Cardiac surgery in Singapore
There are several types of bypass surgery, namely heart bypass surgery (which includes open heart surgery, triple bypass surgery), and gastric bypass surgery. Coronary artery Bypass Surgery (CABG) is a surgical procedure in which one or even more than one blocked
coronary arteries are bypassed by a blood vessel graft to enable the normal blood flow to the
Heart Bypass Surgery :
When there is a blockage in the coronary arteries, a surgery is done to cure the problem which is known as
heart bypass surgery. In this process of surgery, the blood is channeled to the heart through a new
While doing a coronary artery bypass graft surgery, which is termed as 'cabbage' or CABG , to bypass the
blockage, a blood vessel is grafted from another part of the body and placed in a area to bypass. This is
done to restores the flow of blood to the heart muscle. The vessel that is used is termed as graft. These
grafts usually taken from the patient's own arteries and veins located in the chest (thoracic), leg
(saphenous) or arm (radial). The surgeon, performing the surgery decides which graft vessel to use based
location of the blockage, the amount of blockage, and the size of the
patient's coronary arteries. The new passage is for the smooth flow of oxygen-rich blood around the
blockage to the heart muscle.
Choice of graft:
Generally, blood vessels can be obtained from four areas of the body: leg, arm, chest, and abdomen.
Internal mammary artery (well known as thoracic arteries) is a blood vessel present on the inside of the
chest cavity. It is not a vein but a artery. Under the same blood pressure, it carries red blood as that
seen in the aorta or the coronary arteries themselves.There is one Internal mammary artery on each side of
the breastbone (aka sternum). This unique blood vessel runs along the inside edge of the sternum, sending
off small branches to the bones, cartilage, and soft tissues of the chest wall. Because of the convenient
location of the internal mammary artery that is near to the most important coronary branch, the left
anterior descending, the surgeon can safely transfer the lower end of the internal mammary artery down to
the heart surface and use it as a bypass graft to the coronary vessels.
About 50% of blood is supplied to the heart muscle by the left anterior descending coronary artery.It has
been proved based on studies that an internal mammary artery graft to the left anterior descending coronary
artery increases survival and decreases the case of late myocardial infarction, recurrent angina, and the
need for further cardiac interventions more than vein conduits. Mostly surgeons implant the left internal
mammary artery into the left anterior descending coronary artery, and this is one of the best method to use
for mostly 90% of coronary bypass operations.
In this case, internal mammary grafts are not fully removed from their original position. These grafts
remain connected to their natural site of origin. Only one end is separated from the chest wall. This end
is then attached to one of the coronary arteries.
In case if surgeon removes the mammary artery from its origin, it is known as a 'free' mammary artery. More
than 90% of all patients received at least one internal artery graft, over the last decade.
These are the most widely used bypass grafts, as they have been shown to have the best long-term results.
Mostly, these arteries can be kept intact at their origin because they have their own oxygen-rich blood
supply. During the procedure, the arteries are sewn to the coronary artery below the site of blockage. This
artery is located in the chest and can be accessed through the primary incision for the bypass
Saphenous veins :
From the leg these veins are removed, and then sewn from your aorta to the coronary artery
below the site of blockage. Minimally invasive saphenous vein removal does not require a long incision.
Generally one to two incisions are done at the knee and a small incision is done at the groin. Results is
less scarring and fast recovery.
Another common type of arterial graft is the radial (arm) artery. Ulnar and the radial arteries are the two
arteries in the arm. Blood circulates to the arm through the ulnar artery and will not have any side
effects if the radial artery is removed by ten surgeons. But for this careful preoperative and
intraoperative tests is done which determine if the radial artery can be used. If the radial artery is used
for the bypass, the patient will be put on a medication
called a calcium channel blocker for six months after your surgery to keep the
artery widely open. This medication keeps the artery open. After the surgery numbness in the wrist is
common reported by some people. But, long-term sensory loss or numbness is uncommon.
radial (arm) grafting is a highly effective revascularization strategy resulting in excellent short and
long term results with very low rates of reintervention.
In most of the bypass cases, more than one bypass is done, so artery
on the inside of the breastbone are used for most people, along with some vein from the
leg or the artery from the arm.
The number of blood vessels used to bypass around narrowings or blockages in the coronary arteries are
referred as single, double or treble bypass.
Heart Valve Problem :
In most cases heart valve can develop two main problems they are : narrowing and leaking. Due to thickening
and scarring from just simple wear and tear a heart valve can become narrowed.This is medically termed as
degenerative valve disease. Rheumatic fever and infections of the heart valves are the other diseases that
cause thickening and narrowing of heart valves. as a result of the damage from wear and tear, rheumatic
fever or infection, or even following to a heart attack the heart valve can leak
because the leaflets (leaf-like flaps) of the valve do not meet any more. Commonly two heart valves that
suffers damage are called the aortic valve
and the mitral valve.
