Coronary Bypass Surgery in Singapore

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About Bypass Surgery

Coronary Bypass Surgery also known as CABG or "cabbage" Coronary Artery Bypass, Graft and Open-Heart Surgery.The coronary artery bypass graft (CABG) is the surgical treatment for coronary artery disease (CAD). It is a safe procedure that is mostly performed for treating CAD. Coronary artery disease is due to the hardening and narrowing(atherosclerosis) of the coronary arteries.Actually the arteries that bring blood to the heart muscle (coronary arteries) can become clogged by plaque (a buildup of fat, cholesterol and other substances). This can slow or stop oxygen-rich blood to flow through the heart's blood vessels. If left untreated, this may lead to chest pain and a heart attack.

Coronary Bypass Surgery is a way to treat these blocked heart arteries by creating new passages for blood to flow to your heart muscle. In this process a surgeon uses a segment of a healthy blood vessel (either an artery or vein) from another part of the body (called grafts) and uses it to create a detour or bypass around the blocked portion of the coronary artery. As a result, oxygen-rich blood can flow more freely to nourish the heart muscle. This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery. Depending on the number of blocked coronary arteries, a patient may need one, two, three or more bypasses.

What is Coronary Bypass Surgery?

The coronary artery bypass graft surgery (CABG) is not to repair or remove any blocked arteries, but to make a route for blood around a blockage in a coronary artery and maintain the flow of oxygen-rich blood to the heart. To create this rout, a segment of a blood vessel is grafted from another part of the body. The segment may be taken from the saphenous vein from the leg , the internal mammary artery from the chest (usually preferred for key artery branches because it tends to remain open longer) or the radial artery from the arm and sometimes arteries from the stomach (gastroepiploic artery) may also be used as bypass grafts.

Depending on which blood vessel is used, one end is either sewn to the aorta or may remain connected to the larger artery where it originated. The other end is grafted beyond the blockage in the coronary artery. This leads to the flow of blood around the blocked area and thus increasing the supply of oxygen and nutrients to the heart muscle.

Who are recommended for CABG?

Bypass surgery may be recommended for individuals with a history of any of the following:
  • Narrowing in several coronary artery branches (common in people with diabetes)
  • Severe narrowing in the left main coronary artery
  • Blockage in the coronary artery or another condition that may not or has not responded to other treatments (e.g., angioplasty)
  • Severe angina

Why the Procedure is needed to be Performed?

Coronary arteries are the small blood vessels that supply your heart with oxygen and nutrients that are carried in your blood. When one or more of the coronary arteries becomes partly or totally blocked, heart does not get enough blood. This is called ischemic heart disease or coronary artery disease. It can cause chest pain (angina). Coronary artery bypass surgery can be used to treat coronary artery disease. Your doctor may have tried to treat you with medicines only. You may have also tried cardiac rehabilitation. Coronary artery disease varies a lot from person to person, so the way it is diagnosed and treated will also vary. Heart bypass surgery is just one treatment. It will be right for some people, but others may have other kinds of treatment like Angioplasty.

What are the risk factors associated with Coronary Bypass Surgery?

Bypass surgery also have some risk factors like including a
  • Less than 5 percent chance of heart damage and a less than 2 percent chance of death.
  • Research reveals that women have a slightly higher risk during or immediately after bypass surgery. As because women who undergo the surgery are generally older and in poorer health, and their smaller body size makes the surgery technically more difficult.
  • In some cases, the grafted arteries may also become blocked and require a second bypass surgery. Second bypass has slightly higher risks than the initial surgery, because patients are older and other, less optimal blood vessels must be used for the new grafts.
    However, the overall risks are relatively low when compared to the truth that many of these bypass operations significantly increases and improve the quality of the patient's life. The bypassed arteries can remain functioning properly for many years, if the patient maintains a proper diet and makes adjustments for cardiac health. Therefore, bypass surgery is a popular choice for physicians treating severe coronary artery disease.

    How the procedure of Coronary Bypass Surgery executed?

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    During the days before the surgery

    For several weeks before bypass surgery, patients who smoke will be advised to stop smoking. Many surgeons also advise their patients to stop taking drugs like aspirin, ibuprofen (such as Advil and Motrin), naproxen (such as Aleve and Naprosyn), and other similar drugs to minimize the risks of excessive bleeding during and immediately after surgery. Patients are informed to always let their doctor know if they have a cold, flu, fever, herpes breakout, or any other illness in the days before the surgery. Some days before surgery, the patient undergoes a series of tests, which are an x-ray, blood tests, urinalysis and an electrocardiogram (EKG). The patient's blood is typed and cross matched with units of donor blood( in case if it is needed). Patients will also be asked not to eat or drink anything after midnight before surgery. This includes chewing gum and using breath mints. If the mouth feels dry he or she can rinse the mouth with water, but be careful not to swallow. Certain medications, especially those that affect blood clotting, may be reduced or stopped. Patients should discuss their medication schedules with their physician.

