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Coronary Artery Bypass Surgery

What Is Coronary Artery Bypass Surgery?

Coronary artery bypass surgery can be briefly expressed as bypassing (bridging) away from the stenosis/obstruction area in the coronary arteries with vessels taken from other parts of your body. If we describe the logic of the surgery as follows, it will be more clear.

Imagine a five-lane highway with heavy traffic, all four lanes closed due to the avalanche falling from the mountain next to it, and the last lane where all the traffic flows is at risk due to the slow progression of the avalanche.

In such a case, one of the things road officials would do would be to bypass (bridge) the avalanche area of traffic by creating an alternative side road extending from before to after the avalanche area. Similarly, we plan to bypass the stenosis/obstruction area in the coronary arteriesto ensure that blood reaches the areas of your heart that do not receive enough blood.

What Are The Expected Benefits of Coronary Artery Bypass Surgery?

The aim of coronary artery bypass surgery is to increase the insufficient blood flow caused by narrowed or blocked coronary arteries thanks to the new bypass vessels sutured.

In this way, it is planned to prolong the life span of the patients, to eliminate complaints such as chest pain and shortness of breath caused by the heart, to increase their exercise capacity and to prevent new heart attacks that may occur.

How Is Coronary Artery Bypass Surgery Performed?

In Coronary Artery Bypass Surgery with Traditional Approach:

The patient is taken to the operating room and connected to the monitors and vital signs are monitored instantly. The patient's identity information is checked and the operation plan documents are reviewed. The specialist physician and technicians of the anesthesia department open the vascular pathways of the patient, insert the arterial catheter (through the wrists or the arteries in the groin) to instantly monitor your blood pressure during and after the surgery, apply (put to sleep) general anesthesia drugs, connect it to the respirator, insert the central venous catheters (through the veins on both sides of the neck or in the groin) that allow blood product, fluid and drug treatments to be given and transfer the patient to the surgical team. The areas to be operated on of the patient with a urinary catheter are cleaned with antiseptic solutions and covered with sterile drapes. Then, the patient's chest bone (belief board) is cut and entered into the chest cavity.

The vessels to be used for bridging are prepared. The most commonly used veins are: the internal mammerian artery (the anterior chest wall arteries located on both sides of the breastbone), the large saphenous veins (the veins in both legs that extend under the skin from the ankle to the groin), the radial arteries (the arteries in both forearms that extend from the elbows to the thumbs). The surgeon opens the rib cage with the help of a retractor and reaches the chest cavity. Then it reaches the heart by opening the pericardial sac in which the heart is located. In order to prevent the formation of clots during the surgery, heparin (blood thinner) is given to the patient and the patient is connected to the cardiopulmonary bypass machine (heart-lung machine). The body begins to cool to protect important tissues and organs.

The vital functions of the patient, whose lungs and heart are stopped during the surgery, are maintained by this machine. After stopping the heart with special cardioplegic solutions, bypass anastomoses are performed for narrowed or occluded coronary arteries (one end of the vein to be bridged with very thin sutures is sutured beyond the stenosis in the coronary artery and the other end is sutured to the aorta). This part of the surgery can be called the bridging stage.
In patients with dense plaque in the aorta, the main artery that emerges from the heart during surgery, the surgeon may decide to perform the bridging phase of the surgery without stopping the heart (pumped-pulsed heart) and sometimes to perform the surgery without connecting the patient to the cardiopulmonary bypass machine at all (without pump, off-pump). Following the completion of the bridging phase, the heart and lungs are restarted, the patient is separated from the heart-lung machine and given protamine (a drug that reverses the effects of a blood thinner called heparin).

Following the bleeding control, chest tubes are placed in the opened chest cavities and on the surgical site. Thanks to these chest tubes, it is ensured that the bleeding and fluid accumulations that may occur in the early postoperative period are taken out without accumulating inside and the extinction of the lungs is prevented.
One/two battery wires can be inserted into the heart as a precaution to be used if necessary in patients who are thought to have heart rhythm problems in the early postoperative period. Chest bone is braced. Subcutaneous tissues and skin are closed.
Following the surgery, the patient is taken to the intensive care unit while sleeping and depending on the respirator. Parameters such as vital signs, oxygenation measurements of blood, amount of bleeding from chest tubes, urine output, etc. are closely monitored in the intensive care unit. The patient, who wakes up significantly and has no problems in the monitored parameters, leaves the respirator.

