Coronary Bypass Graft SurgeryPage 1 of 9*****Coronary Bypass Graft Surgery (Part 1): Understanding Treatment Options*****NarratorHarry Warholak has lived a life of adventure. He served in Vietnam and owned a Detroit junkyardfamous for housing vintage cars. His latest adventure, coronary artery bypass graft surgery, or CABGfor short. He’s arrived for pre-op testing and will undergo bypass the next day.A routine physical exam led to the discovery of a blocked artery in Harry’s heart.Harry Warholak, PatientI did that stress test and that’s when they were alerted that something’s wrong.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityUltimately, he ended up having the sort of ‘gold standard’ test which is the cardiac catheterizationwhich takes pictures of all the arteries in the heart. His problem was a complete blockage in the mainartery on the front of the heart.Harry Warholak, PatientHeart wasn’t doing its full time job. I really never had any indication. No palpitations, no otherproblems.NarratorHarry’s severely blocked vessel in his heart is due to coronary artery disease. The surgery works byimproving or restoring blood flow to the heart. It’s the most common open-heart surgery in the UnitedStates.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityFor patients with multi-vessel coronary disease which means multiple blockages in different arteriesin the heart, bypass surgery has been shown to be the most effective and durable treatment, bothwith respect to survival long-term and for relief of symptoms.So, I’m checking your blood pressure, your pulse and your oxygen saturation.NarratorTo better understand bypass surgery it’s helpful to know what coronary artery disease is. Simply put:Joe Miller, MD, Cardiologist, Piedmont Heart InstituteI always like to think of coronary artery disease as blockage in a pipe. Sort of like the junk that buildsup in your kitchen sink and the pipes in the kitchen sink. Most of the things we know that are bad forus help build this clog in the drain.NarratorThe coronary arteries are blood vessels that bring oxygen and nutrient-rich blood to the heart muscle.These arteries can become narrowed due to a build-up of fatty materials known as plaque which mayrestrict blood flow to the heart.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThat causes chest tightness or pain. It can happen at rest but frequently occurs with activity and whenthat does occur and it’s due to inadequate blood flow to the heart muscles that’s called angina.NarratorIf the plaque becomes unstable it can crack or rupture.Page 2 of 9Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThe process of that plaque rupturing triggers a cascade of blood clots at that site, and that’s whatcauses a heart attack because it interrupts blood flow completely to the artery past that.NarratorCABG uses a healthy blood vessel taken from another part of your body and connects it to the otherarteries in your heart so blood is bypassed around the narrowed or blocked area. This can eliminatechest discomfort, reduce fatigue and perhaps the need for some medications.There are two common areas where your surgeon may take blood vessels from, known as bypassgrafts. One is the chest.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityWe take one artery off the chest which is right underneath the ribs and we use that artery to bypassthe artery on the front of the heart.NarratorIt’s called the mammary artery.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThe other arteries typically are bypassed with vein that’s taken from the leg, the saphenous vein. Andthen that vein can be divided into different pieces to provide bypasses to the other blood vessels inthe heart.NarratorBypass surgery is performed by a specialist known as a cardiothoracic surgeon. There are severaldifferent types of CABG procedures surgeons can use based on the patient’s needs. The mostcommon is traditional bypass surgery.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityWith traditional bypass surgery it usually involves an incision down the middle of the chest. And weput a retractor in so we can get access to the heart. In this country most of the operations are donewith the heart lung machine. And that involves using a machine to do the job of the heart and lungs.So that we can stop the heart, sew the bypasses onto the heart that’s quiet and not moving, at thesame time protecting it and that allows us to be very precise with sewing those connections onto theheart.NarratorSurgeons can do more than one graft with this procedure, which is known as multiple arterial grafting.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityAfter the bypasses are completed the heart is restarted again. Using this technique to do bypasssurgery has been associated with excellent 30-day and in-hospital survival and also associated withexcellent long-term results of bypass surgery.NarratorSome doctors use other surgical approaches referred to as minimally invasive or high tech bypassprocedures.