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Coronary artery bypass graft (CABG) or Bypass surgery

This post is also available in: हिन्दी (Hindi)

What is CABG?

CABG is the surgery done to treat blocked coronary arteries which results in decreased blood flow and heart attack.

As the name indicates, the CABG re-establishes the blood flow to the heart by putting a new vessel (bypass graft), at places, proximal and distal to the site of the blocked coronary artery, thus bypassing the blocked portion of the artery.

CABG 1

There is another procedure that is used to treat blockage of coronary artery or coronary heart disease known as percutaneous coronary intervention (PCI) or popularly known as angioplasty. This procedure doesn’t involve opening up the chest as done in a typical CABG procedure. Here, the procedure is done by traveling within the blood vessel via a thin specialized tube called a catheter.

How common is coronary heart disease in India?

It is estimated that more than 3 crore people in India have coronary heart disease. In the last four decades, the prevalence of CHD has increased to 4 times.

It is more common in the urban population where it is said to affect about 1 in 10 people.

There is also an increase in the number of deaths due to CHD. It is estimated to cause death in about 1/4th (23%) of the patients of CHD.

How commonly is the CABG procedure done in India?

There are about 60,000 patients in India who undergo CABG every year.

The first CABG in India was done in 1975 about 13 years after it was first developed, but today more people in India are undergoing bypass surgery than in the US.

About 10-12% of the urban population has CAD in India. The CAD occurs relatively more in the younger population in India when compared to the west. It tends to be detected in a more advanced stage as compared to other populations.

What is the cost of CABG in India?

The cost of CABG varies with the type of hospital setup, reputation, the experience of the doctor, and the type of procedure. In private hospitals, on average it generally costs about 2 lakhs- 4 lakhs. Whereas, in government hospitals, it may cost around 1 lakh rupees.

What is the success rate of the CABG procedure?

The CABG has a high success rate with a low rate of mortality of about 6.6%, that is, about 6-7 people out of 100 dies during or after surgery.

The success rate depends on the associated risk factors like

• Older age,

• Presence of other diseases like diabetes, lung disease, chronic kidney disease, and others.

• Decreased functioning of the heart muscles

• Smaller coronary artery size as seen in women

Depending on the risk factors, the mortality rate may vary from less than 1% in people with very low risk to about 20% in people with high risk.

The correctly selected patients for CABG get excellent results, where 85% of people have significant relief in symptoms, less risk of heart attacks, and lower chances of dying within 10 years after surgery.

It has been found that the survival rate of bypass surgery patients who makes through 1st month is close to the general population but mortality increases significantly after 8-10 years after surgery.

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Who are the candidates of CABG? Which patients require CABG?

CABG is a surgical procedure done to treat coronary heart disease. Not all patients with CHD need surgery and can be treated with lifestyle changes and medicines or with another procedure called angioplasty.

CABG or angioplasty is done when there is a severe blockage in large coronary arteries, especially if the functioning of the heart is weakened.

Angioplasty with or without stent placement (a mesh-like tube put inside the arteries to keep it open) provides quicker recovery and doesn’t need opening up of chest but it can’t be done in all patients.

CABG is considered to be better in the following circumstances:

• Double or triple vessel disease (when the two or three main vessels of the heart have the disease) with left ventricle not functioning well.

• Severe coronary artery disease in the left main coronary artery.

• When angioplasty couldn’t be done or angioplasty hasn’t been successful or there is a development of stenosis again in the coronary artery.

Diabetes

Even with coronary bypass surgery, you’ll need to make lifestyle changes after surgery. Medications are prescribed routinely after coronary bypass surgery to lower your blood cholesterol, reduce the risk of developing a blood clot, and help your heart function as well as possible.

Learn more about how to prepare before surgery.

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How is the CABG done?

The CABG is done after giving general anesthesia which makes the person lose consciousness and sensation of pain. The person is put on ventilator to support breathing.

In CABG, the surgeon takes a blood vessel from the chest, arm, or leg and sew it ends, above and below the blocked part of the coronary artery. This bypasses the blood around the blocked artery, maintaining the blood flow to the heart muscles preventing heart attack.

The number of bypass vessels needed to used depends upon the severity and location of blockages.
There are different types of CABG surgery done, but the basis of putting a bypass vessel remains the same:

Traditional CABG/ Open heart bypass surgery: is the most commonly performed CABG surgery. It generally takes around 3-6 hours to do the surgery. In this method, the surgeon makes a long cut in the breastbone and split open the chest. Certain medicines are given to stop the beating of the heart to allow easier grafting of the vessels. During this period, a machine called the heart-lung bypass machine is used that does the functioning of the heart. The blood vessels from the arm, leg, or chest are then stitched around the blocked portion of the artery forming a bypass of blood flow. Once grafting is done, the doctor will again establish the beating of the heart. Usually, the heart starts to beat on its own, but in a few patients, mild electric shocks are needed to be given. After this, the surgeons will put back the breastbone and sew it.

CABG open heart surgery scaled

CABG 1

 

Off-pump/ Beating-heart bypass surgery: as the name indicates, this procedure doesn’t utilize the heart-lung bypass machine. The surgery is done with a continuously beating heart which is stabilized with a mechanical device. This surgery tends to be more difficult to do, due to continuously beating of the heart. But, it may be considered a safer option in some people with older age and other associated conditions like diabetes, chronic lung disease, kidney disease, or ventricular dysfunction. These patient tends to have higher chances of developing complications on using a heart-lung bypass machine.

Minimally invasive CABG: This surgery is done by making a small cut in the chest on the left side just over the blocked artery. Sometimes this surgery is done using a robot that puts the graft vessel instead of hands.

