What is Coronary Artery Bypass Surgery?

Coronary artery bypass surgery can be briefly expressed as performing a bypass (bridging) away from the stenosis/occlusion area in the coronary arteries with vessels taken from other parts of your body. It will be more understandable if we describe the logic of the operation as follows. Consider a five-lane highway with heavy traffic, all four lanes are closed due to an avalanche from the mountain next to it, and the last lane where all traffic flows is at risk due to the slow progress of the avalanche. In such a situation, one of the things road officials will do is to open an alternative side road that extends from before to after the avalanche zone so that traffic can bypass (bridge) the avalanche area. Similarly, we plan to ensure that blood reaches the parts of your heart that do not receive enough blood, with the bypasses we will make away from the stenosis/occlusion area in the coronary arteries.

What are the Expected Benefits of Coronary Artery Bypass Surgery?

The purpose of coronary artery bypass surgery is to increase the insufficient blood flow caused by narrowed or clogged coronary arteries, by means of sutured new bypass vessels. In this way, it is planned to prolong the life 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 the Traditional Approach: The patient is taken to the operating room and connected to the monitors, and vital signs are instantly monitored. The patient's identity information is checked and the surgery plan documents are reviewed. Anesthesia department specialist doctors and technicians open the patient's vascular access, insert an arterial catheter (via the arteries in the wrists or groin) to instantly monitor your blood pressure during and after the surgery, administer general anesthesia drugs (sleep), connect them to a breathing device, blood product, fluid and blood pressure. He transfers the patient to the operating team by attaching central venous catheters (through the veins on both sides of the neck or in the groin) that allow drug treatments to be given. The surgical areas of the patient with a urinary catheter are cleaned with antiseptic solutions and covered with sterile covers. Then, the patient's sternum (the board of faith) is cut and the chest cavity is entered. The vessels to be used for bridging are prepared. The most commonly used vessels are: Internal mammerian artery (anterior chest wall arteries located on either side of the breastbone), great saphenous veins (subcutaneous veins in both legs from the ankle to the groin), radial arteries (located in both forearms and from the elbows). arteries extending to the thumbs). The surgeon opens the thorax with the help of a retractor and reaches the thoracic cavity. Then it reaches the heart by opening the pericardial sac in which the heart is located. Heparin (blood thinner) is given to the patient to prevent clot formation during the surgery and the patient is connected to a cardiopulmonary bypass machine (heart-lung machine). To protect important tissues and organs, the body begins to cool. The vital functions of the patient, whose lungs and heart are stopped during the operation, 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 vessel 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 phase. In patients with intense plaque detected in the aorta, which is the main artery coming out of the heart, in the intraoperative evaluation, the surgeon may decide to perform the bridging phase of the operation without stopping the heart (pump-beating heart) and sometimes to perform the operation without connecting the patient to the cardiopulmonary bypass machine (no pump, off-pump). Following the completion of the bridging phase, the heart and lungs are restarted, the patient is disconnected from the heart-lung machine and protamine (a drug that reverses the effects of a previously given blood thinner called heparin) is administered. Following the bleeding control, chest tubes are placed in the opened thoracic cavities and in the surgical field. Thanks to these chest tubes, leakage-like bleeding and fluid accumulations that may occur in the early postoperative period are taken out without accumulating inside, and the lungs are prevented from deflating. In patients who are thought to have heart rhythm problems in the early postoperative period, one or two battery wires can be inserted into the heart as a precaution if necessary. The sternum is braced. Subcutaneous tissues and skin are closed. After the operation, the patient is taken to the intensive care unit while asleep and connected to the respirator. In intensive care, vital signs, blood oxygenation measurements, amount of bleeding from chest tubes, urine output, etc. parameters are followed closely. The patient, who wakes up significantly and has no problem in the monitored parameters, leaves the ventilator. The patient, who has no additional problems in the intensive care follow-ups and whose vital functions are stable, is taken to the cardiovascular surgery service within 1-2 days. The patient, who has no additional problems in the service follow-ups and whose vital functions are stable, is discharged home 4-6 days later. Estimated duration of the procedure: There are a number of factors that affect the duration of the operation in coronary artery bypass operations. The duration of the operation varies depending on how many coronary arteries of the patient will be intervened, the diameter of the coronary arteries and the severity of the atherosclerosis, and whether there is an additional intervention to the bypass surgery, but takes an average of 4-6 hours. In Minimally Invasive Direct Coronary Artery Bypass Surgery (MIDKAB): If the surgeon deems it appropriate during the preoperative evaluation of the patient, he can perform the operation between the ribs with a small incision (via left mini-thoracotomy) at the level of the left breast, without cutting the breastbone, provided that the patient's consent is obtained before the operation. . In this surgical technique, unlike the previous ones, the arteries and veins are found after the incisions made in the groin of the patient or under one of the collarbones, and the patient is connected to the heart-lung machine using special cannulas sent from here. The entire operation of the patient is performed with 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 on the beating heart or by stopping the heart. Although it has attractive aspects such as early recovery, less blood product use, and short hospital stay, it is not suitable for all patients. In addition, there are some difficulties caused by working through a small incision. The operation time is much longer. In order to solve some problems encountered in surgeries that start with a small incision, the sternum may also need to be opened. Injuries to the arteries and veins used in cannulation, injuries to the main veins entering the heart (vena cava inferior, pulmonary veins) or to the main arteries leaving the heart (aorta and pulmonary artery), and while positioning the heart through a small incision, there is a possibility of injury to the heart. In addition, it is difficult to control the bleeding that may develop after the surgery with a small incision. After the surgeries performed with this method, chest tubes and one or two battery wires can be placed on the patient. There is no difference in the follow-up of the patient after the surgery. In general, they are discharged by lying 1-2 days less in the service. It is okay for these patients to lie on their side after the chest tubes are removed. Estimated duration of the procedure: There are a number of factors that affect the duration of the operation in coronary artery bypass operations. Although the duration of an operation to be performed with a small incision varies depending on the number of coronary arteries to be intervened, the diameter of the coronary arteries and the severity of the atherosclerosis, and whether there is an additional intervention to the bypass surgery, it takes an average of 6-7 hours.

