"Whenever we tell a patient they have to undergo a bypass they start sweating and think about writing their will," says Dr. K. Kesava Dev, consultant cardiac surgeon. It's an understandable response, considering everything we think we know about bypass surgery - but doctors like Dr. Dev and his cardiac surgery team at Durdans Hospital are helping change patients' experience by employing techniques like auto-transfusion and multiple arterial grafts. They are looking not only to providing quicker short term recovery but also better long term results.
Understanding Heart
Bypass Surgery
"Heart bypass surgery has come a long way since even eight years ago," says Dr. Dev, explaining that "with most patients it's a straightforward, highly predictable, non-risky surgery."
Heart bypass surgeries are most often performed to relieve angina and treat coronary artery disease. A candidate for bypass surgery will initially visit a cardiologist who will first do an ECG and then decide whether the patient requires an angiogram. This test will help the doctor decide on a course of treatment - can the patient make do with medicines? Or will an operation to repair a damaged blood vessel or unblock a coronary artery (angioplasty) be required? For some patients, say those with many blockages, angioplasty may prove unsuitable. It is then that bypass surgery is considered. Clearly, not every patient will require a bypass.
However, if a bypass is decided upon, the patient is given certain goals that he must reach in terms of lowering his cholesterol. Once these goals are reached, a patient is ready for surgery. In the operating theatre, the surgical team employs the well established "beating heart" technique to operate on these patients. In the course of a four- hour long surgery, a blood vessel is removed or redirected so that a "bypass" around the cholesterol based blockages is created, thereby restoring blood flow to the heart muscle. This vessel, known as a graft, may be taken from the chest, arms or legs. Especially in cases of heart attacks, doctors may also have to take into account valve damage.
While most requiring a bypass are over the age of 60, there are cases of people as young as 28 undergoing the process as well. Complications can arise when a patient has two or more problems at the same time - heart damage and leaking valves, renal failure, liver cirrhosis or even a stroke - in addition to the reduced blood flow. Still there are plenty of success stories. Working with Dr. Dev is Dr. Anand Kumar, consultant cardiac anaesthetist. He explains that with advanced pain management techniques, discomfort is considerably reduced and many of these patients can recover well enough to return to their normal lives and even their jobs within a month.
What might put you at risk for coronary heart disease?
As the number of people with diabetes increases, so does the incidence of heart disease. Other related causes include high blood pressure, raised cholesterol and smoking. Occasionally a very strong hereditary predisposition will result in the manifestation of heart disease. However, more often than not, it can be attributed to something all of us are guilty of, says Dr. Dev, that is avoiding exercise and indulging in unhealthy food.
Short term recovery,
long term survival
For the surgical team, the focus is on improving both the patient’s short term as well as long term health. In the short term, this begins simply with a faster return to consciousness post-operation. "Earlier it was routine, whenever there was a bypass operation, that the patient would be ventilated - that is put on a respiratory machine - for almost 12 to 14 hours," says Dr. Kumar. Instead of this, the team uses a technique called fast tracking. Patients are weaned off the machine in the theatre so that once they come out they are able to speak with their family within an hour or two. Their hospital stay is also shortened by as much as two days.
Blood transfusion during a bypass surgery carries many risks, and is associated with reduced life expectancy and long term risks including that of a sudden heart attack. The most obvious way around this is, of course, is avoiding a blood transfusion altogether. But in cases where it is essential, the risk is greatly reduced by using the patient's own blood. Collected before the surgery, this method removes many of the complications associated with regular blood transfusion. In addition, a strong focus on pain relief allows for increased patient mobility.
"We are trying to improve the initial recovery by fast tracking, lack of blood transfusion, better pain relief and increased mobilisation and we are trying to improve the long term prospects by using arterial grafts," explains Dr. Dev. There are two types of grafts: arterial grafts and venous grafts. Arterial grafts are taken from the chest and the hand, and are known to last longer. Creating multiple arterial grafts might be more challenging but contributes greatly to the patient’s long term prospects.
Venous grafts are taken from the leg. Where possible, the team employs endoscopic vein harvesting techniques. These require only two small incisions to be made and the vein drawn out, as if through a keyhole, rather than taken after one long cut.
If there is valve damage, the surgeons will repair what they can, again in the interests of their patient's long term survival.
Recovery
Most patients can begin driving again in six weeks and resume full physical activity after two to three months. The wait is required to allow the sternum to heal completely. The surgeons place no restrictions on activity, but insist on strict dietary control to keep the cholesterol levels manageable - "that is the single most important thing the patient can do to see that he lives a long and problem- free life."
In the end, the basic take home message, says Dr. Dev is that there is "no reason to fear bypass surgery. If you need to undergo it, you can undergo it with every expectation of a good result and very little complications."
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