometimes be opened by stretching or dilating. This is done using a small balloon on a tube inside the artery.

This procedure is called Angioplasty or PTCA (Percutaneous Transfuminal Coronary Angioplasty).

Coronary Artery Bypass Graft surgery is usually recommended when the blockages are more complicated and involve more coronary arteries. Such a surgery will create new pathways to carry blood around the blockages.

What is Coronary Artery Bypass Graft surgery?

Coronary Artery Bypass Graft Surgery is an open heart surgery in which arteries or veins are taken from another part of the body to channel needed blood flow to the coronary arteries. The arteries or veins used in the surgery are expandable and removing them does not significantly affect the blood flow from where they are taken. Typically the arteries used are on the inside of the chest alongside the breast bone (Internal Mammary / Thoracic Artery) or the Radial Arteries from the left, right or both forearms.

The vein that is typically used comes from just beneath the skin on the inside of the leg (Saphenous Vein). Sometimes, arteries in the abdominal cavity can also be used. Bypass Grafting of arteries offer better long term results than veins.

During surgery, these arteries or veins are connected directly to the coronary arteries on the surface of the heart beyond the blockages. This way, blood can flow through them to bypass the narrowed or closed points.

Coronary Artery Bypass Surgeries are performed either using a heart-lung machine or without using it. This machine takes over the functioning of the heart, thereby allowing the grafts to be precisely connected to the tiny coronary arteries.

What will Coronary Artery Bypass Graft surgery accomplish?

The purpose of Coronary Artery Bypass Surgery is to improve blood flow to the heart. More blood flow would reduce the threat to life and will eliminate chest pain (Angina Pectoris) that is witnessed with exercise or exertion. It will also greatly increase the ability to exercise. Other benefits include decrease in fatigue and need for medication, and restoring a sense of well being. Life after undergoing bypass surgery is much healthier and better.

Preparing For Your Surgery

It is natural to feel anxious and nervous once you've made a decision to undergo Coronary Artery Bypass Graft Surgery. Such anxiety will be greatly reduced if you understand the need for the surgery (this booklet will help), meet the members of the professional team and have your questions answered.

What about hospital admission?

Typically a patient is admitted to the hospital one day before the operation. Routine tests including Blood and Urine tests, Electrocardiograms (ECGs), Chest X-rays and others are completed. After completion of these tests, in some cases, patients are directly taken for surgery.

Who will visit before the surgery?

Before the surgery, members of the cardiac surgery team will visit to examine you, discuss the details of the surgery and answer questions. The nursing staff will also evaluate your needs, make you as comfortable as possible, provide information and answer questions. In addition, the Anesthesiologist will evaluate and discuss plans for the care of vital body functions during the surgery. Other members of the technical staff may come to collect blood, insert Intravenous Catheters (IVs), advise you on right breathing and lung care to be followed after the surgery.

You will also be informed on the date scheduled for surgery. Heart surgery is usually scheduled in advance and begins on time. Occasionally a surgery may be delayed when other patients have emergency needs. If this happens, your surgery will be rescheduled at the earliest.

What preparations are required prior to surgery?

Before the surgery, much of your body hair will be shaved off, especially from your chest and legs. You will probably be asked to shower and wash with antiseptic soap to remove bacteria from the skin so as to reduce the chance of infection.

You should remove personal items such as glasses or contact lenses, dentures or detachable bridge work, watches and jewellery and give it to your family members. Usually, medicines are continued as per schedule, but do consult your doctor before taking any medicines. Medications that will make you relaxed and drowsy will be given about an hour before the surgery.

Attendants will wheel you to the surgery theatre on a rolling bed. Once you are in the surgery theatre, the Anesthesiologist will administer an anesthetic that induces sleep and offers freedom from pain during the surgery. Then the surgery is performed.

How long will the surgery last?

Coronary Artery Bypass Graft Surgery usually lasts from three to six hours, depending on the number of vessels to be Grafted. Each surgery varies in complexity, so its duration can only be estimated.
What arrangements can be made for my family during the surgery?
Your family can wait outside the surgery theatre or at the reception. Keep your surgeon informed on this aspect.

AFTER THE SURGERY

Where do patients go after the surgery?

Patients are taken to an Intensive Care Unit after their surgery. They regain consciousness after the anaesthetic affect gets over. Some patients may not be able to move their legs or arms when they first wake up, but in a short time the body regains coordination with the mind.

How soon after the surgery may the family visit?