The patient, who does not have additional problems in intensive care follow-ups and whose vital functions are stable, is taken to the cardiovascular surgery service within 1-2 days. The patient, who does not have any additional problems during the service follow-ups and whose vital functions are stable, is discharged home after 4-6 days.

Estimated time of the procedure:

There are a number of factors affecting the duration of surgery in coronary artery bypass surgeries. The duration of the operation varies depending on how many coronary arteries the patient will be intervened, the diameter of the coronary arteries and the severity of the vascular stiffness, and whether there is an additional intervention to bypass surgery, but it takes an average of 4-6 hours.

Minimally Invasive Direct Coronary Artery Bypass Surgery (MIDCAB):

If the surgeon deems it appropriate during the pre-operative evaluation of the patient, he/she can perform the surgery between the ribs with a small incision (via left mini-thoracotomy) to be made at the left breast level without cutting the breastbone, provided that the patient's consent is obtained before the surgery. In this surgical technique, unlike the previous ones, arteries and veins are found after incisions made from the patient's groin or under one of the collarbones, and the patient is connected to the heart-lung machine using special cannulas sent from there. The entire operation of the patient is performed by means of a small incision made at the level of the left breast, just as it is done with the traditional approach (by cutting the breastbone). Surgery can be performed in the beating heart or by stopping the heart.

Although it has attractive aspects such as early recovery, less use of blood products, short hospitalization period, it is not suitable for all patients. In addition, there are a number of difficulties associated with working through a small incision. The operation time is much longer. In order to solve a number of problems encountered in surgeries started with a small incision, it may be necessary to open the breastbone in addition. There is a possibility of injuries to the arteries and veins used in cannulation, injuries to the main veins entering the heart (vena cava inferior, pulmonary veins) or the main arteries coming out of the heart (aorta and pulmonary artery), and injury to the heart while positioning the heart through a small incision. In addition, it is difficult to control a bleeding that may develop after surgery through a small incision.
After the surgeries performed with this method, chest tubes and one/two battery wires can be placed in the patient. There is no difference in the follow-up of the patient after surgery. They are usually discharged by lying down for 1-2 days less in the service. There is no problem for these patients to lie on their side after the chest tubes are removed.

Estimated time of the procedure:

There are a number of factors affecting the duration of surgery in coronary artery bypass surgeries. The duration of the operation varies depending on how many coronary arteries the patient will be intervened, the diameter of the coronary arteries and the severity of the vascular stiffness, and whether there is an additional intervention to bypass surgery, but it takes an average of 4-6 hours.

Will the planned procedure completely cure the disease?

Unfortunately, no method applied today can completely eliminate coronary artery disease. Since coronary artery disease is a progressive process, new stenoses and obstructions may develop in the later parts of the vessels that are bypassed over time. In order to be able to delay this process, you should quit smoking, exercise regularly, use your medications regularly, follow dietary recommendations, and do not delay your cardiology checks.

Are There Other Treatment Methods Used in Coronary Artery Disease?

Today, there are three main methods used to treat patients with coronary artery disease. These include drug therapy, percutaneous (non-surgical) coronary interventions, and coronary artery bypass surgeries. Non-surgical (percutaneous) coronary interventions are one of the procedures performed by interventional cardiologists under local anesthesia in the angiography unit. The stenosis/obstruction in the coronary artery is passed through the wires sent through the catheter inserted through the inguinal or wrist artery of the patient, the stenosis is tried to be removed by inflating the balloon in this area (balloon angioplasty) and a stent is placed in the problem area after the stenosis is removed. The patient is started on blood thinners. If no problems are encountered, the patient is discharged after one or two days and the cardiology outpatient clinic controls continue.

If there is a treatment method without surgery, why would I prefer to have surgery?

Contrary to popular belief, the treatment methods used in coronary artery disease are often complementary rather than alternative to each other.

Primum non nocere is a Latin expression that means “first of all, do not harm.” It is one of the main rules taught to students in medical schools. It aims to remind the physician, who plans to make any medical intervention to his patient, to take into account, first of all, the possible harms that the intervention may cause.

Considering the principle of "first of all, do no harm" in all decisions made, the members of the Heart Team briefly and respectively seek answers to the following questions while determining the most appropriate and most beneficial treatment method for each patient:

Is the patient's current coronary artery disease serious enough to require intervention? Isn't medication enough?

Is it possible to remove the stenosis in the patient's coronary arteries by percutaneous (non-surgical) coronary intervention?