Will the planned operation completely cure the disease? Unfortunately, no method applied today can completely eliminate coronary artery disease. Since coronary artery disease is a progressive process, new stenosis and occlusions may develop in the more extreme parts of the bypassed vessels over time. In order to delay this process, you should quit smoking, do regular exercise, use your medications regularly, follow the dietary recommendations and not interrupt your cardiology checkups. Are There Other Treatment Methods Used in Coronary Artery Disease? Currently, there are three basic methods used to treat patients with coronary artery disease. These are 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/occlusion in the coronary artery is passed through the wires sent through the catheter inserted from the patient's inguinal or wrist artery, the stenosis is tried to be relieved by inflating the balloon in this area (balloon angioplasty), and a stent is placed in the problematic area after the stenosis is removed. The patient is started on blood thinners. If no problem is encountered, the patient is discharged after one or two days and continues to follow up with cardiology outpatient clinics. If there is a non-surgical treatment method, why should I choose to have an operation? Contrary to popular belief, the treatment methods used in coronary artery disease are often complementary to each other rather than being an alternative to each other. Primum non nocere is a Latin phrase meaning "first, do no harm". It is one of the main rules taught to students in medical faculties. It aims to remind the physician who plans to perform any medical intervention on his patient, first of all, to consider the possible harm that the intervention may cause. Considering the principle of "first, do no harm" in all their decisions, Heart Team members seek answers to the following 3 questions briefly and in order, 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? Is medication not enough? Is it possible to correct the stenosis of the patient's coronary arteries with percutaneous (non-surgical) coronary intervention? a. Is percutaneous (non-surgical) coronary intervention high risk for this patient? In some patients, the anatomy of the coronary artery for which intervention is planned (due to the branching shape and the exit angle of the branches, it may not be possible to direct the balloon and stent of the appropriate size in the vessel) and the structure of the coronary artery involved due to the disease (the diameter of the vessel, the calcification in the vessel is too high, etc.). It may not be possible to open the stenosis, or there may not be healthy vascular tissue to which the stent will attach), trying to open the stenosis with a non-surgical method may be high-risk. Coronary artery bypass surgery may be a more suitable option in these patients. b. Are there any additional problems that may lead to early occlusion of the stent to be placed on the patient? The risk of early stent thrombosis (occlusion) is high in cases such as diabetes, poor coronary anatomy, coronary stenosis requiring long stents, the need for multiple stenting, the inability of the patient to take multiple blood thinners after the procedure due to additional medical problems, and similar conditions. Coronary artery bypass surgery may be a more suitable option in these patients.