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThe first approach to minimally invasive bypass surgery was the introduction of off pump bypasssurgery. And all that means is the bypasses are constructed without the use of the heart-lungPage 3 of 9machine. And that of course should be done in centers with expertise in these approaches andsurgeons that have a lot of experience with them.NarratorNewer minimally invasive bypass procedures differ from traditional bypass in that the chest bone isnot opened; instead, several small incisions are made on the left side of the chest between the ribs. Itmay be referred to as robotic bypass surgery.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityPatients want the durability that’s associated with bypass surgery understandably but have theirdowntime very limited so they can get back to normal, have fewer complications and faster recovery.So with minimally invasive bypass surgery we’re trying to bridge that divide.NarratorA newer high tech procedure is known as hybrid coronary revascularization, or HCR. It combinesbypass surgery with the use of stents, which are tiny metal mesh tubes placed in narrowed or weakarteries to open them and restore blood flow.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityWith the minimally invasive bypass operation, we’re providing that long-term durable bypass graft, theleft internal mammary artery, to the artery on the front of the heart through small incisions. And thenwe’re using the stents to treat the other arteries.NarratorWith different options available, how do you know which bypass surgery is best for you?Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThe best thing for patients to do is to be well informed. And they should have no hesitation askingtheir cardiologist or their surgeon or their primary care physician what their opinion is regarding thebest treatment options for them. It’s ok to get second opinions from different doctors in the samespecialty.NarratorIt’s normal to feel anxious about having bypass surgery. Hospital procedures vary so be sure to askyour healthcare provider any questions you might have. Surgeries are often scheduled about a monthin advance though in more serious cases doctors may perform them right away.That’s what happened with Carol Rosenhaft after tests showed she had four severe blockages.Carol Rosenhaft, PatientThey immediately admitted me to the hospital and this was Friday and Monday morning, first thing, Ihad quadruple bypass.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteBut that kind of presentation doesn’t happen very often. And most patients have a little time to thinkabout it and prepare and plan for going home after surgery too.NarratorTo prepare for your surgery you’ll have tests done that may include:Blood and urine testsEKG, or electrocardiogram, to check your heart’s electrical impulsesChest x-rayPage 4 of 9Cardiac catheterization or angiogram, to look inside your heart a thin tube is threaded througha blood vessel and into your heart to get a series of x-ray pictures.Before surgery you should make plans for the 4 to 6 weeks needed to recover from your operation.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteFor most patients, the transition to going home is fairly routine. They probably need to plan on beingout of work about a month. They may be able to get back into it a little bit after two weeks. Thehardest thing for patients is because they’re feeling pretty good is they can’t get back to driving forabout a month because they have to allow the breast bone to heal up just like any other broken bone.If they have the minimally invasive approach, their options to drive is frequently just limited by pain.NarratorThe results of CABG can last for at least 10 to 15 years or more as long as you take care of yourselfand follow your doctor’s advice.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteModern bypass surgery might last 20 years or even forever for a patient and it’s really a restart on life.*****Coronary Artery Bypass Graft Surgery (Part 2): Avoiding Complications andReadmission*****NarratorIt’s been a week since Harry Warholak was released from the hospital after having coronary arterybypass surgery.Harry Warholak, PatientIt was successful. I feel great. Everything’s working along like they told me so far.NarratorHarry had minimally invasive robotic bypass surgery. Patients typically return home three to sevendays after their surgery. Hospital stays may be a bit shorter for those who get minimally invasiveprocedures as Harry did.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityHe had an excellent outcome. He had a brief period of postoperative atrial fibrillation which is verycommon. His was less than 12 hours and was easily controlled with medication.NarratorA-Fib or atrial fibrillation is an irregular heart beat. It can also be referred to as an arrhythmia. Gettingup and moving can help lower the risk of this complication.