Hybrid surgery: In this procedure, the robot is used to bypass one of the main arteries, whereas a stent is used to open other blocked arteries. This procedure is used when the surgeon is unable to do the traditional bypass surgery.

Watch video to understand it

What are the tests done before CABG?

There are a number of tests that may be used by the doctors to diagnose CHD and assess the functioning of the heart before doing CABG.

These are as follows:

Electrocardiogram (ECG): is a test where multiple leads are put over the chest and other parts of the body to record the electrical activity of the heart. By recording the electrical activity doctors try to figure out the gross functioning of the heart and any obvious signs of heart attack or damage.

Stress tests: this test assesses the functioning of the heart during periods of stress. This test records the electrical activity under stress with the aim to unmask blockages that restrict higher blood flow demand of the heart muscles. The stress can be induced by physical activity, such as walking on a treadmill, or by medicine.

Echocardiogram: this study uses ultrasound waves and doppler to visualize the structure and functioning of the heart. This also provides a good estimate of the functioning of the heart by calculating the ejection fraction.

Coronary angiography: in this test a dye is injected into the coronary arteries and the X-rays (fluoroscopy) are used to see the course and diameter of the vessels. This is done by inserting a thin tube called a catheter into an artery of limb and passing it up to the origin of the coronary arteries. This shows the severity of the disease, the number of arteries involved, and the location of the affected arteries. This test many times can be followed up by PCI/angioplasty.

Coronary calcium scan: CT scan is used to see and calculate the amount of calcium present in the walls of coronary arteries, as a part of coronary artery disease.

CT angiography: this test utilizes a CT scan to make images of the coronary arteries after filling it with contrast. In some patients, it may be a safer alternative to cardiac catheterization which requires cardiac catheterization as discussed above.

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What problems or complications can occur during or after CABG? 

There are risks associated with all types of surgeries. The risk is generally higher for certain people, such as those who get CABG done in an emergency situation, have a plaque in other arteries throughout the body, or have other medical problems, such as major heart failure, or lung or kidney disease. Potentially serious complications may include:

• Bleeding: the person may need to undergo another surgery to control it.

• Irregular heartbeat (Arrhythmia): commonest being atrial fibrillation, which usually resolves on its own.

• Infection: may occur in the chest wall at the surgical cut or inside the chest at the site of surgery. This may also need additional surgeries.

• Postoperative cognitive decline (POCD): some may people develop temporary memory loss, state of confusion, trouble thinking clearly, vision problems, and slurred speech can occur for a short period after surgery. The exact cause is not known, but multiple factors such as the general health of the patient before surgery are considered as risk factors.

• Heart attack

• Kidney failure

Stroke

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How long is the hospital stay? What is done during the hospital stay?

In general, the person stays in the hospital for about a week’s time where the recovery and development of complications are closely monitored. In case of complications and if other additional procedures were done along with CABG, the person may need to stay longer.

Following surgery, the person is kept in ICU for 1 to 2 days after which he is generally shifted to the ward/room. The medical team would keep a close check on the recovery and may do the following things:

• Monitor vitals such as heart rate, blood pressure, breathing rate, and oxygen level.

• Take care of the surgical wound.

• Put tubes in the chest and urinary bladder to drain fluids and monitor its quantity.

• Put an ECG machine to monitor the rhythm and activity of the heart.

• May put a pacemaker for some time to regulate the heartbeat.

• Give medicines to relieve pain and prevent complications like infection, DVT, irregular heartbeat (arrhythmias), and others.

• Put compression stockings on legs to avoid stasis of blood and prevent DVT.

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How long does it take to recover from surgery? What problems a person can have during the recovery period after surgery?

In non-complicated cases, the person may go home usually after a week’s time. During this period, the person might not feel fully fit to do everyday tasks like walking or climbing stairs, or have the following issues:

• Chest pain, discomfort, or itching around the incision site on the chest.

• Muscle aches, tiredness, irritation, or depression.

• Loss of appetite or sleep.

• Constipation

The person may take around 4 to 6 weeks to recover fully and start with work and doing significant physical activities such as exercise or sexual activity.

The recovery time is shorter in people undergoing minimally invasive CABG.

What could be the warning signs that indicate complications after surgery?

Complications may occur during the recovery period to a time long after the surgery.

1. Blockage of the bypass vessels: the graft vessels may get blocked shortly after the surgery or years later. This may result in decreased blood supply to heart muscles resulting in a heart attack or other heart problems. The person may complain of mild or severe pain in chest pain in the center or upper abdomen which feels like squeezing, pressure or heartburn. The main may radiate to the left arm, shoulder, or neck on the left side. These findings may suggest an episode of a heart attack and needs urgent medical help.

Know more about the signs and symptoms of a heart attack.

2. Stroke: some patients after CABG may develop stroke, due to clot blocking the vessels within the brain or neck.
A person can assess stroke at home by using a simple method of evaluating the following things and acting on it immediately. This is termed as FAST.

• F (Face): check the drooping of the face to one side. One can check by asking the person to smile.

• A (Arms): check the power of muscles of shoulder/arm by asking the person to raise both arms and checking if he is not able to lift an arm.

• S (Speech): check the speech for any slurring, by asking the person to repeat a simple sentence.

• T (Time): Any of these signs cause high suspicion of stroke and needs immediate call for help. Early treatment can be significantly helpful in managing stroke and reducing permanent damage to the brain.

3. Infection in the wound or site of surgery, which may lead to fever and raised white blood counts.

Know more about the signs and symptoms of a stroke.

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