CORONARY ARTERY BYPASS SURGERY

“Off-pump” coronary artery bypass grafting on the ‘beating heart” and without the use of the heart lung machine is the standard of the CABG operation with our unit. Only one patient who required CABG operation required the use of heart lung machine and that was because he was very unstable in the intensive care unit before the operation.

Patients undergoing bypass surgery require grafts to bypass their blocked vessels and the aim is to give the patients most number of arterial grafts rather than other grafts. The grafts are of two types: viz: - arterial and venous. The arterial grafts last longer than the venous grafts in terms of patency and therefore long term results. This is important for the patients. The “harvesting” of such grafts does not take longer time or too many incisions without any  negative effects on the patient, either way. Only rarely does a patient go with all venous grafts and that occurs in patients with lot of disease in the arteries and which is spread all over his vascular tree.

 Recently we have started increasing the usage of bilateral IMA in view of the good outcome and we are able to prevent wound sepsis by changing the surgical technique.

VALVULAR HEART DISEASE

The heart valves which regulate the direction of blood flow and prevent the blood from going backwards are subjected to wear and tear and to certain diseases that cause either the narrowing of the valves or the leaking of the valves. The most common disorder is the rheumatic heart disease that affects the children but will present in adulthood with breathlessness and other problems.

The commonest valves that are affected of the four valves that are there in the human heart are the aortic valve and the Mitral valve. The valves may be replaced with valves that may be made of tissue or mechanical valves. The latter valves require the use of drugs to prevent clotting known wrongly as “blood thinners” or anticoagulants. These drugs and the presence of an unnatural thing in the blood stream does cause certain problems and the patients have to live with these problems. Therefore in certain patients in whom the valve is not very badly damaged, we are able to repair the valves and create a competent valve that will not leak nor obstruct. Surprisingly, repaired valves last long and also they give a better result as well as good lifestyle for the patients. If the valve would not have been repaired the defects cause increase in the degeneration and the valves become irreparable in some time. Successful repair needs a good knowledge of anatomy and reconstructive surgery.

Patients with repaired valves must take anticoagulants (“blood thinners”) for three months just as well as those patients with tissue valves, but not unlike the patients with mechanical prosthesis who need to take such drugs for lifetime.

The problem with these drugs is that if taken in too less quantity, they may not be good enough to prevent the clotting on the valve and if the quantity is in excess, then the patients may get side-effects such as bleeding, which may occur in any system of the body including the brain leading to paralysis or bleeding into the intestines or the urine and all these are very serious complications leading to death if it is severe.

CARDIOMYOPATHY

The heart muscle may be affected by various disorders and then cannot function and this leads to the heart dilatation and failure. Once the original disease process becomes quiescent, sometimes the heart regains its tone and the symptoms due to failure come down, but in some patients, the heart muscle does not regain its tone and the heart remains large, dilated and inefficient as a pump. In these patients, when medications cannot bring the heart size down, it is important to bring the size down: this improves the efficiency of contractions and the patients have to consume fewer drugs. The reduction in heart size is done by the cardiomyoplasty operation.

VASCULAR SURGERY

There may be obstruction of the blood vessels in some patients and in some patients there is abnormal swelling of the blood vessels. Obstruction leads to lack of blood supply and this leads to symptoms of pain or loss of function of the part. Such lesions should be repaired or bypassed so that the organs can get the blood supply. Swelling of the blood vessels is called aneurysm and if such swellings are left alone, they are likely to rupture and cause severe bleeding. Also clots may form in the aneurysm and this may lead to the traveling of clot distally and this leads to blockage below.

HEALTH FOR ALL BY 2020!!

Are we in the real process of achieving this landmark or is it another slogan by our health agencies? To achieve this on a plane of cardiovascular medicine requires plenty of work on the preventive aspects at the "grassroot" level.

PREVENTIVE LEVELS

Sr Cholesterol <150 mg/dl

LDL Cholesterol <70 mg/dl

Triglyceride <150 mg/dl

HbA1c <6

It is important for you to know as to how to prevent heart disease or what steps you should take if detected

CORONARY ARTERY DISEASE

PRESENTATION: usually as chest pain and sometimes as vague compression or pressure type sensation  in the middle of the chest and sometimes radiating to left arm, chin, back or upper abdomen. Pain usually occurs with exercise or after eating heavy meal. If the pain is persistant, it may mean that you are having a heart attack. In any case, if there is chest pain or such sensations, you must show a doctor immediately. In some patients with diabetes, there may be silent heart attack and the initial symptom may be breathlessness.

