Cardiac surgery in Singapore

singapore cardiac surgery 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.

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 pathway. 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 on the 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 surgery.

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.

singapore cardiac surgery

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 process.

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 surgery.

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 repeated.
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:
Stop smoking.
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 breastbone.
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 temperature.
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 tube out.
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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