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteIn the old days we used to put you in bed and let you heal. That is the complete opposite of what wewant for patients today. For most patients we want them up and moving in the first 24 hours aftersurgery, really in the first 18 hours after surgery.NarratorIn the hospital, the health care team will watch for a-Fib and other possible complications such aspneumonia, bed sores or infection.To reduce the chance of pneumonia nurses will encourage deep-breathing and coughing exercises tospeed lung recovery. This may be somewhat painful or uncomfortable, but it’s important to workthrough these exercises.Page 5 of 9Wound care following surgery is important to avoid infection and bleeding.Compression stockings may be recommended to reduce swelling in the legs and ankles, especially ifa vein graft has been taken from the leg.Memory loss and confusion or problems concentrating might occur in some people following heartsurgery. These side effects can improve with time.In addition to preventing complications, the healthcare team makes sure patients can do certainthings before sending them home.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityThey have to walk without assistance. They have to be able to eat, use the restroom, keep liquidsdown and have pain controlled with pills.After going home it’s important for patients to follow the health care team’s recommendations foractivity, diet and medications.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteThey should read the list they’re sent home with and it’s good to have another set of eyes read thatlist also. These lists and suggestions are not just things we make up at a whim. These are created bylarge medical societies with reviews and committees that have studied thousands of patients and wereally have a good idea of what works.NarratorHaving support at home is also crucial, as Harry has found.Harry Warholak, PatientMy wife’s been a miracle through this thing, helping me with stuff. Making sure I do the right thing.NarratorDoing the right thing can reduce the odds of having to go back into the hospital.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityHospital readmissions after heart surgery typically occur in 8 to 12-percent of patients. And mostcommonly they can occur for very simple reasons like fever, atrial fibrillation, heart failure relatedsymptoms or just a failure to do well at home in general.NarratorReadmissions are most likely to occur during the first 30 days after surgery. Some common reasonsfor being readmitted include:Activity intolerance, that is an unwillingness to “get moving” due to fear or discomfortChest and leg discomfortDecreased enduranceLack of energy andTirednessAnother possible cause is the build-up of body fluids, which walking can help prevent.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteWe want to watch out for quick accumulation of fluid, but if they notify us quickly we can generallytake care of that for them over the phone and really minimize the chances of them coming back intothe hospital which is what we don’t want to happen.NarratorIt’s also important to let your doctor know if you experience:Page 6 of 9Signs of infection such as increasing redness or drainage at the incision sitesFeverChillsIncreased fatigueShortness of breathSwollen ankles or abdomenWeight gain over 5 pounds in a few daysOr change in your heart rate or rhythmBe sure to know when to schedule follow-up appointments and cardiac rehabilitation. Following yourhealthcare team’s instructions after CABG surgery will help you get better faster, and get back to yourlife and normal activities.Harry Warholak, PatientHere’s a few pictures of the famous GM cars that we had at my salvage yard in Michigan.NarratorHarry’s goal is to make it to a car show for a speaking engagement on vintage cars in less than amonth.Michael Halkos, MD, Cardiothoracic Surgeon, Emory UniversityHe has essentially resumed almost all of his normal pre-operative activities. I told him he can gotomorrow.*****Coronary Artery Bypass Graft Surgery (Part 3): Recovery and Cardiac Rehabilitation*****NarratorIt’s not unusual to feel apprehensive about leaving the security of the hospital after bypass surgery.Be assured that your doctor wouldn’t release you unless you were ready. Since you are not allowedto drive for at least a month after your procedure, you’ll need the support of family or friends.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteI think for most patients when they go home that first 24 hours is a real shock. They’ve had so muchdone for them while they’re in the hospital that they’re extremely tired when they have to do things ontheir own. But in the next 48 hours we really want them to start doing more and more on their own.NarratorSetting up a routine for home will help your recovery. Be sure to:Wake up at a normal and consistent hourBathe or shower if possibleDress in regular clothes during the dayTake naps or rest times in the morning or midafternoon or after activityYour doctor will provide directions about diet and other lifestyle measures. It’s important to followthem.