PREVENTION:

• Smoking  and use of tobacco must be stopped
• Diabetes must be controlled if detected or you must undergo the tests to see if you are diabetic
• Regular exercise: walking is the best exercise that can be undertaken. Any form of hard work that you can bear will be advisable
• Reduce the fatty foods: Use of excess oil or butter is harmful. Frying of foods is tasty but gives slow damage to the body.  Vegetarian foods are preferred. Concerning non-vegetarian foods, consumption of fish and chicken is good especially if it is not cooked by frying. Other meats can be taken but in moderation. Yellow of egg should be used in restricted manner
• Reduction of weight: we have a tendency to put on weight especially if we take rich foods. Weight reduction can be done by careful balanced diet and exercise.
• Testing your body: it is important to regularly check your blood parameters in a laboratory to look for diabetes and to see the lipid level (fat content) of the blood. This fat is harmful in the form of cholesterol, triglycerides and low density lipoproteins. How will you know unless you check the blood? Checking of blood should be regularly done after the age of 35

MODALITIES OF TREATMENT

• Medical management: blood thinners and anti-lipid drugs are used when we are suspecting that blocks are forming in the arteries of the heart. Control of diabetes also needs medicine. These tablets should not be stopped unless advised by a doctor
• In case there are few blocks, one needs to do a balloon dilatation and keep a device known as stent in the blood vessel to keep it open. This is a good line of treatment in some cases
• Surgery is indicated if there are many blocks. Surgery involves putting bypass channels to the blocked arteries and the operation is called CABG (coronary artery bypass grafting). Nowadays, we use more of arterial grafts and are also doing many cases through minimal access route. Surgery has been shown to be superior to both medical management as well as stenting in large studies. Surgery is also important when there is need of simultaneous valve repair or replacement or repair of the heart along with coronary artery disease.

HEART VALVE DISEASE

PRESENTATION:

 Most of the heart valve disease is due to a disease called Rheumatic fever. This illness hits us in early childhood between the age of 5 and 15 but usually presents in that age as fever and joint swelling. Both these symptoms disappear later on. However, the illness leads to a thickening of the heart valves and that gradually causes dysfunction of the valve and sickness. The patient usually complains of breathlessness and palpitation (feeling of one’s own heartbeats).  They may also have chest pain. Some of the patients develop congestive heart failure and may present with coughing and swelling of the legs. Rarely valve disease may also be due to degeneration or myxomatous change in the valve

PREVENTION

Rheumatic heart disease can be diagnosed by the doctor when the patient has the initial pain, fever and joint swellings. A few simple blood tests would suffice. Once detected, the patient must be kept on injection Penicillin (long acting) that has to be taken once in 3 weeks till the age of 42. In case the patient is sensitive to penicillin, other tablets can be prescribed. If rheumatic fever recurrence is prevented, the valve degeneration is also prevented. In rare cases however, there may be progressive valve thickening after the first episode alone!

Diseased heart valves are a favorite place for bacteria to sit and infect. This is known as Infective endocarditis. To prevent this from happening, if a patient’s valves are not normal, we should take antibiotics during fever or dental extraction or during any procedure being undertaken. The doctor is the best person to prescribe the antibiotics

MODALITIES OF TREATMENT

• The mainstay of treatment is management of symptoms of heart failure
• If the symptoms are not controllable with the medications or if the valve lesions are really bad on echocardiogram study, then we have to undergo some surgery
• Balloon Mitral/ Aortic valvoplasty is simply balloon dilatation of the valve and is usually a safe procedure. It gives relief for some months/years
• Valve repair is an open heart surgery that involves repairing the valve. It gives good long term results but all valves are not suitable for repair
• Valve replacement is an option when the valve is beyond repair. It is also an open heart surgery. One can replace the valve with mechanical valve or with a tissue valve. The mechanical valve needs blood thinner tablets (oral anticoagulation) for life. Tissue valves are good in the sense that such medications are not required after the first 3 months after surgery, however the valves do not last forever. There may be a need for re-replacement at some stage; therefore these valve are useful if the patient has to undergo pregnancy or if the patient is very old and the blood thinners are risky at that age.