A member of the family may visit briefly in the recovery or Intensive Care Unit after a few hours of the surgery when the patient is awake.

Will there be pain after the surgery?

There will be some discomfort in the incision made to reach the heart. It is usually made along the midline of the chest through the breastbone. The incisions may cause pain. Medication will be given to relieve the pain.

Will tubes and wires be attached to my body?

Tubes and wires are routinely attached to parts of the patient's body. They provide for safe and efficient recovery.

Catheters, which are small tubes, will be in place usually in the arm. They are used to help the nursing staff administer drugs and fluids, collect blood samples and continuously monitor blood pressure. One or more tubes in the chest will drain off fluid that accumulates normally during and after the surgery. Electrodes on the chest are attached to a Cardiac monitor to allow the nursing staff to monitor the ECG for Heart rhythm and rate. Small wires may be attached to the lower chest to permit pacing the heart, if needed.

A breathing tube (endotracheal tube) in the mouth goes by the vocal chords into the windpipe. Although not a painful procedure, patients experience difficulty in talking.
The nurses will help you find other ways to communicate your needs. The breathing tube is removed when you no longer need help for breathing. It is usually taken out within 2 to 6 hours after the surgery.

What are the common experiences in an Intensive Care Unit (ICU)?

It is hard to keep track of time in an area where the lights remain switched on 24 hours a day, and where continuous activity exists. Such a setting misleads the senses, and you may become disoriented and confused. This temporary confusion, if it occurs, is not serious. It will disappear after a day or two, after you have been moved to a quieter, less intensive nursing unit. With adequate rest, normal patterns of sleep and thought processes will return.

Is fever common after surgery?

Everyone has a fever after an surgery. Sometimes it causes heavy perspiration during the night or even the day. Medicines usually offer relief, but fever may continue for three to four days after the surgery.

What can be done to help recovery?

Deep breathing exercises and coughing are important ways to attain speedy recovery. Coughing reduces the chances of pneumonia and fever and will not harm the incision or bypass grafts. Most patients fearing pain and discomfort, don't like to cough after an surgery. Still, coughing is essential. Some patients find it easier to cough if their chest is supported by a pillow or a rolled towel. Spirometer which is like a toy with balls in it, is offered for breathing exercises and will ensure proper lung expansion.

You can quicken recovery by repeatedly changing positions in the bed.

When can I eat and drink?

Once your breathing tube is removed, you will be able to swallow liquids. How quickly you will progress from liquids to a regular diet differs from person to person.
Also, it depends on your digestive system. It is possible that you may have a depressed appetite for some days due to a mild indigestion caused by stress. It will return to normalcy on your return to normal activities.

When can I get out of bed?

Patients may get out of bed and sit in a chair or walk around the room usually within a day or two. Later they can take short walks in the hall. Eventually they can climb stairs and take brisk or long walks.

What about bathing?

Sponge baths are given right away. It will be a few days however before you are allowed to shower and shampoo.

Is one position better than another for sleeping?

Lying on your back all the time isn't good for your lungs. It is best to shift position while in bed, but avoid positions that cause pain at the operation site.

How long will the pain last after the surgery?

Most patients complain of soreness but don't have severe pain. The soreness comes from the surgical incisions and muscle spasms. It can be helped by good posture and frequent movement of arms and shoulders. If pain is severe, request the nurse for medicines. Severe pain rarely lasts more than three days.

What about the healing of the incisions?

Soon after the surgery, the chest wound is exposed to air, which allows it to dry. The wound can be washed with soap and water after a few days.

The number and length of leg incisions varies from patient to patient. Some patients have an incision in one or both arms while others have incisions in one or both the legs.

There may be some tendency for the hand or ankle to swell. You may also feel a burning sensation when standing on the leg where the graft was taken. Elastic support stockings help circulation and reduce swelling. Walking helps blood circulate in the legs and also helps the heart.

If strips of tape are placed over an incision that has been closed by absorbable stitches under the skin, the strips should remain as long as the regular stitches stay (since these tapes are used as a substitute for stitches).

These wounds require about six weeks to heal completely.

It is beneficial to avoid lifting heavy objects and driving during this period. The colour of the wound will gradually change from purple to red to pink, returning to normal after a few months.

Some of the scars or parts of these, may become thicker or remain reddened for a few months after the surgery in some patients. These scars may pain, burn or itch. It is best ignored.

How long is the convalescent period in the hospital?

