BEATING HEART BYPASS SURGERY
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    BEATING HEART BYPASS SURGERY BEATING HEART BYPASS SURGERY Document Transcript

    • BEATING HEART BYPASS SURGERYWhat Every Patient Should Know
    • Introduction Contents Introduction: Beating Heart CABG Surgery . . . . . . . . . . 1This booklet provides The Heart and its Blood Supply . . . . . . . . . . . . . . . . . . . 2general information Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . 3about Coronary Artery Atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Disease (CAD) and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Beating Heart Coronary CAD Treatment Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Artery Bypass Grafting Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5[often called “CABG” Stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5pronounced “cabbage” Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . 6or “bypass”] surgery. Coronary Bypass Graft Harvesting . . . . . . . . . . . . . . . . . . 6 Types of Graft Bypasses . . . . . . . . . . . . . . . . . . . . . . . . . . 7This booklet is written Conventional CABG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8for patients, although Beating Heart CABG . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Potential Advantages of Beating Heart CABG . . . . . . . . . 8family members or The Surgical Experience . . . . . . . . . . . . . . . . . . . . . . . . . 9friends may find it Outpatient Pre-op Preparation . . . . . . . . . . . . . . . . . . . . . 9 Same Day Admission . . . . . . . . . . . . . . . . . . . . . . . . 9useful as well. This Intra-operative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Artery and Vein Harvest . . . . . . . . . . . . . . . . . . . . . 10booklet is not intended Coronary Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . 11as a substitute for an End of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11informed discussion Post-op Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Patient Education. . . . . . . . . . . . . . . . . . . . . . . . . . . 12with a surgeon. Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Incision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Activity Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 When to Call Your Doctor . . . . . . . . . . . . . . . . . . . . 13 Recovering at Home . . . . . . . . . . . . . . . . . . . . . . . . 13 Physician Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
    • Beating Heart CABGSurgery: RevolutionaryProgress in the SurgicalTreatment of CoronaryArtery DiseaseUntil a few years ago, most patientshaving Coronary Artery Bypass Grafting(CABG) surgery were placed on theheart-lung machine, which substitutedfor the patient’s own heart and lungsand allowed surgeons to perform theirdelicate, precise cutting and sewing ona still heart.Now, surgeons and medical devicecompanies have collaborated to developimprovements on the well-established,traditional bypass surgery procedure.Working together, they have developedBeating Heart CABG surgery productsand techniques, with the goal of makingthe procedure less traumatic and thepatient’s stay in the hospital shorter,improving comfort and speedingrecovery.Beating Heart CABG surgery has beenperformed successfully on thousandsof patients worldwide, and surgeonscontinue to recommend it for thosepatients who are appropriate candidatesfor this type of procedure. 1
    • The Heart and itsBlood SupplyThe heart is a muscular organ thatcontinuously pumps blood rich withoxygen throughout the entire body.In order to function properly, the heartmuscle itself must also receive oxygen-rich blood. This blood is deliveredthrough blood vessels on the surface ofthe heart, called the coronary arteries. Left Coronary Artery Circumflex Coronary Artery Right Coronary Left Anterior Artery Descending Coronary Artery Left Diagonal Coro. Artery Coronary Arteries on the Front of the Heart Coronary Arteries on the Back of the Heart2
    • Coronary Artery Disease CAD can appear as a single blockage or multiple blockages, and can vary inAccording to the American Heart severity and location. These blockagesAssociation’s most current (1997) in the coronary arteries can have astatistics, an estimated 12 million variety of effects on heart function, butpeople have coronary artery disease basically, the blockages mean that these(CAD). In addition, coronary heart small, but very important vessels are nodisease caused 466,101 deaths in 1997, longer able to supply the heart withand it is the single leading cause of adequate oxygen and nutrients.death in America today. Any narrowing, or blockage, of the coronary arteries reduces the bloodAtherosclerosis supply to the heart. Heart cells are veryThe coronary arteries can become demanding in terms of their use ofblocked by a build-up of cholesterol fats. oxygen, and they are quite sensitive toThis build-up is called “atherosclerotic oxygen levels. A blockage reducesplaque”—often simply referred to as oxygen delivery and does not allow“plaque.” Plaque deposits can make the the heart to properly function.arteries stiff and irregular, resulting in“hardening of the arteries.” Normal or Clear Artery Plaque Forming in Occluded Artery Normal 10% 40% 90% Artery Blocked Blocked Blocked 3