Before Bypass Surgery :
To find out the problem with the heart the cardiologist will do some tests. Which includes blood test to
measure your cholesterol, the function of the kidneys and liver and also the blood count. A chest x-ray
and a tracing of the electrical activity of the heart will be done. Mostly people have to do an ECHO or an
angiogram or both.
An ultrasound scan of the heart is known as ECHO. Some jelly is put on the patients chest and then a probe
is placed on the chest to give some moving pictures of the inside of patients heart. This gives very good
picture of the heart valves as well as any problems with the chambers of the heart and is a painless
An angiogram is a specialized test. In this case a small needle is passed through a blood vessel in the
patient's groin. Then through this needle dye can be injected, that will show up through the patient's
coronary arteries on x-rays, so that any narrowings or blockages can be seen. In is process the
cardiologist can look at patients heart valves and assess how well the heart is working.
CT scans are also be done to see the coronary arteries. This is a x-ray test which is non-invasive which
can show narrowings in the coronary arteries.
After cardiologist has done all the test and = makes the diagnosis, he will discuss the problem with
a cardiac surgeon and they will come to a joint decision as to whether the problem might best be treated
with surgery or it can be simply cured be medicine. If surgery is needed they will plan the timing of
Planning of the Surgery :
The day before the surgery the patient will be admitted to hospital.The surgical team will enquirer about
the patient's medical history, examine the patient, and all the patient's investigations that have been
done will be assess. To make sure there is no new problem blood tests, ECG, and chest x-ray will be
The surgical team will discuss the operation with the patient and
explain what can be expect during recovery. The patient is free to ask questions as well.
The anaesthetist will meet with the patient to talk about any pain relief needed after the
operation. The physiotherapist will show the patient some breathing exercises that he need to do after the
operation, in case to prevent chest infection.
The patient will be instructed to follow the followings:
Bring all the normal medication and show it to the surgical team.
Patient need to take complete bed rest for the first two weeks at home after release from hospital.
During the Operation :
Patients will be deep asleep at the time of the operation. This operation mostly take from three to four
hours. To get access to the heart, most of the heart operations are done through the front of the
Generally in heart operations, the patient is passed on the heart and lungs machine. This machine takes
over the function of the patient's heart and the lungs. This allows to stop the function of the heart and
the lungs for the operation. Then the heart surgery like the heart bypass, valve repair or valve
replacement are done. One the surgery is over, the surgeons gets the patient's heart beating
again and then stops the heart and lung machine. If any bleeding is there it will be stopped by the
surgeons then. They will put in some temporary wires that will come out through the patients skin, so that
if there are problems with the heart rhythm following the surgery, then the wire can be attached to an
artificial pacemaker. The surgeons will then close the breastbone of the patient with wires to give it
strength while it is healing. These wires are buried between the bone and the patient won't be able to feel
them. Forever the wires are left there and they rarely cause any problem, so the patient will not be aware
of them. The wound is closed with absorbable stitches.
After the Operation :
The patient will be brought back to the intensive care unit (ICU) an will be kept asleep on the ventilator
for at least the first few hours after your operation.
The patient will be connected to monitors to keep a watch of his blood pressure, heart rhythm and
The patient's family are allowed to visit the patient in the ICU.
The ICU team will wake the patient up, once his blood pressure has settled and there is no bleeding.
When the patient is breathing well, the ICU team will take you off the ventilator and take the breathing
For the first few hours after the operation, the patient will be given an oxygen
mask to wear. A small tube will be inserted in the patient's bladder to drain the urine for monitoring the
kidneys. He will also have some tubes in his chest to drain away any blood from around the heart and re-
expand his lungs. These tubes are normally removed a day after your surgery before leaving the ICU.
The patient will be given regular painkillers by the doctors.
He will be allowed to eat and drink one day after the surgery.
Generally most patient need to stay in tjhe ICU for one to two days, but some patients may need more time
in tjhe ICU and then they are sifted to high dependency unit (HDU) or the ward.
In most cases Six to Seven days after the operation the patients are discharged and are able to go home. At
the time of discharge physiotherapist will check to make sure that the patient can cope with going up and
down stairs.A final chest x-ray and ECG of the patient will be done and he will be given advice about what
to do when he go home and what medication he should be taking.
For a further details on the surgical treatment of coronary artery disease, visit the page discussing Coronary Artery Bypass Surgery
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