The usual hospital stay after a surgery is from seven to ten days. During that period and beyond, most patients have "good days" and "bad days" with overall progress and a gain in strength.

RETURNING HOME

Can leaving the hospital cause mixed feelings?

It isn't unusual to feel apprehensive or depressed about returning home. Sometimes these feelings are prompted by concerns about leaving the security of the hospital, with its expert medical team and equipment. Home care by comparison, may seem uncertain. Remember however, that no patient is allowed to go home until the doctor is certain that their condition is satisfactory and stable for them to continue their safe recovery at home.

First few days after returning home

Weakness is a common feeling on returning home. Typically, a healthy individual put to bed for a week, loses about 15% of muscle strength. It is no surprise therefore, that after a week or more in hospital, a person feels tired and weak when trying to resume the routine of home life.

Also, please note that healing of the incisions require a tremendous amount of energy. This process depletes body strength. The body's demand for energy decreases significantly about three to four weeks after the Surgery, following which patients feel better.

Exercising is a good way to regain strength. Walking in particular is beneficial after Coronary Bypass Graft Surgery. Patients should gradually increase the time and distance they exercise every day without overdoing it.

Depression is common for patients when they return home. The emotional letdown after any surgery may cause such feelings. Progress may not seem fast enough, and time may stand still. The best way to get rid of depression is to talk about it with your spouse, family or close friends. Exercise also helps relieve depression.

Patients and their families also commonly feel angry and frustrated. These feelings normally subside after normal activities resume.

What medicines should be taken?

You should only take medicines prescribed by your doctor.
Discontinue medication you took prior to surgery unless they have been specifically re-prescribed. Even common nonprescription or over-the-counter drugs should be taken only after consulting your doctor.

When should the doctor be contacted?

Call your family doctor immediately if there are signs of infections (redness or drainage at the incision), fever, chills, increased fatigue, shortness of breath, swelling of the ankles, weight gain of over two kgs. in a few days, change in heart rate or rhythm, or any other sign or symptom that seems disturbing.

How long will I have to wait before returning to work?

If you perform a sedentary job, the average time to get back to work is between three to six weeks. If your job involves heavy work, the time is six weeks or even longer. Your doctor will guide you through the process.

What about sexual activity?

Typically patients may resume sexual activity when they feel like it. If you have questions, talk to your doctor.

Will there be restrictions on driving an automobile?

It is usually best to wait for six to eight weeks after leaving the hospital to begin driving a car.

When are routine follow-ups with the doctor scheduled?

Post-operative visits vary depending on patients needs and the requirements of the cardiovascular surgeon. Patients are usually advised about future surgical appointments while being discharged from the hospital. You should make an appointment with your personal or family physician soon after returning home.

PLANNING FOR THE FUTURE

What can I look forward to after the surgery?

Coronary Artery Bypass Graft surgery is performed to restore a person to an active and normal life. The goals of the surgery are to enable a person to return to gainful employment or active retirement (in case of older patients) and to enhance patient's sense of well-being.

As your recovery progresses, you will be able to fully appreciate the effects of your Coronary Bypass Surgery. Increased blood flow through your coronary arteries should mean less angina or none at all. You may find yourself needing much less medication, if any, and that your ability to sustain physical activity and exercise has improved. Life after a Bypass Surgery will be better & healthier.

AFTER THE SURGERY

Where do patients go after the surgery?

How soon after the surgery may the family visit?

A member of the family may visit briefly in the recovery or Intensive Care Unit after a few hours of the surgery when the patient is awake.

Will there be pain after the surgery?

Will tubes and wires be attached to my body?

Tubes and wires are routinely attached to parts of the patient's body. They provide for safe and efficient recovery.

What are the common experiences in an Intensive Care Unit (ICU)?

Is fever common after surgery?

What can be done to help recovery?

You can quicken recovery by repeatedly changing positions in the bed.

When can I eat and drink?

When can I get out of bed?

What about bathing?

Sponge baths are given right away. It will be a few days however before you are allowed to shower and shampoo.

Is one position better than another for sleeping?

Lying on your back all the time isn't good for your lungs. It is best to shift position while in bed, but avoid positions that cause pain at the operation site.

How long will the pain last after the surgery?

What about the healing of the incisions?

Soon after the surgery, the chest wound is exposed to air, which allows it to dry. The wound can be washed with soap and water after a few days.

The number and length of leg incisions varies from patient to patient. Some patients have an incision in one or both arms while others have incisions in one or both the legs.