    • Risk Factors for CAD – Thallium Stress Test: The thallium stress test evaluates myocardial per-The following factors can increase one’s fusion (blood flow). This test showsrisk for coronary artery disease: how well blood flows to the heart• Family history of CAD muscle. It is usually done in con-• Smoking junction with an exercise stress test.• High cholesterol A small amount of harmless• High blood pressure radioactive material is injected into• Obesity a vein, usually in the arm. A scan-• Male gender ning camera records the radioactive• Age material as it is enters the heart muscle through the coronary arter-Diagnosis ies. If there are blockages in the coronary arteries, no radioactiveAfter taking a detailed medical history of material will be seen in the heartyour symptoms and risk factors (includ- muscle fed by those coronary arter-ing excessive weight, smoking, high ies.cholesterol and a family history of CAD),as well as a physical exam, your doctor – Dobutamine Stressmay use some of the following tests to Echocardiogram: This test evaluatesdiagnose CAD: coronary artery disease in patients who are unable to exercise on a• Electrocardiogram (EKG or ECG): This treadmill. Dobutamine is a medica- painless test provides a graphic record tion that increases heart rate and of the heart’s electrical activity as it blood pressure similar to the effect contracts and rests. The electrocardio- of exercise. After receiving the gram can detect abnormal heartbeats, dobutamine medication, the patient areas of damage, inadequate blood is monitored to assess the heart’s flow, and possible heart enlargement. performance while being “stressed”• Stress Tests by dobutamine. – Exercise Stress Test: This test helps • Coronary Catheterization: This test is doctors find out how well the heart used to explore the coronary arteries. handles work. The test can show if A small, soft tube called a catheter is the blood supply is reduced in the put into an artery in an arm or leg and arteries that supply the heart. The passed into the arteries of the heart. patient being tested is hooked up to A dye that shows up on film is injected heart monitoring equipment and through the catheter and into the walks slowly on a treadmill. The heart. The heart and blood vessels are treadmill speed and incline is then filmed while they function. increased while the doctor monitors The picture that is seen, called an the patient’s heart rate, breathing, angiogram or arteriogram, can show blood pressure, electrocardiogram problems such as blockages in the (EKG or ECG), and the level of coronary arteries. tiredness during the test. Your doctor will choose the appropriate diagnostic tests to correctly diagnose your CAD.4
    • CAD Treatment Basics: • Stents: A small device called a stent is placed in the artery afterRestore Blood Flow to the angioplasty to ensure that the arteryHeart Muscle remains open. • Surgical Intervention: CoronaryEach year many patients with CAD will Artery Bypass Grafting (CABG) is theneed treatment to increase the flow of most common surgical treatmentblood to the heart. Treatment options that creates alternate routes aroundinclude: coronary artery blockages for the• Medications: Drugs work to dilate the blood flow to reach the heart muscle. coronary arteries, enabling more oxy- Two techniques may be used: gen to be delivered (via the blood) to a conventional (stopped heart) or the surrounding heart tissue. a beating heart approach. The remainder of this booklet will focus• Angioplasty: Angioplasty is a on surgical intervention. procedure that uses a balloon on a catheter to expand the diameter of the vessel and squeeze the plaque against the wall of the vessel, thereby increasing the area for blood flow. 5
    • Surgical Intervention Coronary Bypass Graft HarvestingCoronary Artery Bypass Grafting The following diagram shows the(CABG) is a surgical procedure that arteries and veins that are mostrestores blood flow to the portion of the commonly used to create theheart beyond the blockage. This proce- bypass grafts.dure reroutes the blood around theblockage, creating an alternative path- A. The Internal Mammaryway for blood to reach the heart muscle Artery, which is detachedthat is not receiving sufficient blood from the chest wall,flow. and the open end attached to theGrafts are created by using portions of coronary belowanother artery or vein from the patient’s the blocked area.body (the portions of artery or vein arereferred to as “grafts”) (see illustration).The grafts are connected to the diseased B. The Radial Artery,artery beyond the blockage to reestab- which is in yourlish blood flow. arm, may beYour cardiologist and cardiac surgeon removed, andwill review your coronary angiogram to one end sewndetermine the number of bypasses you to the largewill need. artery leaving your heart (the aorta). The other end is attached to the coronary below the blockage. C. The Greater Saphenous Vein, which is in your leg, may be removed, and one end attached to the aorta, and the other end attached to the coronary artery, beyond the blockage. Coronary Artery Bypass Graft Harvesting6