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteWhen patients go home they get the standard list which includes sodium and salt restriction,increasing physical activity, lowering cholesterol, and maintaining their medications on a daily basis.Page 7 of 9NarratorMake sure you’re clear on what medications you should take. They may be different than what youtook before surgery.Joe Miller, MD, Cardiologist, Piedmont HealthcarePatients go home from bypass surgery, they are going to go home with a whole list of medicationswhich may be new for them. And, so part of that time period is getting adjusted and used to thesemedications. Several of these medications lower cholesterol and work on long-term risk factors, someof them might be short-term and just help with fluid build up and accumulation and preventing thatfrom happening.NarratorDon’t use any over-the-counter pain relievers like aspirin or ibuprofen or vitamin and herbalsupplements without checking first with your doctor. Before leaving the hospital, check with yourdoctor on when you should have staples or stitches removed. Also be sure to schedule anappointment with your personal or family doctor. Find out what activities you can and should do, suchas walking.It’s been a key part of Harry Warholak’s recovery.Harry Warholak, PatientI love to walk. Walking’s been good. I’ve been walking more and more every day.Narrator Begin with short walks lasting 5-10 minutes.Gradually build up to at least 40 minutes 3 to 4 days a week.Walk at a comfortable pace that allows you to hold a conversation.Let your doctor know if you experience chest pain while walking.Nikki McGlamery, Nurse, Gwinnett Medical CenterAfter your bypass surgery you should avoid extreme temperatures during exercise. You shouldn’t gooutside to walk whenever the temperature is very cold nor should you go outside whenever it’s hotand humid. During those times you’ll want to exercise inside.NarratorIn addition to walking, you should be able to do light work around the house, visit friends, and go tothe theater, restaurants, stores, and your place of worship. Ask your doctor about when you canresume sexual activity.Joe Miller, MD, Cardiologist, Piedmont HealthcarePatients are uncomfortable discussing this with us, but it’s something most clinicians are verycomfortable with talking about because we get asked about it so much and not only that there’sscience around it, and for most patients once they can walk one flight of stairs without beinguncomfortable it’s safe for them to return to normal sexual activity.NarratorCardiac rehabilitation is a key part of recovery. Many hospitals have rehab facilities or they canadvise you on finding a local cardiac rehab program, as can your doctor. To choose a rehab facilitythat’s right for you or a loved one, you should ask:Is the facility accredited?What type of rehabilitation does it specialize in?Are there board-certified staff members available at all times?Page 8 of 9Who develops the treatment plan?Will the staff work with your caregivers to help you continue your rehabilitation safely at home?What will and will not be covered by your health insurance?Joe Miller, MD, Cardiologist, Piedmont Heart InstituteOne of the greatest benefits about cardiac rehab especially for patients who are enrolled fairly earlyinto their recovery is that they have ongoing monitoring 3 times a week by trained staff, they’rewatching for fluid retention, they’re watching for irregular heart rhythms and we know that addscomfort both to the patient but also to the clinician.NarratorParticipating in cardiac rehabilitation can improve stamina and strength, helping patients return totheir usual activities. In addition, it can lessen the emotional effects of heart disease, which mayinclude stress and depression.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteAbout 30% of patients actually have some form of temporary clinical depression and it’s just that firstwake up call that there’s something wrong with them physically.NarratorIf feelings of depression last for more than two or three weeks, tell your doctor. Cardiac rehab alsohelps you prevent a return to the hospital.What’s more, by controlling risk factors such as high blood pressure, abnormal cholesterol levels,excess weight, diabetes, smoking, and lack of physical activity, cardiac rehab helps lower the risk offuture heart problems.Nikki McGlamery, Nurse, Gwinnett Medical CenterIt helps you to increase your level of activity so that you can get through your activities of daily livingmore comfortably. It’s important to participate in these programs so that you heal more quickly.NarratorCoronary artery bypass surgery is a reset. It can lead to a longer life and a return to activities thatmay have been limited in the past.Joe Miller, MD, Cardiologist, Piedmont Heart InstituteI think a lot of it is up to the patient. The patient really needs to be willing to make the lifestylechanges.NarratorCarol Rosenhaft has done just that since her bypass surgery, going through cardiac rehab andfollowing all her doctor’s instructions.Carol Rosenhaft, PatientI have a perfectly normal life, which I wouldn’t have had. Bypass saved my life!© American Heart Association/American Stroke Association and The Wellness NetworkPage 9 of 9