Is the risk of percutaneous (non-surgical) coronary intervention high for this patient?

In some patients, due to the anatomy of the coronary artery (it may not be possible to direct the balloon and stent of the appropriate size in the vein due to the branching shape and the angle of exit of the branches)and the structure of the coronary artery held due to the disease (it may not be possible to open the stent properly due to reasons such as the diameter of the vein, the calcification in the vein is too high, or there may be no healthy vascular tissue to hold the stent), trying to open the stenosis may be high-risk.

Coronary artery bypass surgery may be a more appropriate option in these patients.

Are there additional problems that may lead to early obstruction of the stent to be placed in the patient?
The risk of early stent thrombosis (obstruction) is high in cases such as diabetes mellitus, poor coronary anatomy, coronary strictures requiring long stents, the need for multiple stents, the patient's inability to take multiple blood thinners after the procedure due to additional medical problems, and similar cases. Coronary artery bypass surgery may be a more appropriate option in these patients.

Is it possible to remove the stenosis in the patient's coronary arteries with coronary artery bypass surgery?

Is the patient's general medical condition suitable for removing open-heart surgery?

Some patients' general medical conditions (such as very advanced age, severely fond, inadequate mobility, bedbound and fragile patients) may not be suitable for removing open-heart surgery, the estimated risk of coronary artery bypass surgery may be very high due to additional medical problems of the patient, or the life expectancy of the patient due to additional medical problems may be quite low. In patients with this condition, it may be more appropriate to prefer non-surgical (percutaneous) coronary intervention methods rather than open-heart surgery in terms of patient health and comfort.

In order for the bridging process performed in coronary artery bypass surgery to work in a healthy way for many years, the part of the vessel after stenosis/obstruction should be healthy enough to draw the blood brought to it and its diameter should be above a certain value. In patients with a coronary artery diameter of 1 mm or less, where the coronary artery is widely involved from the beginning to the end due to coronary artery disease, the benefit to be expected from the surgery and the rate of risk to be brought by the surgery are evaluated separately for each patient. In some patients, it may be more appropriate to prefer non-surgical (percutaneous) coronary intervention methods and in some patients, to continue only drug treatment instead of performing any coronary intervention.

Although it seems very attractive to get rid of the stenosis/obstructions in the coronary arteries with a non-surgical method, unfortunately, the most appropriate and/or most beneficial treatment method for each patient may be different. In some patients, the risk of non-surgical (percutaneous) intervention may be much higher than the risk of surgery.

Is the Risk of Coronary Artery Bypass Surgery High?

What are the Risks and Complications of the Surgery?

All interventions and surgeries performed on the human body have some risks.
Generally speaking, approximately 95-98% of patients who undergo coronary artery bypass surgery are discharged home without encountering a serious adverse condition.
If you have any difficulties in understanding these issues, you can ask your doctor for a more detailed explanation.

What are the risks that increase the likelihood of complications in coronary artery bypass surgeries?
The risk of complications in patients undergoing coronary artery bypass surgery varies from patient to patient.

Individual factors that increase the risk of developing complications include:

Your age (risk is higher in older patients),
Your gender (risk is higher in female patients),
Your weight (risk is higher in patients who are overweight or underweight than normal),
Sedentary lifestyle (the risk is higher in patients who do not have regular physical activity in their normal life)

Whether you have concomitant chronic diseases;
Diabetes (if you have high blood sugar despite insulin treatment, the risk is higher)
Hypertension (especially in patients with uncontrolled high blood pressure)
Kidney failure (risk is higher in patients with kidney failure or on dialysis)
Liver Disease (risk is higher in patients with liver failure)
Lung Disease (patients with lung disease have a higher risk)
Smoking (those who smoke or use tobacco products, and especially those with COPD, have a higher risk)
The risk is higher in patients with a history of stroke (thin) or stenosis/obstruction in the vessels feeding the brain)
Peripheral artery disease (risk is higher in patients with obstruction/stenosis of leg arteries)
Aortic aneurysm (risk is higher in patients with ballooning in any part of the main artery)
Brain aneurysm (risk is higher in patients with ballooning detected in brain vessels)
Other conditions that increase the risk of complications include:
The risk is higher in patients with borderline vital signs, taking heart-supporting drugs, wearing a cardiac support device, and intubated patients.