    The day of surgery

    Step 1 : The patient is usually admitted the morning of surgery.
    Step 2 : The patient will be given specific pre-operative medications and is then prepared for surgery.
    Step 3 : The patient is asked to wash the whole body below your neck with a special soap. The chest, groin and leg areas are shaved, and a bacteria-killing (bactericidal) solution is applied to the operative site and surrounding area, to guard against infection .
    Step 4 : The patient is then sedated with medication. When the patient is asleep, an anesthetic inhalation gas that is a general anesthesia is continuously given through an endotracheal tube (breathing tube). This is constantly monitored by the anesthesiologist.
    Step 5 : Then a device called Swan-Ganz catheter is inserted through a needle stick into the jugular vein in the neck and this is threaded to the pulmonary artery which goes from the heart to the lungs. The catheter is used to measure heart function, measure the pressures in both the heart and lungs.The endotracheal tube, which is inserted into the mouth and down the windpipe, is used to maintain an airway. A urinary catheter is also inserted and connected to a collection bag to measure the patient's urine output.
    Step 6 : In the chest an incision is made through the breastbone. The two halves of the breastbone are divided and a medical device called a retractor is used to pull back the two halves of the breastbone.This give plenty of room to the surgeon to work.
    Step 7 : The blood vessels to be used as grafts are removed from their source location before the heart is stopped. If they are located in the chest, then one end of the blood vessels will remain connected to the larger artery from where it originated, or it may be sewn to the aorta. This depends on which blood vessel is used for the graft. The other end is sewn in the place below the blockage in the coronary artery. Note [The functions of the heart, including blood flow and oxygenation, are rerouted through a heart-lung machine.While the machine takes care of the heart's functions, the heartbeat can be carefully stopped by administering a cardioplegic solution. The heart can remain stopped for about 30 to 90 minutes during the four to five hours of surgery. ]
    Step 8 : After the grafts are completed, and blood is successfully flowing around the blockage, the heart is restarted and the patient is removed from the heart-lung machine.
    Step 9 : Finally, the surgical site is carefully closed layer by layer, when normal blood flow and heartbeat are re-established. The sternum is usually closed with wire and the surface incision is closed with staples or sutures.

    After coronary bypass surgery

    After surgery is over, the patient is taken to a hospital bed in the cardiac surgical intensive care unit. Monitoring devices continuously monitor the patient's heart rate and blood pressure for 12 to 24 hours. Medications that regulate circulation and blood pressure is given through the intravenous tube. A breathing tube known as endotracheal tube will remain in place until the physicians are confident that the patient is awake and ready to breathe comfortably without assistance.
    The patient may feel groggy and disoriented. The sites of incisions that is both the chest and the leg( if a segment of blood vessel was taken from the leg) may be sore. Painkillers are given if needed. Patients usually stay in the hospital for at least three to five days but sometimes even longer. In this period, tests are conducted to assess and monitor the patient's condition.

    Side effects after Coronary Bypass Surgery?

    The patient may experience some side effects after release from the hospital such as...
  • Loss of appetite
  • Area from which the segment of blood vessel was removed may be swelling.
  • Patient may experience some difficulty in sleeping.
  • Patient may experience Constipation problem.
  • Patients may suffer from mood swings and a feelings of depression.
  • Patients sometime experience a muscle pain or tightness in the shoulders and upper back.
  • Patient may experience a mild disorientation.
  • A low-grade fever and chest pain that can last up to 6 months.
  • Some temporary memory loss and loss of mental clarity or "fuzzy thinking.".
  • Poor concentration.
  • Fatigue.
    However most of these side effects usually disappear over the course of four to six weeks.

    What is the recovery period for Coronary Bypass Surgery?

    For full recovery it may take a few months or more. When the patient is fully recovered, he or she is advised for a physician-supervised program of cardiac rehabilitation. This program teaches stress management techniques and other important issues like about diet and exercise. This may helps the patient a lot to rebuild his or her strength and confidence.

    What complications may arise after the Coronary Bypass Surgery?

    Complications that may arise from bypass surgery include :-
  • Difficulty breathing
  • Bleeding
  • Infection including in the lungs, urinary tract, and chest
  • High blood pressure (hypertension)
  • Abnormal heart rhythm (arrhythmias), particularly atrial fibrillation.
    Mostly all these complications are short-term and are not serious,but advanced age and poor overall health may increase their risk and severity.

    Due to the use of the heart-lung machine some Serious complications that may arise like..
  • kidney failure
  • heart attack
  • stroke
  • death.
    These risks are higher for older patients, people with diabetes and patients with other major health problems. However now with the advancement of science ane technology physicians have a number of tools at their disposal to further reduce the risk of post-operative complications. This includes the use of medications, such as aspirin and beta blockers, and very strict blood sugar control.
    Another area of mazor complication occurs when grafted arteries become blocked over time and a patient needs a second bypass surgery. This procedure presents greater risks for many valid reasons. The patient is older and their heart disease has becomed more worsened. Moreover the blood vessels used as grafts in the first surgery are not available to use for the second surgery. In addition, there may be adhesions around the original grafts that make the second surgery more difficult. Patients is needed to discuss all additional risks with their physician.

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    What are the advantages of Coronary Bypass Surgery?

    However, it's also important to note that in recent years, the risk of serious complications due to cardiopulmonary bypass has been dramatically reduced due to improved surgical techniques. After the bypass patients can improve their health and lessen their likelihood of further cardiac disease. Maintaining a good and balanced lifestyle like eating a heart-healthy diet, quitting smoking, monitoring blood pressure on regular basis, taking all medications exactly as prescribed and developing and practicing stress management techniques changes can help to achieve this.
    The first few months after the surgery the bypass patient is encouraged to slowly resume an enjoyable and active life and minimizing the risks associated with overexertion. Relaxation is extremely important during this period. He or she have to make sure that the physical process of healing goes smoothly, that is he or she should restrict certain activities like lifting objects over 20 pounds, driving, and should not net involved in highly stressful or strenuous situations. According to the patient's comfort he or she should do some light aerobic exercise and particularly walking to regaining strength and maintaining a healthy heart. Patients who do jobs which do not require heavy physical labor such as desk work can return to work in about four to six weeks. Family members are the friends of the patient have a major role. They should spend time with the patient which will keep him stay active and help in patient's mental recovery. Eventually, most people returns to their places of employment or find another type of work or volunteer activity that keeps them both fulfilled and medically safe.

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