    • Two Types of Graft Bypasses (blockage) (blockage)Internal Mammary Artery (IMA) Radial Artery or Saphenous Vein Graft Bypass Graft Bypass 7
    • Conventional CABG The Medtronic Octopus® Stabilizer isDuring conventional CABG surgery, used by thousands ofthe heart is stopped. In order to do this surgeons worldwide tosafely and effectively, the patient is stabilize the heart whileplaced on the heart-lung machine they perform the CABG(which is also referred to as being surgery. The Octopusplaced “on-pump”). The heart-lung has small suction podsmachine maintains circulation and does that gently grip thethe work of the patients heart and heart to steady it whilelungs, providing blood flow to the the surgeon works.entire body. Potential AdvantagesThe heart-lung machine has allowedcardiac bypass surgery to be performed of Beating Heart Surgerysafely and effectively for many years, Beating Heart Surgery eliminates thebut the use of the heart-lung machine need for the patient to be put on thealso has risks. The heart-lung machine heart-lung machine (pump). Recentcan increase the risk for potential prob- clinical studies have suggested that thelems such as lung problems (pneumo- following are potential benefits to thenia), fluid retention, stroke, abnormal patient:heart rhythms, bleeding, and death. Itmay also potentially increase the length • Shorter length of stay: Some patientsof hospitalization and prolong the are discharged from the hospital inrecovery period. 2-3 days versus the typical 7 to 10 days for conventional CABG surgery.In the past few years, technology hasrevolutionized how cardiac bypass • Faster recovery: Patients are returningsurgery is performed. These advance- to their normal activities in 4 weeksments have allowed for a CABG proce- rather than the typical 6 to 8 weeksdure to be performed without the use of with conventional surgery.a heart-lung machine. The new proce- • Less damage to blood cells: The usedure is called “Beating Heart CABG.” of the heart-lung machine damages blood cells, which may affect theBeating Heart CABG Surgery blood’s ability to clot after surgery.Beating Heart Surgery allows the heart Without the use of the heart-lungto continue beating while the surgery is machine, the blood is not exposed toperformed. This procedure/surgery this potential damage.incorporates state-of-the-art technology • Shorter surgery time: The patient mayof a heart-stabilizing device. The spend about one hour less time in thestabilizing device immobilizes a small operating room; and may be removedsection of the heart that needs the from the breathing machine (extubat-bypass graft while the rest of the heart ed) sooner.muscle continues to beat and pumpblood to the body. • Better outcomes: Patients may have less risk of complications after surgery such as stroke, pneumonia or kidney problems.8
    • The Surgical Experience • Medications: You will usually need to take a few medications starting the day before surgery to help prepareOut-Patient Pre-op Preparation your body for the surgery.Today much of the preparation for • Social Services: Prior to the surgery,cardiac surgery can be easily and staff are available to meet with yousuccessfully completed as an outpatient. and your family, if necessary, to iden-If your heart surgery is urgent, you may tify any potential discharge needs.need to remain in the hospital until thesurgery is completed. Preparation for • Valuables: You should leave yoursurgery involves many different activi- valuables and jewelry at home.ties: Same Day Admission –• Tests: Tests may include chest X-ray, ECG, and blood work. This provides Most of the preparation is done on an the surgical team with baseline outpatient basis, so most patients are information on the current state of admitted to the hospital the morning of your health. surgery. You will be required to come to the hospital a couple of hours prior to• Consent form: You will need to sign a the scheduled time of the surgery. In consent form granting the surgeon the pre-op holding area, the nurse will and his/her team permission to per- take your blood pressure and heart rate form the surgery. and perform a basic assessment. The nurses are resources for any additional• Shower with antibacterial soap: You questions that you or your family may will be asked to shower the evening have. In the pre-op area, your chest will prior to surgery with a special antibac- be shaved and pre-op sedation medica- terial soap, which helps to decrease tion given. You will then be transferred the amount of bacteria on your skin. to the operating room.• Patient education: The nurse, physicians and other health team Intra-Operative professionals will provide you with Once in the operating room, the the necessary patient education anesthesiologist will give you additional information through verbal instruction, medication to help you sleep. Once videos and written material. asleep, many things happen: You and/or your family should feel comfortable to ask any questions that • Intubation: You will be intubated, may come up. which means that you will be placed on a breathing machine. The breath-• Diet: Usually, the evening before ing machine helps you to breathe surgery, you should only have a light during the surgery and is different meal to eat, and then nothing to eat or than the heart-lung machine. drink after midnight. You may have sips of water with medications unless • Foley Catheter: A foley catheter will otherwise directed by your doctor. be placed to drain urine from your bladder. 9