There may be some tendency for the hand or ankle to swell. You may also feel a burning sensation when standing on the leg where the graft was taken. Elastic support stockings help circulation and reduce swelling. Walking helps blood circulate in the legs and also helps the heart.

These wounds require about six weeks to heal completely.

It is beneficial to avoid lifting heavy objects and driving during this period. The colour of the wound will gradually change from purple to red to pink, returning to normal after a few months.

Some of the scars or parts of these, may become thicker or remain reddened for a few months after the surgery in some patients. These scars may pain, burn or itch. It is best ignored.

How long is the convalescent period in the hospital?

The usual hospital stay after a surgery is from seven to ten days. During that period and beyond, most patients have "good days" and "bad days" with overall progress and a gain in strength.

RETURNING HOME

Can leaving the hospital cause mixed feelings?

First few days after returning home

Depression is common for patients when they return home. The emotional letdown after any surgery may cause such feelings. Progress may not seem fast enough, and time may stand still. The best way to get rid of depression is to talk about it with your spouse, family or close friends. Exercise also helps relieve depression.

Patients and their families also commonly feel angry and frustrated. These feelings normally subside after normal activities resume.

What medicines should be taken?

You should only take medicines prescribed by your doctor.

Discontinue medication you took prior to surgery unless they have been specifically re-prescribed. Even common nonprescription or over-the-counter drugs should be taken only after consulting your doctor.

When should the doctor be contacted?

How long will I have to wait before returning to work?

Typically patients may resume sexual activity when they feel like it. If you have questions, talk to your doctor.

Will there be restrictions on driving an automobile?

It is usually best to wait for six to eight weeks after leaving the hospital to begin driving a car.

When are routine follow-ups with the doctor scheduled?

Post-operative visits vary depending on patients needs and the requirements of the cardiovascular surgeon. Patients are usually advised about future surgical appointments while being discharged from the hospital. You should make an appointment with your personal or family physician soon after returning home.

PLANNING FOR THE FUTURE

What can I look forward to after the surgery?

DIETARY & LIFESTYLE

GUIDELINES

For patients with Coronary Artery Disease

Coronary Artery Disease (CAD) involves the arteries that supply blood to the heart and leads to development of blocks in these vessels which are very small in size (the largest ones being 3 mm in sizes). Despite their small size, these arteries are the primary source of blood supply to the heart, and if they get blocked completely, patients may develop fatal heart attacks.

CAD commonly affects people with some risk factors like,

High Blood Pressure (Hypertension)
Diabetes Mellitus
High Blood Cholesterol
Smoking
Eating Fatty foods
Sedentary Lifestyle
Stress
Family History

If you or your family members have been diagnosed to have CAD or are at risk of its related complications, there are few lifestyle changes that need to be adopted immediately and carried on for a life time to help you live long and remain fit with a healthy heart.

PLANNING FOR THE FUTURE

Don’ts

Smoking - The benefits of quitting smoking will start the moment you do it. Smoking affects body in many ways - it damages your lungs, makes your blood vessels stiff and develops blocks in them (which results in paralytic stroke, limbs needing to be amputated, or heart attacks). Each cigarette takes away a certain length of your life and quitting the habit lessens earlier damage and prevents further damage.

Salt - Foods containing excess salt should be avoided, such as

Pickles or pickled foods
Chips, or French fries, Poppadoms
Salted fish
Caffeine containing beverages (such as Coke, Pepsi, Thumbs up)
Sauces

Adding table salt (additional salt while eating) to food should be avoided. Salt or sodium in the food increases body fluid and blood pressure, and hence its consumption should be reduced to the bare minimum necessary.

Alcohol and drugs - Consuming alcohol affects the liver primarily but can sometimes cause the heart function to deteriorate, and if that happens there are no medicines or operations that can reverse this condition. Certain drugs like cocaine affects the heart rhythm and can kill people even if consumed in small quantities. All kinds of abusive drugs and alcohol should be avoided.

Fatty foods - Blocks are built by way of fats deposited on the walls of the coronary arteries. It is similar to grit getting accumulated in the pipelines causing the pipe to be partially blocked, only that the grit in the human body is excess fat in the form of cholesterol. This excess fat is formed when we consume far more calories than what is needed on a daily basis.

The body converts these excess calories into cholesterol which gets deposited on the walls of arteries. The best way to prevent this phenomenon from occurring is to reduce the calories intake and exercise regularly so that excess calories are burnt.