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

a. Is the patient's general medical condition suitable to remove open heart surgery?

 Bazı hastaların genel tıbbi durumları (çok ileri yaşta, ileri derecede düşkün, yeterli hareket imkanı olmayan, yatağa bağımlı ve kırılgan hastalarda olduğu gibi) açık kalp ameliyatını kaldırmaya müsait olmayabilir, hastanın sahip olduğu ek tıbbi sorunlar nedeni ile koroner arter bypass ameliyatının tahmin edilen riski çok yüksek olabilir, veya hastanın ek tıbbi sorunları nedeni ile beklenen yaşam süresi oldukça düşük olabilir. Bu durumdaki hastalarda açık kalp ameliyatından ziyade ameliyatsız (perkütan) koroner girişim yöntemlerini tercih etmek hasta sağlığı ve konforu açısından daha uygun olabilir.

b. Are stenosis in the patient's coronary arteries suitable for coronary artery bypass surgery?

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 the stenosis/occlusion must be healthy enough to draw the blood brought to it and its diameter must be above a certain value. In patients with extensive involvement of the coronary artery from the beginning to the end due to coronary artery disease and with a coronary artery diameter of 1 mm or less, the expected benefit from the operation and the ratio of the risk of the operation are evaluated for each patient individually. In some patients, it may be more appropriate to prefer non-surgical (percutaneous) coronary intervention methods, and in some patients, it may be more appropriate to continue drug therapy instead of any coronary intervention. Although it may seem tempting to get rid of stenosis/occlusions in the coronary arteries with a non-surgical method, unfortunately, the most appropriate and/or most beneficial treatment method may be different for each patient. 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 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 any serious adverse events. If there are points that you have difficulty in understanding, you can ask your doctor for a more detailed explanation. What Are the Risks That Increase the Chance of Complications in Coronary Artery Bypass Surgery? The risk of developing 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 (the risk is higher in older patients), your gender (the risk is higher in female patients), Your weight (the risk is higher in patients who are overweight or underweight), Sedentary lifestyle (in patients who are more likely to engage in regular physical activity in their normal life). The risk is higher in patients who do not have it) Whether you have any concomitant chronic diseases; Diabetes (risk is higher if you have high blood sugar despite insulin therapy) Hypertension (risk is higher especially in patients with uncontrolled high blood pressure) Kidney failure (risk is higher in patients with kidney failure or on dialysis) Lung Disease (risk is higher in patients with lung disease) Smoking (risk is higher in those who smoke or use tobacco products and especially those with COPD) Patients with a history of stroke (thin) or stenosis/occlusion of the vessels feeding the brain are at higher risk) Peripheral arterial disease (The risk is higher in patients with occlusion/stenosis in the leg arteries) Aortic aneurysm (the risk is higher in patients with ballooning in any part of the main artery) Brain aneurysm (the risk is higher in patients with detected ballooning in the cerebral vessels) Other conditions that increase the risk of complications include: The risk is higher in patients whose vital values ​​are at the limit at the time of surgery, who are taking heart-supporting drugs, who are fitted with a heart support device, and who are operated on as intubated (depending on a breathing device). The risk is higher in these patients because of incomplete completion of the disease) The risk is higher in patients with severe left main coronary artery or LAD (left anterior descending coronary artery) stenosis. In addition to coronary artery bypass surgery, the risk is higher if you have another heart disease that requires intervention during surgery. Low heart reserve (the risk is higher in patients with heart failure or low-performance heart) Plaque load in the main artery leaving the heart (intensive lime or plaque load in the main vein) The risk is higher in patients with coronary artery disease) Anatomy of the coronary arteries (the risk is higher in those with