    • • IV lines: You will have several IV lines In most cases, the small-incision inserted. These IVs provide the doc- approach can be used successfully. tors the necessary access to give you However, every surgical patient is medications during the surgery. unique, and your surgical team will recommend the best procedure for you.• Skin Preparation: Your skin is scrubbed with a strong antibacterial The removal of the radial artery is done solution to help prevent an infection. through an incision in your arm Once it is scrubbed thoroughly, you (extending from your wrist to elbow). will be covered with sterile drapes. (Fig. 3)• Chest Opening: During surgery, an incision is made down your chest, and your sternum (breastbone) is divided to allow access to your heart.Artery and Vein Harvest DuringBypass Surgery –As mentioned earlier in this booklet(page 5), to create the grafts that willallow blood to flow past the blockage orblockages in your coronary arteries, thesurgeon will need to use veins and/orarteries from your body. If a mammaryartery (located in the chest) is used, sur-geon detaches it from the chest walland attaches the open end to the coro-nary artery past the blockage.Vein Removal Techniques –If a vein from your leg is needed, tradi-tionally, the vein is removed through along incision that may stretch from Fig. 1 Fig. 2ankle to groin (Fig. 1). Using special Traditional Incision Alternative Incisionsinstruments, an alternative and less inva- for Vein Removal for Vein Removalsive vein removal technique can be per-formed using smaller incisions (Fig. 2).Through these smaller openings, yoursurgical team will use instrumentationto view the saphenous vein and remove Fig. 3the needed portions with minimal Incision for Radialtrauma to the leg. Artery Removal10
    • Coronary Grafting – • Monitoring: Your heart rhythm will be continuously monitored, and 12 leadOnce the grafts are removed, the sur- ECGs may also be done immediatelygeon attaches them to the aorta (major following cardiac surgery. Your vitalblood vessel carrying oxygen rich blood signs and physical assessment will beout of the heart), and to the coronary completed often to note any subtleartery past the blockage. To attach the changes in your condition.grafts while the heart is beating, thesurgeon will use a stabilization device, • Chest tubes: The nurses and doctorslike the Octopus®3, to keep a small sec- will monitor the amount of drainagetion of the heart still. from tubes placed in your chest dur- ing the surgery. Chest tubes are usual-End of Surgery – ly removed one day after the surgery.At the end of the surgery, chest tubes are • Foley catheter: The Foley catheterplaced in order to drain any excess which was placed prior to the surgerydrainage of fluid out of the chest. is removed once you are able to moveThe chest is then closed. about and can get up to the bathroom.Many beating heart patients are able • Activity: Activity progression is key toto be successfully extubated (removed successful recovery from CABGfrom the breathing machine) in the oper- surgery. Once you are extubated, theating room. If not extubated in the OR, nurses will begin an aggressive activi-beating heart patients are usually able to ty protocol, which requires you to sitbe extubated within a short time of arriv- on the side of the bed, to stand and toing in the intensive care unit (ICU). walk. These activities can all occur within a few hours after surgery.Recovery Cardiac Rehabilitation staff will beAfter surgery, you will be monitored involved with your activity in theclosely in the ICU. Once you have been step-down unit.stabilized and are alert, you will be • Cardiac Rehab: Cardiac Rehab is antransferred to a step down unit where intricate part of successful recoveryyou will stay until discharge. Beating following cardiac surgery. You will beheart patients are commonly trans- seen by Cardiac Rehab as an inpatientferred out of ICU as early as the same for activity progression and some basicday as surgery. patient education. Cardiac RehabPost-op Recovery – involves progression of activity within limits that you can tolerate.• Tests: It is common to have daily blood draws as your body recovers • Pain management: Although you may from the surgery. experience pain following cardiac surgery, it can be controlled with pain• Chest X-rays: Chest X-rays are also medications. It is important for commonly done following cardiac recovery that your pain is kept under surgery. control. It is your responsibility as a patient to notify your nurse and physi- cian if you are experiencing pain or if the pain medications are not helping. 11