The urgency of the surgery (the risk is higher in patients who are urgently operated due to the inability to complete routine examinations/imaging before surgery)

The risk is higher in patients with severe stenosis in the left main coronary artery or lad (left anterior descending coronary artery).

In addition tocoronary artery bypass surgery, the risk is higher if you have another disease in your heart that requires intervention during surgery.

Low heart reserves (patients with heart failure or low heart performance have a higher risk)
Plaque load in the main vessel exiting the heart (risk is higher in patients with dense lime or plaque load in the main vessel)

Anatomy of coronary arteries (risk is higher in those with diffuse and diffuse stenosis in coronary arteries and those with severe lime load)

What Should I Consider Before Coronary Artery Bypass Surgery?

If you use cigarettes, tobacco products or drugs, you should stop immediately. These products constrict the coronary arteries (vessels that feed the heart), raise blood pressure, cause the accumulation of sputum in the lungs. Increases the risk of complications after surgery

Some blood thinners need to be discontinued before surgery. You should act as recommended by your doctor regarding which of these drugs are, how long before the surgery should be discontinued and the drugs to be used instead. Otherwise, your risk of complications due to bleeding during and after surgery will increase.

In order for the preoperative examinations and consultations of the patients to be operated on in a planned manner to be completed on time, they must be hospitalized by 12:00 at the latest the day before the surgery. Unless your doctor tells you otherwise, you don't need to come to the hospital hungry.

Blood and blood products to be used during and after the surgery are obtained from the Turkish Red Crescent Society. The Turkish Red Crescent Society is able to continue this service thanks to blood donations. You should arrange for people who can donate blood to the Turkish Red Crescent Society before surgery so that your surgery program is not disrupted.

When you are hospitalized, service nurses will ask you questions about your allergy information, previous surgeries, past health information, and harmful habits (cigarettes, tobacco, alcohol, and drugs). It is very important that you answer these questions accurately and completely.

The night before the surgery, the relevant staff will give you a full body shave and bowel cleaning and give you sedative medication to reduce your stress. It is important that you follow the instructions. If you have any questions about this, you can ask your doctor.

When you are hospitalized, you will be given triflo to increase your lung capacity and reduce shortness of breath, and you will be informed about how to use it after surgery. Please obey the instructions.
You should not eat or drink anything (such as fasting) from 24:00 on the night before your surgery.

Plaque load in the main vessel exiting the heart (risk is higher in patients with dense lime or plaque load in the main vessel)

Following your admission to the cardiovascular surgery service, you will be asked to be mobilized (walking) as much as possible, to regularly work on triflo and not to lie on your right/left side. Following the instructions will help you heal sooner.

During your stay in cardiovascular surgery, blood tests will be performed periodically, ECG (cardiac X-ray) and lung X-ray will be taken. If necessary, these examinations can be expanded and their intervals can be shortened. These examinations are necessary for your close follow-up in the early postoperative period.
Your surgical sites will be regularly dressed and wound healing will be monitored. If you detect discharge, opening or contamination in your wound areas, please inform the service nurses before waiting for the next dressing time.

After the surgery, some patients may have loss of appetite and difficulty falling asleep. Do not worry about this, if you inform your doctor, medicines will start to comfort you.

Your doctor may ask you to wear a chest corset depending on your risk status following the removal of the chest tubes. Following the recommendations of your doctor and service nurse will reduce the risk of your breast bone opening.

In the postoperative period, visitor restriction is applied in the cardiovascular surgery service. This is for your health. You may develop an opening in your chest bone due to severe coughing attacks that may develop after an infection that a relative who is not aware of being sick will infect you. You may need to have surgery again because of this condition.

Due to the risk of infection, it is recommended that your relative, who will accompany you during your service follow-up, wear a mask and pay attention to his/her personal hygiene.
During your hospital stay, you should act in accordance with the recommendations of your doctor and nurse, and pay maximum attention to visit restrictions, personal hygiene and hand hygiene. Otherwise, you may be exposed to hospital infections.

You should not use any medication other than your doctor and other healthcare professionals recommend to you after surgery. Using certain medications that you use before surgery can harm you. You can consult your doctor about this.

After you are discharged to your home, you should definitely come to your outpatient clinic controls during the recommended periods, use the recommended drugs after discharge, stop smoking, tobacco products or drugs, exercise regularly and follow dietary recommendations. If you have a drug addiction, inform your doctor. It will help you get professional help. If you stop taking your medicines without your doctor's knowledge, your health could be seriously compromised.

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