diffuse and diffuse stenosis in their 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 quit immediately. These products narrow the coronary arteries (vessels feeding the heart), raise blood pressure, and cause sputum accumulation in the lungs. Increases the risk of post-operative complications Some blood thinners need to be discontinued before surgery. You should act as your doctor recommends about which of these drugs are, how long before the surgery they should be discontinued and the drugs to be used instead. Otherwise, your risk of complications due to bleeding during and after the surgery will increase. In order to complete the pre-operative examinations and consultations of the patients who will be operated on a planned basis, they must be hospitalized until 12:00 the day before the operation. You do not need to come to the hospital hungry unless your doctor tells you otherwise. The blood and blood products to be used during and after the operation are obtained from the Turkish Red Crescent Society. Thanks to the blood donations, the Turkish Red Crescent Society can continue its service. It is necessary to arrange the people who can donate blood to donate blood to the Turkish Red Crescent Society before the surgery so that your surgery program is not disrupted. When you are admitted to the hospital, the service nurses will ask you questions about your allergy information, previous surgeries, past health information and harmful habits (cigarettes, tobacco products, alcohol and drugs). It is very important that you answer these questions completely and accurately. The night before the surgery, the relevant staff will give you a full body shave and bowel cleansing and give you sedatives to relieve 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 the surgery. Please follow the instructions. You should not eat or drink anything (like fasting) from 24:00 on the night before your surgery. What are the things I should pay attention to after the Coronary Artery Bypass Surgery? After coronary artery bypass surgery, patients who are followed up in the intensive care unit for one or two days are taken to the cardiovascular surgery service. Following your admission to the cardiovascular surgery service, you will be asked to mobilize (walk) as much as possible, to work triflo regularly and not to lie on your right/left side. Following the instructions will help you recover sooner. During your stay in cardiovascular surgery, blood tests will be done from you at regular intervals, ECG (heart graphy) and chest x-rays will be taken. If necessary, these examinations can be expanded and their intervals 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 the dressing on your wounds, please inform the service nurses without waiting for the next dressing. Some patients may experience loss of appetite and difficulty falling asleep after surgery. Do not worry about this, if you inform your doctor, drugs will start to relax you. After the chest tubes are removed, your doctor may ask you to wear a chest corset, depending on your risk situation. Following the recommendations of your doctor and service nurse will reduce the risk of opening your sternum. In the postoperative period, visitor restriction is applied in the cardiovascular surgery service. This is for your health. Your sternum may open due to severe coughing attacks that may develop after an infection that a relative of yours is unaware of being sick. Because of this situation, you may need to have surgery again. 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 personal hygiene. During your stay in the hospital, 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. After the surgery, you should not use any medication other than what your doctor and other health personnel have recommended to you. The use of certain medicines that you used before the surgery may harm you. You can consult your doctor about this. After you are discharged home, you should definitely come to your outpatient clinic controls within the recommended times, use the recommended medications after discharge, quit smoking, use tobacco products or drugs, engage in regular physical activity, and follow dietary recommendations. Inform your doctor if you have a drug addiction. It will help you get professional help. Your health can be seriously compromised if you stop taking your medications without your doctor's knowledge.