Foods to be avoided

Chips and French fries
Animal fat
Whole chicken
Egg yellow
Deep fried curries
Any food that has been cooked in boiled oil
Deep grilled food
Sweets particularly made with ghee
Butter
Whole milk
Excess ghee in food or curries
Coconut oil

(This list is not exhaustive but includes most of the food items)

Avoid 5 whites

1.   Salt
2.   Butter
3.   Whole milk
4.   Sugar
5.   Coconut

Avoid boiled oil or deeply fried foods (samosas, curry puffs, french fries and any food with lots of oil or ghee).
The more the oil boils, the more poisonous it becomes because of release of toxic fatty acids
Avoid excess masala (spices)

Do's

Eat healthy food: Healthy food constitutes low calorie, high fiber, with vitamins, minerals and other essential elements.

Low oil content
Fresh vegetables, salads
Leafy vegetables
Fresh fruits
White fish
Skinned chicken
Egg white
Food rich in fiber content should be consumed like tomatoes, carrots, cabbage, peas, mushrooms, oranges etc.
Nuts and raisins (at least 1 fist full of nuts and raisins/ day)
Raw oil on salads like olive oil or sunflower oil is better than boiled oil

Regular exercise

Regular exercise in the form of brisk walking or jogging or gym exercises will ensure losing excess calories and helps reduce obesity and blood cholesterol. Exercise is adequate when at the end of it, you are sweating and feel warm.

Do not exercise beyond what you are accustomed to. Increase the duration slowly over a period of time such as a month or so.

Relaxation

In contemporary times, stress has become a part of life and is an important contributor to the increased incidences of heart disease. Find time to relax with family and plan to go on vacations at regular intervals. Yoga is a great way to relax frayed nerves.

Regular medication

Continue your medication as directed by your Cardiologist. Some medications are better taken at the following times:

Aspirin / Clopidogrel – after breakfast
Antacid tablets – in the morning after breakfast and sometimes in the night after dinner
Anti hypertensive medication – after food as directed by the Cardiologist
Anti cholesterol medication – in the night after dinner around 8 pm to 10 pm
Acitrom – in the evening at 6 pm (for patients who've underwent valve replacement with metallic valve only)
Diuretics (water tablets) – in the morning before 8 am and in the afternoon between 12 noon and 2 pm

Medication

Never stop any medication prescribed post-stenting, heart operations or after having been diagnosed with a heart problem. Consult your Cardiologist before you discontinue, as such medication is normally for a life time. Also, these medicines are part of secondary prevention strategy, aimed at preventing the disease from getting worse and in some instances to improve some of the blocks.

Many of these medicines help your heart recover from the previous occurrences such as heart attacks. Medicines aimed at reducing blood pressure, control of diabetes and reduction of cholesterol have a protective effect and help the stent or bypass graft to function for a long time, else blocks can develop in these areas again.
Aspirin has been found to have many protective effects such as preventing clot formation, reducing block size, and increasing longevity of the stent or graft. Clopidogrel is another important medicine that acts similar to Aspirin and is very helpful in keeping stents working. It is essential for at least the first 6 months to 1 year after special stent insertion (Drug Eluting Stents).

It is important not to stop any of these medications until your Cardiologist asks you to do so.

Some common foods and their calories are given here (this is not an exhaustive list).

1 cup = 150 ml
1 cup of Coffee, Tea with semi skimmed milk: 80 calories
Idli (3) + Sambhar or chutney: 225 calories
Chapathi (2) + curry (1 cup): 220 calories
Upma (Wheat) (1 cup): 210 calories
Dosa / Vada (2) + chutney: 225 calories
Rice (2 cups) or 3 Pulkas: 220 calories
Dhal or curry with dhal (1 cup): 120 calories
Vegetable curry: 60 calories
Butter milk (1 cup): 40 calories
Marie biscuits (3): 70-100 calories
Bread (2 Slices): 70-100 calories
Germinating Bengal gram or Green gram (1 cup): 70-100 calories
Ground rice or puffed rice crispies (1 cup): 70-100 calories
Snacks (Bombay mixture type) 1 cup: 70-100 calories

General advice

Try and rotate the use of oils between rice bran oil, sunflower oil or olive oil
Try and use 3 - 4 teaspoons of oil a day (roughly ½ a litre of oil/ person/ month)
Restrict use of salt / do not add table salt to food

TYPICAL FOOD INTAKE FOR A CARDIAC PATIENT (sample menu)

Breakfast