    • • Respiratory: It is important for you to to an Outpatient Cardiac Rehabilitation do deep breathing/coughing exercises Program for monitored exercise, blood every hour while you are awake. This pressure surveillance, and continued helps to open up or re-expand your education. You will begin the program lungs. Your nurse will help you learn about one week after discharge. The to do these exercises properly. following are "normal" feelings follow- ing cardiac surgery:• Medications: Depending on your medical history, your medications • “Aches and pains” as you heal may vary. However, you will need to take your regularly scheduled medica- • Fatigue with exertion tions, with the addition of antibiotics • Irritability and pain medications. • Difficulty in sleepingPatient Education – • Loss of appetiteFollowing cardiac surgery, your nurse,doctor and cardiac rehab staff are avail- • Constipation (from pain medication)able to answer any questions that you or • Slight swelling at the vessel harvest siteyour family may have. They will alsoensure that you and your family under- General discharge instructions maystand what you need to know to be safe follow the plan below. These dischargeat home. Education includes: instructions are specific to the All Saints Healthcare System, Inc. pro-• Incision care gram, and you should always refer to• Diet for strength/energy and wound your physician’s instructions. healing Incision Care –• Medications • Watch your incisions for signs of• Activity expectations, limitations and infection: redness, drainage (pus), and exercises increased tenderness.• Pulse checking • Shower daily. You should not swim or take a tub bath for 2 weeks.• Smoking cessation (if appropriate) • You will have steri-strip bandages over• Follow-up appointments your incision. These will fall off in• Discharge instructions 10 to 14 days.Discharge – • It is a good idea to wear sunblock if exposing the incision to direct sunlight.Discharge following cardiac surgerycan occur as soon as you are medically Activity Restrictions –stable. This may occur as soon as the • You should not lift, push or pull any-second day after surgery, particularly if thing heavier than 10-15 pounds for 6you are a beating heart patient. It may weeks.take at least 4 weeks before you feel“back to normal.” You will be referred • You should not drive for 1 month.12
    • Medications – smoking cessation (if appropriate), and blood pressure control. A plan, with spe-You may be on new medications, or your cific goals set collaboratively between youphysician may have discontinued some and your cardiac rehab staff, will beof your previous medications. Your doc- designed for you. Specific outcomes fortor and nurses will thoroughly review your to return to work are also consid-these with you prior to discharge. Never ered. Strength training classes are avail-stop taking a medication or start a new able to help you regain the strength andmedication without consulting with your endurance to return to work or partici-doctor. Always continue to take your pate in other previously enjoyed recre-medications as directed by your doctor. ational activities. Once the goals areWhen to Call Your Doctor – obtained, you can “graduate” from the Cardiac Rehab program, but you will be• Chest pain similar to your angina encouraged to continue in a regular exer-• Shortness of breath cise routine.• Dizziness Conclusion• Palpitations Today, technology, doctors and other• Fever greater than 101.0 degrees F healthcare professionals are working together to provide you with the best• Redness around incisions care possible. The beating heart• Drainage (pus) from the incisions approach to coronary artery bypass surgery allows the possibility of superior benefits to you including a quicker recov-Recovering At Home ery time and decreased complications. It can be a highly stressful time, but youPhysician Follow-Up can be assured your team of doctors,Follow-up may vary from hospital to hos- nurses, respiratory therapists, cardiacpital, but in general, you should see the rehab staff and other health care profes-nurse in the clinic about one week post sionals are here to help your surgery bedischarge, and follow up with your sur- successful and return you to an activegeon about one month after discharge. and healthy life for years to come.Usual follow up is at 4 months and oneyear following the surgery.Following discharge, you will attend out-patient Cardiac Rehab sessions for about4-6 weeks, depending on your specificneeds. These sessions not only consist ofmonitored exercise sessions, but alsopatient education classes that focus onrisk factor modification.Risk factor modification is extremelyimportant in the prevention of the con-tinued development of coronary arterydisease. Classes include: diet, exercise, 13
    • The information contained in this booklet should not be considered a replacement fora consultation with a medical professional.Medtronic wishes to thank:Paul Chomiak, M.D., Cardiovascular Surgery Associates, S.C.Sarah Bose, RN, B.S.N., All Saints Healthcare Systemand Maura Page, RN, Cardiovascular Surgery Associates, S.C.for their invaluable contributions to this booklet.Medtronic Cardiac Surgery7000 Central Avenue NEMinneapolis, MN 55432-3576USAInternet: www.medtronic.comTelephone: (763) 514-4000FAX: (763) 514-4879UC200103016EN© Medtronic, Inc. 2001All Rights ReservedPrinted in USA